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Ayub G, De Francesco T, Costa VP. Bent ab interno needle goniotomy versus gonioscopy-assisted transluminal trabeculotomy in primary open-angle glaucoma: study protocol of a randomized clinical trial. Trials 2024; 25:300. [PMID: 38702810 PMCID: PMC11069271 DOI: 10.1186/s13063-024-08134-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Minimally invasive glaucoma surgery (MIGS) is a new class of surgeries, which combines moderate to high success rates and a high safety profile. Bent Ab interno Needle Goniotomy (BANG) and Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) are two low-cost MIGS procedures that communicate the anterior chamber to Schlemm's canal. Most of the available publications on MIGS are either case series or retrospective studies, with different study protocols. The aim of this manuscript is to describe a randomized clinical trial (RCT) protocol to compare the long-term intraocular pressure (IOP) control and the safety of both procedures in eyes with primary open-angle glaucoma. METHODS This is a parallel, double-arm, single-masked RCT that includes pseudophakic primary open-angle glaucoma (POAG) eyes. After inclusion criteria, medications will be washed out to verify baseline IOP before surgery. Patients will be randomized to BANG or GATT using a sealed envelope. Follow-up visits will be 1, 7, 15, 30, 60, 90, 180, 330 and 360 days after surgery. On PO330, a new medication washout will be done. The main outcome is the IOP reduction following the procedures. Complimentary evaluation of functional and structural parameters, safety, and quality of life will be done after 30, 90, 180, and 360 days. DISCUSSION Our study was designed to compare the long-term efficacy and safety of two low-cost MIGS. Most of the published studies on this subject are case series or retrospective cohorts, with different study protocols, which included different types and severities of glaucomas, combined with cataract extraction. Our study only included mild to moderate POAG eyes, with previous successful cataract extraction. Moreover, it provides a standardized protocol that could be replicated in future studies investigating various types of MIGS. This would allow comparison between different techniques in terms of efficacy, safety, and patients' quality of life. TRIAL REGISTRATION Retrospectively registered at the Registro Brasileiro de Ensaios Clínicos (ReBEC) platform RBR-268ms5y . Registered on July 29, 2023. The study was approved by the Ethics Committee of the University of Campinas, Brazil.
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Affiliation(s)
- Gabriel Ayub
- Department of Ophthalmology, University of Campinas, 251 Vital Brazil St., Campinas, São Paulo, 13083-888, Brazil.
| | - Ticiana De Francesco
- Department of Ophthalmology, University of Campinas, 251 Vital Brazil St., Campinas, São Paulo, 13083-888, Brazil
| | - Vital Paulino Costa
- Department of Ophthalmology, University of Campinas, 251 Vital Brazil St., Campinas, São Paulo, 13083-888, Brazil
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De Francesco T, Mikula E, Lummis W, Sangalang N, Ahmed IIK. Intraocular Pressure While Using Gonioscopy, SLT, and Laser Iridotomy Lenses: An Ex Vivo Study. Invest Ophthalmol Vis Sci 2024; 65:13. [PMID: 38713484 PMCID: PMC11086705 DOI: 10.1167/iovs.65.5.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/20/2024] [Indexed: 05/08/2024] Open
Abstract
Purpose The purpose of this study was to measure intraocular pressure (IOP) elevation while applying standard gonioscopy, selective laser trabeculoplasty (SLT), and laser iridotomy procedural lenses. Methods Twelve cadaver eyes were mounted to a custom apparatus and cannulated with a pressure transducer which measured IOP. The apparatus was mounted to a load cell which measured the force on the eye. Six ophthalmologists performed simulated gonioscopy (Sussman 4 mirror lens), SLT (Latina lens), and laser iridotomy (Abraham lens) while a computer recorded IOP (mm Hg) and force (grams). The main outcome measures were IOP and force applied to the eye globe during ophthalmic diagnostics and procedures. Results The average IOP's during gonioscopy, SLT, and laser iridotomy were 43.2 ± 16.9 mm Hg, 39.8 ± 9.9 mm Hg, and 42.7 ± 12.6 mm Hg, respectively. The mean force on the eye for the Sussman, Latina, and Abraham lens was 40.3 ± 26.4 grams, 66.7 ± 29.8 grams, and 65.5 ± 35.9 grams, respectively. The average force applied to the eye by the Sussman lens was significantly lower than both the Latina lens (P = 0.0008) and the Abraham lens (P = 0.001). During gonioscopy indentation, IOP elevated on average to 80.5 ± 22.6 mm Hg. During simulated laser iridotomy tamponade, IOP elevated on average to 82.3 ± 27.2 mm Hg. Conclusions In cadaver eyes, the use of standard ophthalmic procedural lenses elevated IOP by approximately 20 mm Hg above baseline.
