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Kiramira D, Voßmerbäumer U, Pfeiffer N, Linnerth-Braun LKM, Lorenz K, Prokosch V. Mid-term real world outcomes of the Hydrus ® Microstent in open angle glaucoma. Eye (Lond) 2024; 38:1454-1461. [PMID: 38182656 PMCID: PMC11126590 DOI: 10.1038/s41433-023-02920-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/15/2023] [Accepted: 12/20/2023] [Indexed: 01/07/2024] Open
Abstract
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.
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Affiliation(s)
- David Kiramira
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
- Department of Periodontology and Operative Dentistry, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Urs Voßmerbäumer
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
- Frankfurt Hoechst Eye Hospital, Frankfurt, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Lea K M Linnerth-Braun
- Department of Periodontology and Operative Dentistry, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Katrin Lorenz
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Verena Prokosch
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany.
- Department of Ophthalmology, University Hospital of Cologne, Cologne, Germany.
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Castillejos AG, Chen TC. A Guide to the Repair of Traumatic Cyclodialysis Clefts: Medical, Laser, and Surgical Treatment. Int Ophthalmol Clin 2024; 64:75-87. [PMID: 38525983 DOI: 10.1097/iio.0000000000000497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
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Luo S, Mikula ER, Khazaeinezhad R, Bradford SM, Zhang F, Jester JV, Juhasz T. Evaluating the effect of pulse energy on femtosecond laser trabeculotomy (FLT) outflow channels for glaucoma treatment in human cadaver eyes. Lasers Surg Med 2024; 56:382-391. [PMID: 38570914 PMCID: PMC11361556 DOI: 10.1002/lsm.23783] [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: 11/13/2023] [Revised: 02/19/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Femtosecond laser trabeculotomy (FLT) creates aqueous humor outflow channels through the trabecular meshwork (TM) and is an emerging noninvasive treatment for open-angle glaucoma. The purpose of this study is to investigate the effect of pulse energy on outflow channel creation during FLT. MATERIALS AND METHODS An FLT laser (ViaLase Inc.) was used to create outflow channels through the TM (500 μm wide by 200 μm high) in human cadaver eyes using pulse energies of 10, 15, and 20 μJ. Following treatment, tissues were fixed in 4% paraformaldehyde. The channels were imaged using optical coherence tomography (OCT) and assessed as full thickness, partial thickness, or not observable. RESULTS Pulse energies of 15 and 20 μJ had a 100% success rate in creating full-thickness FLT channels as imaged by OCT. A pulse energy of 10 μJ resulted in no channels (n = 6), a partial-thickness channel (n = 2), and a full-thickness FLT channel (n = 2). There was a statistically significant difference in cutting widths between the 10 and 15 μJ groups (p < 0.0001), as well as between the 10 and 20 μJ groups (p < 0.0001). However, there was no statistically significant difference between the 15 and 20 μJ groups (p = 0.416). CONCLUSIONS Fifteen microjoules is an adequate pulse energy to reliably create aqueous humor outflow channels during FLT in human cadaver eyes. OCT is a valuable tool when evaluating FLT.
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Affiliation(s)
- Shangbang Luo
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA 92697, USA
- Department of Ophthalmology, University of California, Irvine, Irvine, CA 92697, USA
| | - Eric R. Mikula
- Department of Ophthalmology, University of California, Irvine, Irvine, CA 92697, USA
- ViaLase Inc., Aliso Viejo, CA 92656, USA
| | | | - Samantha M. Bradford
- Department of Ophthalmology, University of California, Irvine, Irvine, CA 92697, USA
| | - Fengyi Zhang
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA 92697, USA
- Beckman Laser Institute, University of California, Irvine, Irvine, CA 92697, USA
| | - James V. Jester
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA 92697, USA
- Department of Ophthalmology, University of California, Irvine, Irvine, CA 92697, USA
| | - Tibor Juhasz
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA 92697, USA
- Department of Ophthalmology, University of California, Irvine, Irvine, CA 92697, USA
- ViaLase Inc., Aliso Viejo, CA 92656, USA
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Lusthaus JA. Imaging of aqueous outflow in health and glaucoma. Justifying the re-direction of aqueous. Eye (Lond) 2024:10.1038/s41433-024-02968-8. [PMID: 38429503 DOI: 10.1038/s41433-024-02968-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/17/2023] [Accepted: 01/26/2024] [Indexed: 03/03/2024] Open
Abstract
A wave of less invasive surgical options that target or bypass the conventional aqueous outflow system has been incorporated into routine clinical practice to mitigate surgical risks associated with traditional glaucoma drainage surgery. A blanket surgical approach for open-angle glaucoma is unlikely to achieve the desired IOP reduction in an efficient or economical way. Developing a precise approach to selecting the most appropriate surgical tool for each patient is dependent upon understanding the complexities of the aqueous outflow system and how devices influence aqueous drainage. However, homoeostatic control of aqueous outflow in health and glaucoma remains poorly understood. Emerging imaging techniques have provided an opportunity to study aqueous outflow responses non-invasively in clinic settings. Haemoglobin Video Imaging (HVI) studies have demonstrated different patterns of aqueous outflow within the episcleral venous system in normal and glaucomatous eyes, as well as perioperatively after trabecular bypass surgery. Explanations for aqueous outflow patterns remain speculative until direct correlation with findings from Schlemm's canal and the trabecular meshwork are possible. The redirection of aqueous via targeted stent placement may only be justifiable once the role of the aqueous outflow system in IOP homoeostasis has been defined.
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Affiliation(s)
- Jed A Lusthaus
- Department of Ophthalmology, Sydney Eye Hospital, Sydney, NSW, Australia.
- Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia.
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Shultz M, Chorbajian A, Zohouralen A. Comparative Effectiveness and Safety of Two Different Trabecular MIGS Devices With and Without Ab Interno Canaloplasty in Patients with Primary Open-Angle Glaucoma. Ophthalmol Ther 2023; 12:3307-3322. [PMID: 37801274 PMCID: PMC10640541 DOI: 10.1007/s40123-023-00819-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION This study compared outcomes of the iStent inject trabecular micro-bypass system versus the Hydrus Microstent in patients with primary open-angle glaucoma (POAG). METHODS Forty subjects (80 eyes) with POAG were included in this single-center, retrospective, contralateral-eye analysis. All patients underwent phacoemulsification with either iStent inject or Hydrus implantation in one eye and the other device in the contralateral eye, with ≥ 3-month follow-up. In 58 eyes (27 iStent inject, 31 Hydrus) the surgery also included ab interno canaloplasty (ABiC). Twelve-month outcomes included intraocular pressure (IOP), medications, and adverse events. Subgroup analyses were completed for iStent inject versus Hydrus, and with versus without ABiC. RESULTS At 12 months versus baseline, mean IOP reduced from 16.8 ± 3.7 to 13.6 ± 2.9 (p = 0.003) in iStent inject eyes, and from 18.1 ± 4.5 to 14.9 ± 3.2 mmHg (p = 0.003) in Hydrus eyes (between-group IOP reduction p = 0.582). Mean number of glaucoma medications reduced from 1.23 ± 0.97 to 0.30 ± 0.76 (p < 0.001) in iStent inject eyes and from 1.20 ± 1.02 to 0.39 ± 0.72 (p = 0.001) in Hydrus eyes (between-group medication reduction p = 0.943). At 12 months, 82.6% of iStent inject eyes and 73.9% of Hydrus eyes were medication-free versus 20.0% preoperatively in both groups (p < 0.0001 both groups). There were no statistically significant IOP or medication differences between iStent inject and Hydrus pre- or postoperatively, both in the overall cohort and in the with/without ABiC subgroups. Outcomes also were similar between eyes with/without ABiC in the overall cohort and in the iStent inject/Hydrus subgroups. There were no adverse events in the iStent inject group; two eyes in the Hydrus group had device-related complications requiring five additional surgeries (one Hydrus repositioning, one Hydrus exchange, one Hydrus removal, two goniotomies). CONCLUSION In this contralateral-eye comparison of iStent inject versus Hydrus, the groups had similar IOP and medication outcomes, regardless of stratification by ABiC completion. Eyes receiving Hydrus had more complications and subsequent surgeries.
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Affiliation(s)
- Mitchell Shultz
- Shultz Chang Vision, 18350 Roscoe Blvd #101, Northridge, CA, 91325, USA.
| | - Abraham Chorbajian
- Shultz Chang Vision, 18350 Roscoe Blvd #101, Northridge, CA, 91325, USA
- Western School of Medicine, Pomona, CA, USA
| | - Ala Zohouralen
- Shultz Chang Vision, 18350 Roscoe Blvd #101, Northridge, CA, 91325, USA
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Lo J, Mehta K, Dhillon A, Huang YK, Luo Z, Nam MH, Al Diri I, Chang KC. Therapeutic strategies for glaucoma and optic neuropathies. Mol Aspects Med 2023; 94:101219. [PMID: 37839232 PMCID: PMC10841486 DOI: 10.1016/j.mam.2023.101219] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/02/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
Glaucoma is a neurodegenerative eye disease that causes permanent vision impairment. The main pathological characteristics of glaucoma are retinal ganglion cell (RGC) loss and optic nerve degeneration. Glaucoma can be caused by elevated intraocular pressure (IOP), although some cases are congenital or occur in patients with normal IOP. Current glaucoma treatments rely on medicine and surgery to lower IOP, which only delays disease progression. First-line glaucoma medicines are supported by pharmacotherapy advancements such as Rho kinase inhibitors and innovative drug delivery systems. Glaucoma surgery has shifted to safer minimally invasive (or microinvasive) glaucoma surgery, but further trials are needed to validate long-term efficacy. Further, growing evidence shows that adeno-associated virus gene transduction and stem cell-based RGC replacement therapy hold potential to treat optic nerve fiber degeneration and glaucoma. However, better understanding of the regulatory mechanisms of RGC development is needed to provide insight into RGC differentiation from stem cells and help choose target genes for viral therapy. In this review, we overview current progress in RGC development research, optic nerve fiber regeneration, and human stem cell-derived RGC differentiation and transplantation. We also provide an outlook on perspectives and challenges in the field.
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Affiliation(s)
- Jung Lo
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, 83301, Taiwan
| | - Kamakshi Mehta
- Department of Ophthalmology, Louis J. Fox Center for Vision Restoration, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15219, USA
| | - Armaan Dhillon
- Sue Anschutz-Rodgers Eye Center and Department of Ophthalmology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Yu-Kai Huang
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, 80708, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 80708, Taiwan
| | - Ziming Luo
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, 94304, USA
| | - Mi-Hyun Nam
- Sue Anschutz-Rodgers Eye Center and Department of Ophthalmology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA.
| | - Issam Al Diri
- Department of Ophthalmology, Louis J. Fox Center for Vision Restoration, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15219, USA.
| | - Kun-Che Chang
- Department of Ophthalmology, Louis J. Fox Center for Vision Restoration, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15219, USA; Department of Neurobiology, Center of Neuroscience, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 80708, Taiwan.
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Qin Q, Zhang C, Yu N, Jia F, Liu X, Zhang Q, Chen M, Wang K. Development and material characteristics of glaucoma surgical implants. ADVANCES IN OPHTHALMOLOGY PRACTICE AND RESEARCH 2023; 3:171-179. [PMID: 38106549 PMCID: PMC10724012 DOI: 10.1016/j.aopr.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/12/2023] [Accepted: 09/21/2023] [Indexed: 12/19/2023]
Abstract
Background Glaucoma is the leading cause of irreversible blindness worldwide. The reduction of intraocular pressure has proved to be the only factor which can be modified in the treatment, and surgical management is one of the important methods for the treatment of glaucoma patients. Main text In order to increase aqueous humor outflow and further reduce intraocular pressure, various drainage implants have been designed and applied in clinical practice. From initial Molteno, Baerveldt and Ahmed glaucoma implants to the Ahmed ClearPath device, Paul glaucoma implant, EX-PRESS and the eyeWatch implant, to iStent, Hydrus, XEN, PreserFlo, Cypass, SOLX Gold Shunt, etc., glaucoma surgical implants are currently undergoing a massive transformation on their structures and performances. Multitudinous materials have been used to produce these implants, from original silicone and porous polyethylene, to gelatin, stainless steel, SIBS, titanium, nitinol and even 24-carat gold. Moreover, the material geometry, size, rigidity, biocompatibility and mechanism (valved versus nonvalved) among these implants are markedly different. In this review, we discussed the development and material characteristics of both conventional glaucoma drainage devices and more recent implants, such as the eyeWatch and the new minimally invasive glaucoma surgery (MIGS) devices. Conclusions Although different in design and materials, these delicate glaucoma surgical implants have widely expanded the glaucoma surgical methods, and improved the success rate and safety of glaucoma surgery significantly. However, all of these glaucoma surgical implants have various limitations and should be used for different glaucoma patients at different conditions.
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Affiliation(s)
- Qiyu Qin
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Chengshou Zhang
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Naiji Yu
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Fan Jia
- MOE Key Laboratory of Macromolecule Synthesis and Functionalization of Ministry of Education, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Liu
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Qi Zhang
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Min Chen
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Kaijun Wang
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
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Balas M, Mathew DJ. Minimally Invasive Glaucoma Surgery: A Review of the Literature. Vision (Basel) 2023; 7:54. [PMID: 37606500 PMCID: PMC10443347 DOI: 10.3390/vision7030054] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/24/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023] Open
Abstract
Minimally invasive glaucoma surgery (MIGS) has emerged as a novel approach in the glaucoma treatment spectrum, offering a range of diverse procedures and devices aimed at reducing intraocular pressure (IOP). MIGS can be broadly classified into several categories: those that enhance trabecular outflow (Trabectome, iStent, Hydrus Microstent, Kahook Dual Blade, high frequency deep sclerotomy, and gonioscopy-assisted transluminal trabeculotomy), those that augment suprachoroidal outflow (CyPass Microstent and iStent Supra), those that target Schlemm's canal (TRAB360 and the OMNI Surgical System, Streamline, and Ab Interno Canaloplasty), and conjunctival bleb-forming procedures (EX-PRESS Glaucoma Filtration Device, Xen Gel Stent and PreserFlo MicroShunt). MIGS is considered to have a shorter surgical time and fewer severe complications when compared to traditional glaucoma surgeries such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves). This literature review comprehensively examines the distinct MIGS devices and procedures, their underlying mechanisms, and clinical outcomes, emphasizing the importance of evaluating the efficacy and complications of each approach individually. As the field of MIGS continues to evolve, it is crucial to prioritize high-quality, long-term studies to better understand the safety and effectiveness of these innovative interventions in glaucoma management.
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Affiliation(s)
- Michael Balas
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada;
| | - David J. Mathew
- Donald K. Johnson Eye Institute, Krembil Research Institute, University Health Network, Toronto, ON M5T 0S8, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON M5T 2S8, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
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Zimmermann JA, Storp JJ, Merté RL, Heiduschka P, Eter N, Brücher VC. Position of the ISTENT Inject ® Trabecular Micro-Bypass System Visualized with the NIDEK GS-1 Gonioscope-A Postoperative Analysis. J Clin Med 2023; 12:5171. [PMID: 37629213 PMCID: PMC10455890 DOI: 10.3390/jcm12165171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/03/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Glaucoma is one of the leading causes of irreversible blindness globally and is characterized by the gradual loss of retinal ganglion cells. The primary risk factor for the development and progression of glaucoma is increased intraocular pressure (IOP). Numerous surgical interventions exist to lower IOP should conservative therapy fail. One trend in recent years has been minimally invasive glaucoma surgery (MIGS) as an alternative to traditional methods. The ISTENT inject® is an ab interno trabecular micro-bypass implant designed to be implanted through the trabecular meshwork into the Schlemm's canal to lower IOP. The aim of the study was the postoperative visualization and description of the positioning of the ISTENT inject® using automated circumferential goniophotography. Patients with symptomatic cataracts and mild to moderate primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PEX), and pigment-dispersion glaucoma were included who underwent combined cataract surgery with the ISTENT inject® and received postoperative automated gonioscopy with the NIDEK Gonioscope GS-1 to visualize the location of the implant. Twenty-four implants of 14 eyes in 11 patients could be visualized. Out of the implants, 14.3% were in the trabecular meshwork, 46.4% were at the border between the trabecular meshwork and scleral spur, 25% were below the trabecular meshwork, and 14.3% of the implants were not detectable in the gonioscopy. In the overall cohort, a statistically significant IOP reduction was found over the 12-month postoperative observation period. Even in three eyes, in each of which both stents were located below the trabecular meshwork, an IOP reduction over 12 months was observed compared to the baseline IOP. In this study, vertical two-dimensional positioning of the ISTENT inject® was performed for the first time using NIDKE GS-1 automated 360° goniophotography. The method is suitable for postoperative visualization, control, and documentation of positioning after ISTENT inject® implantation. Further studies are needed to analyze the correlation between positioning of the ISTENT inject® in the chamber angle and postoperative IOP reduction.