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Affiliation(s)
- Ticiana De Francesco
- John Moran Eye Center, University of Utah, Salt Lake City, Utah, United States
- Clinica de Olhos De Francesco, Fortaleza, Brazil
- Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil
| | - Eric Mikula
- ViaLase Inc., Aliso Viejo, California, United States
- Department of Ophthalmology, University of California, Irvine, Irvine, California, United States
| | - Wes Lummis
- ViaLase Inc., Aliso Viejo, California, United States
| | | | - Iqbal Ike K. Ahmed
- John Moran Eye Center, University of Utah, Salt Lake City, Utah, United States
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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Ahmed IIK, Sheybani A, De Francesco T, Samuelson TW. Corneal endothelial safety profile in minimally invasive glaucoma surgery. J Cataract Refract Surg 2024; 50:369-377. [PMID: 37988037 PMCID: PMC10959532 DOI: 10.1097/j.jcrs.0000000000001365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/08/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE To compare 5-year corneal endothelial safety of 3 minimally invasive glaucoma surgery (MIGS) devices (iStent inject , Hydrus Microstent, CyPass Micro-Stent). SETTING U.S. multicenter trials. DESIGN Post hoc 5-year analysis from prospective randomized single-masked pivotal trials. METHODS Mild to moderate open-angle glaucoma subjects received a MIGS implant with phacoemulsification (implant + phaco) or phaco alone (control). In addition, 5-year end points comparing the implant and control groups included proportion of eyes with significant endothelial cell loss (ECL) (>30% or ≥30% vs baseline) and mean endothelial cell density (ECD). RESULTS Comparable proportions of eyes in the iStent inject + phaco and control groups had significant 60-month ECL (9.4% vs 6.3%, respectively, diff: 3.2%, 95% CI, -5.0% to 11.3%, P = .77). Hydrus (20.8% vs 10.6%, diff: 10.2%, 95% CI, 3.2% to 17.2%, P = .01) and CyPass (27.2% vs 10.0%, diff: 17.2%, 95% CI, 5.6% to 28.7%, P = .02) had more eyes with ECL vs controls (iStent inject 1.49X, Hydrus 1.96X, CyPass 2.72X vs controls). Mean ECD over 60 months for iStent inject was indistinguishable vs control, whereas greater ECL was observed primarily 3 months postoperative (Hydrus) or accelerated after 2 years (CyPass). No iStent inject or Hydrus subjects developed persistent corneal edema, whereas 7 CyPass-implanted eyes developed ECL-related complications. CONCLUSIONS Through 5 years postoperative, there were no differences in proportion of eyes with significant ECL or mean ECD between the iStent inject and control groups. There was greater 5-year ECL and lower ECD in the Hydrus and CyPass groups vs controls. The Hydrus ECL rate mirrored control after 3 months; the CyPass ECL rate accelerated vs control.
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Affiliation(s)
- Iqbal Ike K. Ahmed
- From the John A. Moran Eye Center, University of Utah, Salt Lake City, Utah (Ahmed, Sheybani, De Francesco); Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada (Ahmed); Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri (Sheybani); Clinica de Olhos de Francesco, Fortaleza, Brazil (De Francesco); Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil (De Francesco); Minnesota Eye Consultants, University of Minnesota, Minneapolis, Minnesota (Samuelson)
| | - Arsham Sheybani
- From the John A. Moran Eye Center, University of Utah, Salt Lake City, Utah (Ahmed, Sheybani, De Francesco); Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada (Ahmed); Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri (Sheybani); Clinica de Olhos de Francesco, Fortaleza, Brazil (De Francesco); Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil (De Francesco); Minnesota Eye Consultants, University of Minnesota, Minneapolis, Minnesota (Samuelson)
| | - Ticiana De Francesco
- From the John A. Moran Eye Center, University of Utah, Salt Lake City, Utah (Ahmed, Sheybani, De Francesco); Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada (Ahmed); Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri (Sheybani); Clinica de Olhos de Francesco, Fortaleza, Brazil (De Francesco); Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil (De Francesco); Minnesota Eye Consultants, University of Minnesota, Minneapolis, Minnesota (Samuelson)
| | - Thomas W. Samuelson
- From the John A. Moran Eye Center, University of Utah, Salt Lake City, Utah (Ahmed, Sheybani, De Francesco); Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada (Ahmed); Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri (Sheybani); Clinica de Olhos de Francesco, Fortaleza, Brazil (De Francesco); Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil (De Francesco); Minnesota Eye Consultants, University of Minnesota, Minneapolis, Minnesota (Samuelson)
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Samuelson TW, De Francesco T, Ahmed IIK, Gedde SJ, Paranjpe VR, Singh K, Brubaker JW, Grover DS, Fellman RL, Zhang AD, Barton K. Difficult decisions, filtration surgery, and the heartbreak of the numerator. J Cataract Refract Surg 2024; 50:97-103. [PMID: 38133650 DOI: 10.1097/j.jcrs.0000000000001366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
A 70-year-old man had progressive and severe glaucoma in each eye. He was intolerant to dorzolamide, brimonidine, and netarsudil. Each eye had prior selective laser trabeculoplasty (SLT) as well as phacoemulsification plus minimally invasive glaucoma surgery (MIGS) 6 years before current presentation (iStent [Glaukos Corp.] in the right eye and Cypass [Alcon Laboratories, Inc.] in the left eye). Postoperative acuities were 20/20 and 20/25 in the right and left eyes, respectively. When his left eye progressed with loss of central acuity despite peak intraocular pressures (IOPs) in the middle to upper teens, neuro-ophthalmology consultation was obtained (Figure 1JOURNAL/jcrs/04.03/02158034-202401000-00017/figure1/v/2023-12-22T124801Z/r/image-tiff). That workup included magnetic resonance imaging scan and hematologic screening, but all results were negative, and the neuro-ophthalmic consultant concluded that the vision loss was likely on the basis of glaucoma. Accordingly, a trabeculectomy was performed in the left eye achieving consistent IOPs in the range of 7 to 10 mm Hg without medications, rending the left eye stable since the filtration surgery nearly 2 years previously. The right eye continued to progress both subjectively and objectively, and on recent examination, the IOP measured 20 mm Hg and 09 mm Hg in the right and left eyes, respectively (Figure 2JOURNAL/jcrs/04.03/02158034-202401000-00017/figure2/v/2023-12-22T124801Z/r/image-tiff). Medications included timolol and latanoprostene bunod in the right eye only. Central corneal thickness was 526 μm and 527 μm in the right and left eyes, respectively. The visual acuity now measured 20/25 in the right eye and 20/250 in the left eye. The vertical cup-to-disc ratio was 0.9 in the right eye and 1.0 in the left eye. Gonioscopy revealed a wide open angle in each eye with a patent sclerostomy superiorly in the left eye. The conjunctiva and sclera were healthy and without scarring in the right eye. The bleb in the left eye was diffuse, lightly vascularized, and seidel negative. Axial length (AL) was 26.88 μm in the right eye and 26.77 μm in the left eye. The patient was in good health and was not anticoagulated. An extensive discussion ensued about the best course of action for the right eye. How would you proceed in managing definite progression in this individual's right eye, knowing that he had lost fixation in his left eye at similar pressures?
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Nagy ZZ, Kranitz K, Ahmed IIK, De Francesco T, Mikula E, Juhasz T. First-in-Human Safety Study of Femtosecond Laser Image-Guided Trabeculotomy for Glaucoma Treatment: 24-month Outcomes. Ophthalmol Sci 2023; 3:100313. [PMID: 37363134 PMCID: PMC10285639 DOI: 10.1016/j.xops.2023.100313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 06/28/2023]
Abstract
Purpose Pilot study to evaluate adverse events and intraocular pressure (IOP)-lowering of a novel, noninvasive glaucoma procedure, femtosecond laser, image-guided, high-precision trabeculotomy (FLIGHT). Design Prospective, nonrandomized, single-center, interventional, single-arm clinical trial. Participants Eighteen eyes from 12 patients with open-angle glaucoma. Methods Eighteen eyes from 12 patients underwent FLIGHT, creating a single channel measuring 500-μm wide by 200-μm high through the trabecular meshwork and into Schlemm's canal. Adverse events, IOP, and other parameters were evaluated out to 24 months. Main Outcome Measures Outcomes were the rates and types of adverse events and the rate of postprocedure best-corrected visual acuity loss (≥ 2 lines) compared with baseline. Efficacy outcomes were reduction in mean intraocular pressure (IOP) with respect to baseline and the percentage of eyes with a ≥ 20% reduction in IOP. Results Eighteen eyes from 12 patients were enrolled in the study; 11 patients (17 eyes) returned at 24 months. There were no serious adverse events related to the laser treatment. Well-defined channels were clearly visible at 24 months by gonioscopy and anterior segment OCT, with no evidence of closure. At 24 months, the mean IOP was reduced by 34.6% from 22.3 ± 5.5 to 14.5 ± 2.6 mmHg (P < 5e-5), with an average of 2.0 ± 1.2 hypotensive medications compared with 2.2 ± 1.1 at baseline (P = 0.22). Fourteen out of the 17 study eyes (82.3%) achieved a ≥ 20% reduction in IOP at 24 months when compared with baseline. Conclusion The FLIGHT system demonstrated a favorable safety profile in this initial pilot study, with no device-related serious adverse events. The channels appeared patent at 24 months, indicating medium-term durability. Financial Disclosures Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Zoltan Z. Nagy
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Kinga Kranitz
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Iqbal Ike K. Ahmed
- John Moran Eye Center, University of Utah, Salt Lake City, Utah
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Ticiana De Francesco
- John Moran Eye Center, University of Utah, Salt Lake City, Utah
- Clinica de Olhos De Francesco, Fortaleza, Brazil & Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil
| | - Eric Mikula
- ViaLase Inc., Aliso Viejo, California
- Department of Ophthalmology, University of California, Irvine, Irvine, Califorania
| | - Tibor Juhasz
- ViaLase Inc., Aliso Viejo, California
- Department of Ophthalmology, University of California, Irvine, Irvine, Califorania
- Department of Biomedical Engineering, University of California, Irvine, Irvine, California