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Affiliation(s)
- Julian Alexander Zimmermann
- Department of Ophthalmology, University of Muenster Medical Center, 48149 Muenster, Germany; (J.J.S.); (R.-L.M.); (P.H.); (V.C.B.)
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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.
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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
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Jabłońska J, Lewczuk K, Rękas MT. Comparison of Safety and Efficacy of Hydrus and iStent Combined with Phacoemulsyfication in Open Angle Glaucoma Patients: 24-Month Follow-Up. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4152. [PMID: 36901162 PMCID: PMC10002347 DOI: 10.3390/ijerph20054152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
The paper presents the results of a 24-month-long observation comparing the effectiveness and safety of two micro-invasive glaucoma surgery (MIGS) devices: Hydrus Microstent and iStent Trabecular Bypass in combination with cataract phacoemulsification in the treatment of open-angle glaucoma. We also analyzed the impact of preoperative factors on achieving surgical success in both surgical methods. The prospective, comparative, non-randomized study included 65 glaucoma surgeries. In 35 patients (53.8%), an iStent implant procedure was performed, while 30 patients (46.2%) underwent a Hydrus implant procedure. The demographic data was similar in both treatment groups. At 24 months after surgery, the mean IOP in the iStent group was 15.9 ± 3.0 mmHg and in the Hydrus group 16.2 ± 1.8 mmHg. The difference between the mean iStent vs Hydrus after two years of treatment was -0.3 (p = 0.683). At the 24 month follow-up, the average change in the number of antiglaucoma medications used was 71.7% in the iStent group and 79.6% in the Hydrus group. The difference in mean percentage change between groups was 7.9% in favor of Hydrus. Patients under the age of 70 may benefit from a greater risk reduction in the Hydrus group (HR = 0.81), while those over the age of 70 may benefit from a risk reduction in the iStent group (HR = 1.33). IOP cases with >18 mmHg before the surgery have a better chance of surgical success with the Hydrus method (HR = 0.28), and with IOP < 18 mmHg in the iStent group (HR = 1.93). Cases with more drugs (≥3 drugs) are more favorable in the Hydrus group (HR = 0.23), while those with a maximum of two drugs have a better prognosis in the iStent group (HR = 2.23). The most common postoperative complication was the presence of erythrocytes in the anterior chamber (AC), found in 40.0% of operated eyes in the Hydrus group. The profile of observed complications and significant improvement in visual acuity allows us to consider both implants as a safe way of treating patients with early or moderate glaucoma and co-existing cataracts.
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Saeed E, Gołaszewska K, Dmuchowska DA, Zalewska R, Konopińska J. The PreserFlo MicroShunt in the Context of Minimally Invasive Glaucoma Surgery: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2904. [PMID: 36833599 PMCID: PMC9957246 DOI: 10.3390/ijerph20042904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 05/13/2023]
Abstract
Recently, the quest for novel glaucoma surgical techniques and devices has been underway. Trabeculectomy remains the gold standard, but it requires the implantation of glaucoma drainage devices and frequent follow-ups, and it also carries a high risk of serious complications. The need for less invasive and safer procedures has led to the development of minimally invasive glaucoma surgery (MIGS), particularly for patients with mild-to-moderate disease. Among them, minimally invasive bleb surgery seems to be effective in classical glaucoma surgery, while maintaining MIGS benefits. The relatively new PreserFlo® MicroShunt (Santen, Osaka, Japan) is registered in Europe. It was released in 2019 for the treatment of patients with early-to-advanced open-angle glaucoma, where intraocular pressure (IOP) remains uncontrolled while on maximum tolerated medication and/or where glaucoma progression warrants surgery. This review focuses on the place of the PreserFlo MicroShunt, characterized by ab externo implantation, among MIGS procedures, discussing its advantages and disadvantages. The mechanisms of action, technical aspects, efficacy, and safety issues are summarized. The surgical technique, its efficacy, and safety profile are described, and directions for future studies are indicated. The PreserFlo MicroShunt ensures a high safety profile, minimal anatomical disruption, meaningful IOP-lowering effect, and ease of use for patients and physicians.
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Affiliation(s)
| | | | | | | | - Joanna Konopińska
- Department of Ophthalmology, Medical University of Bialystok, Kilinskiego 1 STR, 15-089 Bialystok, Poland
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Khalilova TA, Zaitseva AA, Koveshnikov AI. [Micro-invasive glaucoma surgery]. Vestn Oftalmol 2023; 139:90-95. [PMID: 37942602 DOI: 10.17116/oftalma202313905190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Glaucoma is a severe, rapidly progressing disease that in the absence of proper treatment leads to blindness in 20% of patients. According to the World Glaucoma Association, this disease is the most socially significant in modern ophthalmology and requires searching for new and effective methods of treatment. This article presents the results of research and reviews on this issue, considers both conservative therapy and surgical methods of treatment, analyzes in detail modern methods of micro-invasive eye surgery actively used in clinical practice. The article also describes indications for a various types of interventions, as well as the effect achieved by them and the possible complications, and presents the conclusions about the possibility of using these procedures in wide clinical practice.