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Hussein IM, De Francesco T, Ahmed IIK. Intermediate Outcomes of the Novel 63-μm Gelatin Microstent versus the Conventional 45-μm Gelatin Microstent. Ophthalmol Glaucoma 2023; 6:580-591. [PMID: 37169174 DOI: 10.1016/j.ogla.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/24/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE To determine intermediate intraocular pressure (IOP)-lowering and adverse event profile of the 63-μm gelatin microstent (Xen63) with mitomycin C (MMC) compared with the 45-μm gelatin microstent (Xen45) with MMC. DESIGN Single center, consecutive, retrospective cohort study. PARTICIPANTS Eighty-four glaucomatous eyes (42 63-μm gelatin microstent and 42 45-μm gelatin microstent) with or without previous subconjunctival glaucoma surgery. METHODS Consecutive eyes that underwent 63-μm gelatin microstent implantation with MMC from February 2020 to June 2021 were compared with eyes that underwent 45-μm gelatin microstent implantation with MMC. Standalone and combined cases with phacoemulsification were included. MAIN OUTCOME MEASURES Primary outcome was the hazard ratio of failure of 45-μm gelatin microstent vs. 63-μm gelatin microstent eyes at 12 months, with failure defined as 2 consecutive IOPs, (1) >17 mmHg, (2) <6 mmHg with 2 lines of vision loss, or (3) <20% reduction from baseline IOP, without (complete) or with (qualified) glaucoma medications. Secondary outcomes included IOP thresholds of 14 mmHg and 21 mmHg, postoperative IOP, medications, adverse events, interventions, and reoperations. RESULTS The complete success rate was higher in the 63-μm gelatin microstent group (59.5% vs. 28.6%, P = 0.009) at the primary IOP threshold of 6 to 17 mmHg but did not differ significantly for qualified success (66.7% vs. 45.2%, P = 0.08). The crude hazard ratio of failure of 45-μm gelatin microstent relative to 63-μm gelatin microstent was 2.28 (95% confidence interval [CI], 1.21-4.32), and the adjusted hazard ratio was 7.90 (95% CI, 2.12-29.43). 63-μm gelatin microstent eyes had significantly lower mean IOP (12.7 ± 4.8 vs. 15.5 ± 5.1 mmHg, P = 0.001) and fewer medication classes (0.6 ± 1.1 vs. 1.7 ± 1.6 medications, P = 0.0005), with the degree of reduction in IOP and medication count being significantly greater in 63-μm gelatin microstent eyes. There were 28 and 21 distinct interventions in 63-μm gelatin microstent and 45-μm gelatin microstent eyes respectively, with 11.9% of eyes undergoing needling in each group. There were 34 and 19 distinct adverse events, in 63-μm gelatin microstent and 45-μm gelatin microstent eyes, respectively, most of which were early and transient. Nine Xen63 eyes (21.4%) and 6 45-μm gelatin microstent eyes (14.3%) underwent reoperation. CONCLUSIONS 63-μm gelatin microstent resulted in higher surgical success rates and fewer medications compared with 45-μm gelatin microstent. This was tempered by more postoperative interventions and adverse events, although most were transient. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Isra M Hussein
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Prism Eye Institute, Mississauga, Canada.
| | - Ticiana De Francesco
- Hospital de Olhos Leiria de Andrade, Fortaleza, Ceara, Brazil; Clinica de Olhos De Francesco, Fortaleza, Ceara, Brazil; John A. Moran Eye Center, University of Utah, Salt Lake City, Utah
| | - Iqbal Ike K Ahmed
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Prism Eye Institute, Mississauga, Canada; John A. Moran Eye Center, University of Utah, Salt Lake City, Utah
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Schlenker MB, Armstrong JJ, De Francesco T, Ahmed IIK. All Consecutive Ab Externo SIBS Microshunt Implantations With Mitomycin C: One-Year Outcomes and Risk Factors for Failure. Am J Ophthalmol 2023; 255:125-140. [PMID: 37352909 DOI: 10.1016/j.ajo.2023.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/28/2023] [Accepted: 06/07/2023] [Indexed: 06/25/2023]
Abstract
PURPOSE To present the effectiveness, risk factors for surgical failure, and adverse events over 12 months in a consecutive diverse cohort of glaucoma patients who underwent solo or combined ab externo SIBS microshunt with mitomycin C (MMC) with or without previous subconjunctival surgery. DESIGN Retrospective, consecutive, interventional case series. METHODS Consecutive glaucomatous eyes on maximally tolerated medical therapy received ab externo SIBS microshunt with MMC implantation as a solo or combined procedure with phacoemulsification from July 2015 to January 2020. The primary outcome was the proportion of eyes at 12-months with the following: (1) no 2 consecutive intraocular pressures (IOPs) >17 mm Hg or clinical hypotony, without (complete success) or with (qualified success) glaucoma medications; and (2) ≥20% reduction from baseline IOP. Secondary outcomes included upper IOP thresholds of 14 and 21 mm Hg with and without a 20% IOP reduction from baseline, median IOP, medications, risk factors for failure, postoperative interventions, complications, and reoperations. RESULTS A total of 436 eyes underwent surgery; 86 (20%) combined with phacoemulsification, 127 (29%) in eyes with refractory glaucoma, and 234 (51%) stand-alone procedures in non-refractory eyes. Complete success (6-17 mm Hg with no medications) was achieved in 64.0% of combined eyes, 58.1% of refractory eyes, and 74.8% of stand-alone non-refractory eyes; and qualified success rates (6-17 mm Hg with medications) were 90.7%, 84.7%, and 92.4% of eyes, respectively. At 12 months, 67% of eyes were medication free. Significant risk factors for failure included combined procedures in refractory eyes (hazard ratio [HR] = 3.2; 95% CI = 1.4-7.4), receiving <0.4 mg/mL of MMC (HR = 2.2; 95% CI = 1.6-3.1), refractory eyes (HR = 1.7; 95% CI = 1.2-2.5), combined procedures (HR = 1.6; 95% CI = 1.0-2.5), and each additional baseline medication class (HR = 1.3; 95% CI = 1.1-1.5). Postoperative complications occurred in 31% of eyes, and more often in those receiving ≥0.4 mg/mL MMC (odds ratio [OR] = 2.2, 95% CI 1.2-3.8). Needling occurred in 12% of eyes, with significantly higher frequency in refractory eyes (23%) and combined procedures (13%) compared to stand-alone (7%; P < .001). Revisions and reoperations occurred in 4% and 1.4% of eyes, respectively. CONCLUSIONS The 1-year follow-up data from this large and diverse cohort support promising rates of qualified and complete surgical success with decreased medication burden and few postoperative complications and interventions. Combined phacoemulsification, refractory glaucoma, and receiving <0.4mg/mL MMC were associated with reduced surgical success rates.