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Affiliation(s)
- T A Khalilova
- S.N. Fedorov National Medical Research Center "MNTK "Eye microsurgery", Moscow, Russia
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14
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Karaca I, Korot E, Ghoraba H, Regenold J, Mobasserian A, Khan Y, Zaidi MH, Or C, Nguyen QD. Acute iridocyclitis and cystoid macular edema related to kinked Hydrus ® Microstent in advanced glaucoma. Saudi J Ophthalmol 2022; 36:390-393. [PMID: 36618568 PMCID: PMC9811929 DOI: 10.4103/sjopt.sjopt_215_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/30/2021] [Indexed: 01/10/2023] Open
Abstract
A 58-year-old male who underwent cataract extraction with combined intraocular lens and Hydrus® Microstent (Ivantis Inc, Irvine, CA, US) implantation 2 years ago in the right eye (OD) due to advanced glaucoma presented with blurry vision in right eye (OD) for 3 months. The visual acuity was 20/60 and slit-lamp examination indicated mild anterior chamber inflammation with unexposed, functioning tube shunt superotemporally in OD. Optical coherence tomography demonstrated cystoid macular edema (CME) with subretinal fluid. Fluorescein angiography demonstrated petaloid pattern leakage of CME. Gonioscopy revealed a kinked appearance of a Hydrus® Microstent protruding into the anterior chamber and causing iris chafing. Topical ketorolac tromethamine and prednisolone acetate were started. At the 2nd month of follow-up, the anterior chamber was quiet, and the CME resolved completely. Protruded kinked Hydrus® Microstent may lead to acute iridocyclitis and CME through iris chafing, which may be responsive to topical anti-inflammatory drops.
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Affiliation(s)
- Irmak Karaca
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Edward Korot
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Hashem Ghoraba
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Jonathan Regenold
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Azadeh Mobasserian
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Youan Khan
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Moosa H. Zaidi
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Christopher Or
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Quan D. Nguyen
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA,Address for correspondence: Prof. Quan D. Nguyen, Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Palo Alto, California, USA. E-mail:
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15
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Creagmile J, Kim WI, Scouarnec C. Hydrus Microstent implantation with OMNI Surgical System Ab interno canaloplasty for the management of open-angle glaucoma in phakic patients refractory to medical therapy. Am J Ophthalmol Case Rep 2022; 29:101749. [PMID: 36544749 PMCID: PMC9762144 DOI: 10.1016/j.ajoc.2022.101749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Purpose To report a series of 8 phakic eyes of 8 patients with open angle glaucoma with uncontrolled intraocular pressure on maximum tolerable medical therapy receiving Hydrus Microstent implants combined with concomitant OMNI Surgical System ab interno canaloplasty. Observations 8 phakic eyes underwent Hydrus Microstent implantation with OMNI Surgical System ab interno canaloplasty. 2 patients underwent concurrent Kahook Dual Blade goniotomy and 1 patient underwent a concurrent micropulse transscleral cyclophotocoagulation. 6 out of 8 eyes achieved successful intraocular pressure reduction. Only 1 achieved success without the need for additional medical therapy. 1 required Neodymium-doped yttrium aluminum garnet laser to clear iris obstruction of the Hydrus inlet and 1 required selective laser trabeculoplasty for additional intraocular pressure lowering. 2 out of 8 eyes required subsequent incisional glaucoma surgery for unacceptable intraocular pressure levels despite maximum tolerable medical therapy. Conclusions and Importance The Hydrus Microstent combined with OMNI Surgical System ab interno canaloplasty can safely and successfully reduce intraocular pressure in phakic patients with open-angle glaucoma with uncontrolled intraocular pressure on maximum tolerable medical therapy with a low complication rate and rapid visual recovery.
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Affiliation(s)
- Jack Creagmile
- Corresponding author. 1301 U St Nw apt 609, Washington DC, 20009, USA.
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16
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Advances in Excimer Laser Trabeculostomy within the Landscape of Minimally-Invasive Glaucoma Surgery. J Clin Med 2022; 11:jcm11123492. [PMID: 35743562 PMCID: PMC9225025 DOI: 10.3390/jcm11123492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/13/2022] [Accepted: 05/27/2022] [Indexed: 11/29/2022] Open
Abstract
Primary open-angle glaucoma (POAG) is currently treated with a variety of surgical and non-surgical approaches. Minimally invasive glaucoma surgery (MIGS) involves several devices and procedures that lower intraocular pressure (IOP) by increasing aqueous outflow. The first laser-based MIGS procedure, Excimer Laser Trabeculostomy (ELT), has emerged as a safe and effective treatment option. This article reviews ELT within the context of alternative MIGS procedures and focuses on the historical development of ELT, principles and techniques of the ELT procedure, safety and efficacy data, comparison to other outflow procedures, and future augmentations to expand the use of ELT. Performed alone or as an adjunct to cataract surgery, ELT has minimal complications and has shown long-term effectiveness in lowering intraocular pressure in thousands of patients. The non-thermal laser-tissue interactions of excimer lasers minimize peripheral tissue damage and ensure outflow channel patency without requiring foreign body implants or creating blebs. The development of 2D optical and 3D optical coherence tomography (OCT) guidance systems will eliminate the need for a goniolens to visualize angle structures and enable thousands more surgeons to perform ELT in the future.
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17
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Pereira ICF, van de Wijdeven R, Wyss HM, Beckers HJM, den Toonder JMJ. Conventional glaucoma implants and the new MIGS devices: a comprehensive review of current options and future directions. Eye (Lond) 2021; 35:3202-3221. [PMID: 34127842 PMCID: PMC8602385 DOI: 10.1038/s41433-021-01595-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 04/19/2021] [Accepted: 05/05/2021] [Indexed: 02/05/2023] Open
Abstract
Glaucoma is a progressive optic neuropathy that is the second leading cause of preventable blindness worldwide, after cataract formation. A rise in the intraocular pressure (IOP) is considered to be a major risk factor for glaucoma and is associated with an abnormal increase of resistance to aqueous humour outflow from the anterior chamber. Glaucoma drainage devices have been developed to provide an alternative pathway through which aqueous humour can effectively exit the anterior chamber, thereby reducing IOP. These devices include the traditional aqueous shunts with tube-plate design, as well as more recent implants, such as the trabeculectomy-modifying EX-PRESS® implant and the new minimally invasive glaucoma surgery (MIGS) devices. In this review, we will describe each implant in detail, focusing on their efficacy in reducing IOP and safety profile. Additionally, a critical and evidence-based comparison between these implants will be provided. Finally, we will propose potential developments that may help to improve the performance of current devices.
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Affiliation(s)
- Inês C. F. Pereira
- grid.6852.90000 0004 0398 8763Microsystems Research Section, Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands ,grid.6852.90000 0004 0398 8763Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Rosanne van de Wijdeven
- grid.6852.90000 0004 0398 8763Microsystems Research Section, Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands ,grid.6852.90000 0004 0398 8763Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Hans M. Wyss
- grid.6852.90000 0004 0398 8763Microsystems Research Section, Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands ,grid.6852.90000 0004 0398 8763Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Henny J. M. Beckers
- grid.412966.e0000 0004 0480 1382University Eye Clinic Maastricht, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Jaap M. J. den Toonder
- grid.6852.90000 0004 0398 8763Microsystems Research Section, Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands ,grid.6852.90000 0004 0398 8763Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
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18
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Elhusseiny AM, Yannuzzi NA, Khodeiry MM, Lee RK, Smiddy WE. Cost-analysis of Surgical Intraocular Pressure Management in Glaucoma. J Glaucoma 2021; 30:947-951. [PMID: 34506357 DOI: 10.1097/ijg.0000000000001938] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/23/2021] [Indexed: 02/03/2023]
Abstract
PRCIS The multiplicity of treatment options for lowering intraocular pressure (IOP) is both a blessing and a challenge. Some attention to cost-analysis might assist in choosing an optimal therapy, especially in a cost-constrained, international setting. PURPOSE The aim of this study was to quantify and to analyze the relative cost of various glaucoma surgical procedures and selective laser trabeculoplasty surgery per mm Hg IOP reduction ($/mm Hg) since standard cost-utility methods are not well suited to the study of glaucoma which characteristically only claims visual acuity in its end stages. METHODS Published glaucoma treatment studies were reviewed to quantitate the reduction of mean IOP and glaucoma medications for a given treatment modality. A US perspective was adopted, using Medicare allowable costs were used to calculate a newly introduced parameter-cost per mm Hg IOP reduction-at 1 year postoperatively. RESULTS The cost per mm Hg IOP reduction after 1 year of treatment ranged from $190/mm Hg for trabeculectomy to $1376/mm Hg for iStent. For reference, the cost of selective later trabeculoplasty surgery was $121/mm Hg. After the first year, cost/mm Hg ranged from $12 to $61/mm Hg. CONCLUSIONS Conventional glaucoma surgeries and selective laser trabeculoplasty surgery were the most cost-efficient surgical methods to lower IOP compared with the various minimally invasive glaucoma surgeries options. They may be more appropriate management when cost is an important issue.
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Affiliation(s)
- Abdelrahman M Elhusseiny
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Nicolas A Yannuzzi
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mohamed M Khodeiry
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Richard K Lee
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - William E Smiddy
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
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Collar B, Shah J, Cox A, Simon G, Irazoqui P. Parylene-C Microbore Tubing: A Simpler Shunt for Reducing Intraocular Pressure. IEEE Trans Biomed Eng 2021; 69:1264-1272. [PMID: 34714731 DOI: 10.1109/tbme.2021.3123887] [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: 11/06/2022]
Abstract
OBJECTIVE Current minimally-invasive glaucoma surgery (MIGS) devices promise to control elevated levels of intraocular pressure (IOP) while avoiding many of the downsides of traditional glaucoma surgery. However, there remains room for improvement in performance metrics, including drainage efficacy, device longevity, and time to implant, as outlined by benchmarks set forth by the Audacious Goals Initiative. We introduce a better shunt, which achieves similar or improved pre-clinical safety and efficacy outcomes to commercial MIGS devices, while reducing surgical profile and implantation time. METHODS We developed a parylene-based microbore glaucoma drainage device capable of modulating IOP via a minimally-invasive implantation procedure. We surgically implanted microbore tubing in five healthy New Zealand White rabbits and measured IOP levels biweekly using handheld applanation tonometry to assess device efficacy in lowering and maintaining IOP. After 6 weeks, the rabbits were euthanized and eyes were enucleated to evaluate inflammatory and histologic response to a foreign-body implant. RESULTS This device is the only one that fulfills the 10-minute benchmark for implantation time compared to other commercial MIGS devices. In 4 of 5 animals implanted, post-op IOP in the experimental eye dropped by an average of 16.17%. Histopathologic evaluation revealed localized evidence of minor inflammatory reaction and tissue irritation, as well as minimal fibrosis along the tube-tissue interface. CONCLUSION AND SIGNIFICANCE Based on these findings, this device stands as a promising platform to lowering IOP, particularly in patients with mild to moderate glaucoma requiring no need for cataract intervention, without eliciting a severe biological response.