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Affiliation(s)
- Matthew B Schlenker
- From the Department of Ophthalmology and Vision Sciences (M.B.S., J.J.A.,I.I.K.A.), University of Toronto, Toronto, Ontario, Canada; Prism Eye Institute (M.B.S., J.J.A., I.I.K.A.), Mississauga, Ontario, Canada; John A. Moran Eye Center (M.B.S., T.D.F., I.I.K.A.), University of Utah, Salt Lake City, Utah, USA.
| | - James J Armstrong
- From the Department of Ophthalmology and Vision Sciences (M.B.S., J.J.A.,I.I.K.A.), University of Toronto, Toronto, Ontario, Canada; Prism Eye Institute (M.B.S., J.J.A., I.I.K.A.), Mississauga, Ontario, Canada
| | - Ticiana De Francesco
- John A. Moran Eye Center (M.B.S., T.D.F., I.I.K.A.), University of Utah, Salt Lake City, Utah, USA; Hospital de Olhos Leiria de Andrade (T.D.F.), Fortaleza, Ceará, Brazil
| | - Iqbal Ike K Ahmed
- From the Department of Ophthalmology and Vision Sciences (M.B.S., J.J.A.,I.I.K.A.), University of Toronto, Toronto, Ontario, Canada; Prism Eye Institute (M.B.S., J.J.A., I.I.K.A.), Mississauga, Ontario, Canada; John A. Moran Eye Center (M.B.S., T.D.F., I.I.K.A.), University of Utah, Salt Lake City, Utah, USA
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Armstrong JJ, De Francesco T, Ma J, Schlenker MB, Ahmed IIK. Ab Externo SIBS Microshunt with Mitomycin C for Open-Angle Glaucoma: Three-Year Results as a Primary Surgical Intervention. Ophthalmol Glaucoma 2023; 6:480-492. [PMID: 37044278 DOI: 10.1016/j.ogla.2023.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE To determine the effectiveness, risk factors for surgical failure, and adverse events in a large cohort of patients receiving stand-alone ab externo poly(styrene-block-isobutylene-block-styrene) (SIBS) microshunt implantation with mitomycin C (MMC) over 3 years of follow-up. DESIGN Retrospective, interventional case series. PARTICIPANTS Glaucomatous eyes on maximally tolerated medical therapy with no previous subconjunctival glaucoma surgery. METHODS Records of eyes that underwent ab externo SIBS microshunt with MMC between July 2015 and November 2017 were reviewed. Data from all follow-up visits were utilized and included intraocular pressure (IOP), medication use, postoperative interventions, complications, and reoperations. MAIN OUTCOME MEASURES The primary outcome was proportion of eyes at 3 years with (1) no 2 consecutive IOPs > 17 mmHg (or < 6 mmHg with > 2 lines of vision loss from baseline); (2) ≥ 20% reduction from baseline IOP; and (3) using no glaucoma medications (complete success). Secondary outcomes included 14 and 21 mmHg upper IOP thresholds with and without ≥ 20% IOP reduction from baseline, qualified success (with glaucoma medications), risk factors for failure, median IOP/medications, postoperative interventions, complications, and reoperations. RESULTS One hundred fifty-two eyes from 135 patients were included. Complete and qualified success was achieved in 55.6% and 74.8% of eyes, respectively. Time to first glaucoma medication use was a median of 16.9 (interquartile range [IQR], 12.1-34.1) months; however, 59.4% of eyes remained medication free at 3 years. Significant risk factors for failure included receiving < 0.4 mg/ml of MMC (adjusted hazard ratio [HR], 2.42; 95% confidence interval [CI], 1.44-4.05) and baseline IOP < 21 mmHg (adjusted HR, 1.79; 95% CI, 1.03-3.13). The most common complications were choroidal detachment, hyphema, and anterior chamber shallowing, occurring in 7%, 5%, and 5% of eyes, respectively. The needling rate was 15.1%, with significantly higher frequency for baseline IOP > 21 mmHg (HR, 3.21; 95% CI, 1.38-7.48). Revisions occurred in 7% of eyes and reoperations in 2.6%. Eyes receiving < 0.4 mg/ml of MMC underwent more revisions (odds ratio, 4.9; 95% CI, 1.3-18.3). CONCLUSIONS Three-year follow-up data from this large cohort continues to support promising rates of qualified and complete success, with decreased medication burden postoperatively and few postoperative complications and interventions. Comparisons to other filtering surgeries will further facilitate integration of the SIBS microshunt into the surgical treatment paradigm. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- James J Armstrong
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Prism Eye Institute, Mississauga, Canada
| | | | - Jenny Ma
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Matthew B Schlenker
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Prism Eye Institute, Mississauga, Canada.