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20
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The role of trabeculectomy in the era of minimally invasive glaucoma surgery. Curr Opin Ophthalmol 2021; 33:112-118. [DOI: 10.1097/icu.0000000000000811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Sood S, Heilenbach N, Sanchez V, Glied S, Chen S, Al-Aswad LA. Cost-Effectiveness Analysis of Minimally Invasive Trabecular Meshwork Stents with Phacoemulsification. Ophthalmol Glaucoma 2021; 5:284-296. [PMID: 34563713 DOI: 10.1016/j.ogla.2021.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the costs and effects of implanting trabecular meshwork bypass stents during cataract surgery from a societal perspective in the United States. DESIGN Cost-utility analysis using Markov models and efficacy/safety data from published pivotal or randomized control trials (RCTs) of devices investigated. PARTICIPANTS Patients aged 65 years and older with mild to moderate primary open-angle glaucoma with or without visually significant cataract. METHODS With the use of Markov models, glaucoma progression through 4 glaucoma states (mild, moderate, advanced, severe/blind) and death were simulated over 35 years. The cohort with cataract entered the model and received cataract surgery with or without device implantation. We included a medication management only reference group to calculate total costs and outcomes for those without cataract. Intraocular pressure (IOP) reductions from RCTs were converted to glaucoma state transition probabilities using visual field (VF) mean deviation (MD) decline rates from the Early Manifest Glaucoma Trial. Progressive thinning of the retinal nerve fiber layer (RNFL) on OCT imaging related to IOP control warranted further intervention, including adding medication, selective laser trabeculoplasty (SLT), or incisional glaucoma surgery. We estimated whole costs at Medicare rates and obtained utility values for glaucoma states from previous studies. Incremental costs per quality-adjusted life-year (QALY) gained were evaluated at a QALY threshold of $50 000. One-way deterministic sensitivity analysis, scenario analyses, and probabilistic sensitivity analyses addressed parameter uncertainty and demonstrated model robustness. MAIN OUTCOME MEASURES Total costs, QALY, and incremental cost-effectiveness ratio (ICER). RESULTS Over 35 years in the base case, the Hydrus (Ivantis, Inc.) implanted with cataract surgery arm cost $48 026.13 and gained 12.26 QALYs. The iStent inject (Glaukos Corp.) implanted with cataract surgery arm cost $49 599.86 and gained 12.21 QALYs. Cataract surgery alone cost $54 409.25 and gained 12.04 QALYs. Initial nonsurgical management cost $57 931.22 and gained 11.74 QALY. The device arms dominated or were cost-effective compared with cataract surgery alone within 5 years and throughout sensitivity analyses. The iStent inject arm was cost-effective in 94.19% of iterations in probabilistic sensitivity analyses, whereas the Hydrus arm was cost-effective in 94.69% of iterations. CONCLUSIONS Implanting the Hydrus Microstent or iStent inject during cataract surgery is cost-effective at a conservative QALY threshold.
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Affiliation(s)
- Shefali Sood
- New York University, Grossman School of Medicine, Department of Ophthalmology, New York, New York; New York University, Robert F. Wagner School of Public Service, New York, New York
| | - Noah Heilenbach
- New York University, Grossman School of Medicine, Department of Ophthalmology, New York, New York
| | - Victor Sanchez
- New York University, Grossman School of Medicine, Department of Ophthalmology, New York, New York
| | - Sherry Glied
- New York University, Robert F. Wagner School of Public Service, New York, New York
| | - Sien Chen
- New York University, Grossman School of Medicine, Department of Ophthalmology, New York, New York
| | - Lama A Al-Aswad
- New York University, Grossman School of Medicine, Department of Ophthalmology, New York, New York; New York University, Grossman School of Medicine, Department of Population Health, New York, New York.
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22
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Mikula E, Holland G, Srass H, Suarez C, Jester JV, Juhasz T. Intraocular Pressure Reduction by Femtosecond Laser Created Trabecular Channels in Perfused Human Anterior Segments. Transl Vis Sci Technol 2021; 10:22. [PMID: 34406341 PMCID: PMC8374973 DOI: 10.1167/tvst.10.9.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose This study investigated the initial feasibility of using femtosecond laser trabeculotomy (FLT) to create open channels through the trabecular meshwork into Schlemm's canal to lower intraocular pressure (IOP) in a perfused anterior segment model. Methods Human anterior segments (12 eyes) were assigned to either treatment (n = 6) or sham treatment (n = 6) groups. Both groups were perfused until a baseline IOP was recorded upon which a direct FLT treatment or a sham treatment was administered. IOP was recorded before and after the treatment. Spectral domain optical coherence tomography and second harmonic generation imaging we used to investigate the FLT channels. Results In the FLT group, there was a significant mean decrease in the IOP of 22% compared with the pre-FLT IOP (7.13 ± 2.95 mm Hg to 5.34 ± 1.62 mm Hg; P < 0.05). In the control group, the post-sham IOP remained relatively unchanged compared with the pre-sham IOP (6.39 ± 3.69 mm Hg to 6.67 ± 4.12 mm Hg). Conclusions The results of this study indicate that FLT treatment can significantly decrease the IOP in a perfusion model and may provide a potential noninvasive treatment option for primary open angle glaucoma. Translational Relevance Investigating the use of femtosecond lasers for photodisrupting the trabecular meshwork can lead to a clinically relevant alternative to current glaucoma procedures.