| | - Iqbal Ike K Ahmed
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Prism Eye Institute, Mississauga, Canada; John A. Moran Eye Center, University of Utah, Salt Lake City, Utah
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De Francesco T, Ahmed IIK. Surgical Augmentation of the Suprachoroidal Space: A Novel Material and Implant. Clin Ophthalmol 2023; 17:2483-2492. [PMID: 37637970 PMCID: PMC10456019 DOI: 10.2147/opth.s409958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/01/2023] [Indexed: 08/29/2023] Open
Abstract
Microinvasive glaucoma surgery (MIGS) has emerged as a safer method to lower IOP with minimal impact on patient quality of life compared to traditional glaucoma surgeries. With the advent of MIGS, there has been a renewed interest in exploring the suprachoroidal route. MIGS targeting the suprachoroidal space allow for a safe reduction in IOP while sparing conjunctiva and allowing "blebless" surgery, thus avoiding bleb-related complications. This article aims to review the rationale behind the suprachoroidal MIGS procedures and the literature surrounding the efficacy and safety of a novel suprachoroidal device, the MINIject. The available literature has shown promising IOP lowering results with the MINIject implant with a potentially safer and less invasive approach than traditional glaucoma surgeries.
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Affiliation(s)
- Ticiana De Francesco
- Clinica de Olhos De Francesco, Fortaleza, Brazil
- Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Iqbal Ike K Ahmed
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
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Huang MJ, Samuelson TW, De Francesco T, Levin A, Sieck E, Gazzard G, Porter M, Gallardo M, Chang RT, Liu WW, Chaya C, Gulati S, Shah M. Managing primary open-angle glaucoma in the setting of suboptimal surgical outcomes in the fellow eye. J Cataract Refract Surg 2023; 49:764. [PMID: 37390324 PMCID: PMC10688560 DOI: 10.1097/j.jcrs.0000000000001221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
A 62-year-old woman with mild myopia presented to her local optometrist for a routine examination and was found to have intraocular pressure (IOP) of 30 mm Hg in both eyes and cupped nerves. She had a family history of glaucoma in her father. She was started on latanoprost in both eyes and was referred for a glaucoma evaluation. On initial evaluation, her IOP was 25 mm Hg in the right eye and 26 mm Hg in the left eye. Central corneal thickness measured 592 µm in the right eye and 581 µm in the left eye. Her angles were open to gonioscopy without any peripheral anterior synechia. She had 1+ nuclear sclerosis with a corrected distance visual acuity (CDVA) of 20/25 in the right eye and 20/30- in the left eye and uncorrected near visual acuity of J1+ in each eye. Her nerves were 0.85 mm in the right eye and 0.75 mm in the left eye. Optical coherence tomography (OCT) showed retinal nerve fiber layer thinning and a dense superior arcuate scotoma into fixation in her right eye, and superior and inferior arcuate scotomas in her left eye (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202307000-00019/figure1/v/2023-06-26T195222Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202307000-00019/figure2/v/2023-06-26T195222Z/r/image-tiff, Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A882 and http://links.lww.com/JRS/A883). She was successively trialed on fixed combination brimonidine-timolol, dorzolamide, and netarsudil, in addition to her latanoprost, but her IOP remained in the mid- to upper 20s in both eyes. The addition of acetazolamide lowered the pressure to 19 mm Hg in both eyes, but she tolerated it poorly. Methazolamide was also attempted with similar side effects. We elected to perform left eye cataract surgery combined with 360-degree viscocanaloplasty and insertion of a Hydrus microstent (Alcon Laboratories, Inc.). Surgery was uncomplicated with IOP of 16 mm Hg on postoperative day 1 with no glaucoma medications. However, by postoperative week 3, IOP returned to 27 mm Hg, and despite restarting latanoprost-netarsudil and finishing her steroid taper, IOP remained at 27 mm Hg by postoperative week 6. Brimonidine-timolol was added back to her left eye regimen and at postoperative week 8, IOP had elevated to 45 mm Hg. Maximizing her therapy with the addition of topical dorzolamide and oral methazolamide brought her IOP back down to 30 mm Hg. At that point, the decision was made to proceed with trabeculectomy of the left eye. The trabeculectomy was uneventful. However, postoperative attempts to augment filtration were rendered less successful by extremely thick Tenon layer. At her most recent follow-up the pressure in the left eye was mid-teens with brimonidine-timolol and dorzolamide. Her right eye IOP is in the upper 20s on maximum topical therapy. Knowing her postoperative course in the left eye, how would you manage the right eye? In addition to currently available options, would you consider a supraciliary shunt such as the MINIject (iSTAR) if such a device were U.S. Food and Drug Administration (FDA)-approved?
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Prata TS, Daga FB, Francesco TD, Ahmed IIK. 15 years of minimally-invasive glaucoma surgeries (MIGS) experience and data: a rationale for optimal clinical decision-making. Arq Bras Oftalmol 2023; 86:5-8. [PMID: 37466495 DOI: 10.5935/0004-2749.2023-1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 07/20/2023] Open
Affiliation(s)
- Tiago Santos Prata
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida, USA
- Glaucoma Sector, HMO, Opty Group, Brazil
| | - Fabio Bernardi Daga
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Iqbal Ike K Ahmed
- University of Toronto, Toronto, Ontario, Canada
- John Moran Eye Center, University of Utah, Salt Lake City USA
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Ahmed IIK, Sheybani A, De Francesco T, Lass JH, Benetz BA, Samuelson TW, Usner D, Katz LJ. Long-Term Endothelial Safety Profile With iStent Inject in Patients With Open-Angle Glaucoma. Am J Ophthalmol 2023; 252:17-25. [PMID: 36868339 DOI: 10.1016/j.ajo.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE To report 5-year postoperative safety data of iStent inject, including overall stability, endothelial cell density (ECD), and endothelial cell loss (ECL) in patients with mild-to-moderate primary open-angle glaucoma (POAG). DESIGN In this 5-year follow-up safety study of the 2-year iStent inject pivotal randomized controlled trial, patients receiving iStent inject placement and phacoemulsification or phacoemulsification alone were studied for the incidence of clinically relevant complications associated with iStent inject placement and stability. METHODS Corneal endothelial endpoints were mean change in ECD from screening and proportion of patients with >30% ECL from screening, from analysis of central specular endothelial images by a central image analysis reading center at several timepoints through 60 months postoperatively. RESULTS Of 505 original randomized patients, 227 elected to participate (iStent inject and phacoemulsification group, n = 178; phacoemulsification-alone control group, n = 49). No specific device-related adverse events or complications were reported through month 60. No significant differences were observed in mean ECD, mean percentage change in ECD, or proportion of eyes with >30% ECL between the iStent inject and control groups at any timepoint; mean percentage decrease in ECD at 60 months was 14.3±13.4% in the iStent inject group and 14.8±10.3% in the control group (P = .8112). The annualized rate of ECD change from 3 to 60 months was neither clinically nor statistically significant between groups. CONCLUSIONS Implantation of iStent inject during phacoemulsification in patients with mild-to-moderate POAG did not produce any device-related complications or ECD safety concerns compared to phacoemulsification alone through 60 months.
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Affiliation(s)
- Iqbal Ike K Ahmed
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT; Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Arsham Sheybani
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Ticiana De Francesco
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Clínica de Olhos De Francesco, Fortaleza, Brazil, & Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil
| | - Jonathan H Lass
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, OH; Cornea Image Analysis Reading Center (CIARC), University Hospitals Eye Institute, Cleveland, OH
| | - Beth Ann Benetz
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, OH; Cornea Image Analysis Reading Center (CIARC), University Hospitals Eye Institute, Cleveland, OH
| | | | | | - L Jay Katz
- Glaukos Corporation, Aliso Viejo, CA; Wills Eye Hospital, Philadelphia, PA.
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Ahmed IIK, De Francesco T, Rhee D, McCabe C, Flowers B, Gazzard G, Samuelson TW, Singh K. Long term outcomes from the HORIZON randomized trial for a Schlemm's canal microstent in combination cataract and glaucoma surgery. Ophthalmology 2022; 129:742-751. [PMID: 35218867 DOI: 10.1016/j.ophtha.2022.02.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 02/07/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE 5-year results of the HORIZON trial comparing cataract surgery combined with an intracanalicular microstent to cataract surgery alone. DESIGN Prospective, multicenter, controlled randomized clinical trial. PARTICIPANTS Patients with cataract and POAG treated with ≥ 1 glaucoma medication, washed out diurnal intraocular pressure (DIOP) 22-34 mmHg and no prior incisional glaucoma surgery. METHODS Eyes were randomized 2:1 to receive a Hydrus® Microstent (Ivantis, Inc.) or no stent after successful cataract surgery. Follow-up was conducted through 5 years postoperatively. MAIN OUTCOME MEASURES IOP, glaucoma medication usage, repeat glaucoma surgery, visual acuity, visual field, procedure related adverse events, and corneal endothelial cell counts. RESULTS 369 eyes were randomized to microstent treatment (HMS) and 187 to cataract surgery only (CS). Study groups were well matched for preoperative IOP, medication usage, washed out DIOP, and glaucoma severity. Five year follow up was completed in 80% of patients. At 5 years, the HMS group had a higher proportion of eyes with IOP ≤18 mmHg without medications compared to CS (49.5% vs. 34.8%, p=0.003) as well as a greater likelihood of IOP reduction of ≥ 20% without medications compared to CS alone (54.2% vs. 32.8%, p<0.001). The number of glaucoma medications was 0.5 ± 0.9 in the HMS group and 0.9 ± 0.9 in the CS group (p<0.001), and 66% of eyes in the HMS group were medication free compared to 46% in the CS group (p<0.001). The cumulative risk of incisional glaucoma surgery was lower in the HMS group (2.4% vs. 6.2%, log-rank p=0.027). There was no clinical or statistically significant difference in the rate of endothelial cell loss from 3 months to 60 months between the HMS and CS groups (p=0.261). Visual acuity did not differ between groups, and there was no difference in long term postoperative adverse events. CONCLUSIONS The addition of a Schlemm's canal microstent in conjunction with cataract surgery was safe, resulted in lowered IOP and medication use, and reduced the need for postoperative incisional glaucoma filtration surgery compared to cataract surgery alone after 5 years. Long term presence of the implant did not adversely affect the corneal endothelium.