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Affiliation(s)
- Eric Mikula
- Department of Ophthalmology, University of California, Irvine, Irvine, CA, USA.,ViaLase Inc., Aliso Viejo, CA, USA
| | | | | | | | - James V Jester
- Department of Ophthalmology, University of California, Irvine, Irvine, CA, USA.,Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Tibor Juhasz
- Department of Ophthalmology, University of California, Irvine, Irvine, CA, USA.,ViaLase Inc., Aliso Viejo, CA, USA.,Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
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Elksne E, Mercieca K, Prokosch-Willing V. Canaloplasty with mitomycin C after previous combined cataract surgery and Schlemm's canal microstent implantation. Eur J Ophthalmol 2021; 32:712-716. [PMID: 33706574 DOI: 10.1177/11206721211000275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report on a 56-year-old male with primary open-angle glaucoma who underwent mitomycin C augmented canaloplasty enabling filtration in the right eye after cataract surgery combined with a Schlemm's canal microstent 3 years previously. He showed progressive glaucomatous optic neuropathy and was highly myopic (axial length 32.05 mm, spherical equivalent -18.75 dioptres in the right eye). Augmented canaloplasty was performed uneventfully and 360° catheterisation was achieved followed by the placement of a 10-0 polypropylene suture in Schlemm's canal. Intraocular pressure (IOP) in the first post-operative day was reduced from 19 to 6 mmHg. At 1-month follow-up IOP was 12 mmHg off glaucoma medications. The presence of a minimally invasive glaucoma surgery (MIGS) device did not hinder successful catheterisation of Schlemm's canal. Significant reduction of IOP was obtained in the early post-surgical period. No intra-operative complications were registered and only transient hyphema in early post-operative period was reported. This augmented canaloplasty could be an effective alternative to trabeculectomy even after Schlemm's canal microstent implantation.
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Affiliation(s)
- Eva Elksne
- Department of Ophthalmology, Riga Stradins University, Riga, Latvia
| | - Karl Mercieca
- Department of Ophthalmology, Manchester University Hospitals NHS Trust, Manchester Royal Eye Hospital, Manchester, UK
| | - Verena Prokosch-Willing
- Department of Ophthalmology, University Medical Center of Johannes Gutenberg University Mainz, Mainz, Germany
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Abstract
PURPOSE OF REVIEW This article reviews the safety profile of trabecular meshwork/Schlemm's canal-based, subconjunctival, and suprachoroidal minimally invasive glaucoma surgery (MIGS). RECENT FINDINGS Prospective randomized clinical trials and metaanalyses published during the 2019-2020 review period provided important data regarding the safety profile of trabecular meshwork/Schlemm's canal-based MIGS. Transient hyphema and intraocular pressure spikes are among the most common complications associated with this category of MIGS, but more serious adverse events such as cyclodialysis cleft formation may also occur. Trabecular bypass microstents and the intracanalicular scaffold are further subject to device-related complications, including malposition and obstruction. Recent case reports and retrospective case series have further characterized the safety profile of the subconjunctival gel stent, with adverse events ranging from self-limited hypotony to visually devastating endophthalmitis and suprachoroidal hemorrhage. Five-year results of the COMPASS XT study demonstrated significantly greater endothelial cell loss in patients randomized to receive CyPass Micro-Stent (Alcon Laboratories, Fort Worth, TX, USA) in combination with cataract surgery versus those who underwent cataract surgery alone, and ultimately led to a Food and Drug Administration Class I recall of the device. SUMMARY Trabecular meshwork/Schlemm's canal-based procedures are generally among the safest MIGS, with mostly self-limited and nonvision-threatening complications. Subconjunctival gel stent insertion is associated with both bleb-related and stent-specific adverse events, which are similar to those observed with trabeculectomy and tube shunt surgery, respectively. Removal of the CyPass Micro-Stent from the market underscores the need for high-quality, long-term safety data regarding MIGS.
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25
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Laroche D, Nkrumah G, Ng C. Real-world efficacy of the Hydrus microstent in Black and Afro-Latinx patients with glaucoma: a retrospective study. Ther Adv Ophthalmol 2020; 12:2515841420964311. [PMID: 33150299 PMCID: PMC7580146 DOI: 10.1177/2515841420964311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/04/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose: The purpose was to determine the real-world efficacy of phacoemulsification cataract surgery and Hydrus microstent in Black and Afro-Latinx patients with glaucoma. Methods: A retrospective noncomparative single-center study of 76 Black and Afro-Latinx patients with glaucoma who underwent phacoemulsification cataract surgery and Hydrus microstent placement for treatment of glaucoma at single practice. Investigated parameters were intraocular pressure (IOP), number of medications, mean deviation on visual field test, and visual acuity. Patients were also subgrouped into mild, moderate, and advance glaucoma for further analysis. Results: We reviewed a total of 76 patients who had 6 months of follow up in the study. The mean number of medications decreased significantly from 2.6 ± 1.5 preoperatively to 0.72 ± 1.4 in 6 months (p < 0.0010), while IOP decreased from 14.7 ± 3.7 to 13.9 ± 4.3 (p = 0.25). At 6 months, 55 patients (74%) of all patients were medication free (n = 27, 84.4% mild glaucoma; n = 17, 70.8% moderate glaucoma; n = 10, 50% advance glaucoma). There was significant improvement in visual acuity (p < 0.00010) and stabilization of mean deviation on visual field test (baseline −9.2; 6 months −9.1; p = 0.22). The most common adverse effect was a transient IOP spike and transient corneal edema (n = 6, 7.9%; n = 6, 7.9%, respectively) with spontaneous resolution in all cases. No sight-threatening complications were reported at 6 months. Conclusion/clinical relevance: This 6-month retrospective study demonstrated the efficacy of phacoemulsification cataract surgery and Hydrus microstent in reducing the medication burden while maintaining lower IOP in Black and Afro-Latinx patients with glaucoma.
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Affiliation(s)
- Daniel Laroche
- Advanced Eyecare of New York, 49 West 127th Street, New York, NY 10027, USA
| | - Gideon Nkrumah
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chester Ng
- Advanced Eyecare of New York, New York, NY, USA
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