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Affiliation(s)
- Iqbal Ike K Ahmed
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Ticiana De Francesco
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Clinica de Olhos De Francesco, Fortaleza, Brazil & Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil.
| | - Douglas Rhee
- Case Western Reserve University Hospitals, Cleveland, Ohio
| | | | | | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, and Institute of Ophthalmology, University College London, London, United Kingdom
| | - Thomas W Samuelson
- Minnesota Eye Consultants, University of Minnesota, Minneapolis, Minnesota
| | - Kuldev Singh
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
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De Francesco T, Ma J, Ahmed IIK. Endothermal pupilloplasty to optimize pupil centration, size, and contour. J Cataract Refract Surg 2021; 47:e80-e83. [PMID: 34133402 DOI: 10.1097/j.jcrs.0000000000000718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/26/2021] [Indexed: 11/25/2022]
Abstract
Iris defects and distorted pupils are commonly managed with iris suturing techniques that aim to close the defect and/or reform the physiological pupil. The re-creation of an optimally sized and centered pupil is often challenging because of missing iris, asymmetrical iris damage, or variable tension around the pupil. Current options include removing or cutting iris tissue using microscissors or the vitreous cutter, instrument stretching, or postoperative laser photocoagulation. Iris microendodiathermy is a simple technique that is minimally traumatic, titratable, and controlled, avoids excessive tissue manipulation, and is able to create a round cosmetically pleasing pupil. A bipolar endodiathermy cautery is applied to the iris stroma to induce tissue contraction and to gently pull the pupil in the meridian to which probe is applied. Endothermal pupilloplasty (EDP) may be used to recenter or enlarge a small pupil, thereby avoiding additional trauma inflicted by a vitrector or microscissors that physically cuts the iris.
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Affiliation(s)
- Ticiana De Francesco
- From the Clínica De Olhos De Francesco, Fortaleza, Ceara, Brazil (De Francesco), the Hospital De Olhos Leiria De Andrade, Fortaleza, Ceara, Brazil (De Francesco), the Escola Cearense de Oftalmologia, Fortaleza, Ceara, Brazil (De Francesco), the Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada (Ma, Ahmed) , and the Department of Ophthalmology and Visual SciencesUniversity of Utah, Salt Lake City, Utah (Ahmed)
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De Francesco T, K Ahmed II. February consultation #5. J Cataract Refract Surg 2021; 47:276. [PMID: 33901143 DOI: 10.1097/01.j.jcrs.0000733916.96313.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Liu J, De Francesco T, Schlenker M, Ahmed II. Icare Home Tonometer: A Review of Characteristics and Clinical Utility. Clin Ophthalmol 2020; 14:4031-4045. [PMID: 33262568 PMCID: PMC7695605 DOI: 10.2147/opth.s284844] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/30/2020] [Indexed: 12/03/2022] Open
Abstract
The Icare HOME (TA022, Icare Oy, Vanda, Finland) is rebound tonometer recently approved by the US Food and Drug Administration in March 2017 designed for self-measurement of intraocular pressure (IOP). IOP remains a major modifiable risk factor for glaucoma progression; however, IOP measurements typically occur through single office measurements on Goldmann applanation tonometry (GAT) and do not always reveal the complete picture of patient’s IOP patterns and daily fluctuations, which are important for accurate diagnosis and evaluation. Numerous studies have now compared the efficacy of the Icare HOME to that of GAT. The objective of this article is to review the existing literature surrounding the Icare HOME tonometer and its efficacy as a self-tonometer in comparison to GAT. The available literature has shown promising results in its accuracy of measuring IOP but suggests cautious usage in patients with central corneal thicknesses or IOP ranges that are outside of a certain range. This article will also provide details and example cases for when the Icare HOME may be most clinically useful.
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Affiliation(s)
- John Liu
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Prism Eye Institute, Oakville, Ontario, Canada
| | - Ticiana De Francesco
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Prism Eye Institute, Oakville, Ontario, Canada
| | - Matthew Schlenker
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Prism Eye Institute, Oakville, Ontario, Canada
| | - Iqbal Ike Ahmed
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Prism Eye Institute, Oakville, Ontario, Canada
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