Trabecular Procedures Combined with Cataract Surgery for Open-Angle Glaucoma: A Report by the American Academy of Ophthalmology

PURPOSE

To determine the intraocular pressure (IOP) reduction of various trabecular procedures (a form of minimally invasive glaucoma surgery [MIGS]) combined with cataract surgery compared with cataract surgery alone, to compare the safety of the various trabecular procedures, and to highlight patient characteristics that may favor one trabecular procedure over another.

METHODS

A search of English-language peer-reviewed literature in the PubMed database was initially conducted in February 2021 and updated in April 2023. This yielded 279 articles. Twenty studies met initial inclusion and exclusion criteria and were assessed for quality by the panel methodologist. Of these, 10 were rated level I, 3 were rated level II, and 7 were rated level III. Only the 10 level I randomized controlled trials (RCTs) were included in this assessment, and all were subject to potential industry-sponsorship bias.

RESULTS

The current analysis focuses on the amount of IOP reduction (in studies that involved medication washout) and on IOP reduction with concurrent medication reduction (in studies that did not involve medication washout). Based on studies that performed a medication washout, adding a trabecular procedure to cataract surgery provided an additional 1.6 to 2.3 mmHg IOP reduction in subjects with hypertensive, mild to moderate open-angle glaucoma (OAG) at 2 years over cataract surgery alone, which itself provided approximately 5.4 to 7.6 mmHg IOP reduction. In other words, adding a trabecular procedure provided an additional 3.8% to 8.9% IOP reduction over cataract surgery alone, which itself provided 21% to 28% IOP reduction. There was no clear benefit of one trabecular procedure over another. Patient-specific considerations that can guide procedure selection include uveitis predisposition, bleeding risk, metal allergy, and narrowing of Schlemm's canal. There are no level I data on the efficacy of trabecular procedures in subjects with pretreatment IOP of 21 mmHg or less.

CONCLUSIONS

Trabecular procedures combined with cataract surgery provide an additional mild IOP reduction over cataract surgery alone in hypertensive OAG subjects. Additional research should standardize outcome definitions, avoid industry sponsorship bias, and study the efficacy of these procedures in normotensive OAG.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Comparative outcomes of phacoemulsification combined with micro-invasive glaucoma surgery plus: Schlemm canal microstent versus Ab interno trabecular excision

PURPOSE

To report the relative efficacy of combining phacoemulsification with a Schlemm's canal microstent (Phaco/Hydrus) or dual blade trabecular excision (Phaco/KDB).

DESIGN

Retrospective study.

METHODS

One hundred and thirty-one eyes of 131 patients who underwent Phaco/Hydrus or Phaco/KDB procedures from January 2016 to July 2021 at a tertiary care center were included and assessed for up to 36months postoperatively. Primary outcomes were intraocular pressure (IOP) and number of glaucoma medications, evaluated by generalized estimating equations (GEE). Two Kaplan-Meier estimates (KM) assessed survival without additional intervention or pressure lowering medication while maintaining: (1) IOP≤21mmHg and≥20% IOP reduction or (2) IOP≤preoperatively designated goal.

RESULTS

Mean preoperative IOP was 17.70±4.91 (SD) mmHg on 0.28±0.86 medications in the Phaco/Hydrus cohort (n=69) and 15.92±4.34mmHg on 0.19±0.70 medications in the Phaco/KDB cohort (n=62). At 12months, mean IOP was reduced to 14.98±2.77mmHg on 0.12±0.60 medications after Phaco/Hydrus and 13.52±4.13mmHg on 0.04±0.19 medications after Phaco/KDB. GEE models of IOP (P<0.001) and medication burden (P<0.05) showed significant patterns of reduction across all timepoints in both cohorts. There were no differences in IOP reduction (P=0.94), number of medications (P=0.95) or survival (P=0.72 by KM1, P=0.11 by KM2) between procedures.

CONCLUSIONS

Both Phaco/Hydrus and Phaco/KDB resulted in significantly reduced IOP and medication burden for over 12months. Phaco/Hydrus and Phaco/KDB confer similar outcomes in terms of IOP, medication burden, survival, and procedural time in a population with predominantly mild and moderate open-angle glaucoma.

Kahook Dual-Blade Goniotomy with and without Phacoemulsification in Medically Uncontrolled Glaucoma

Purpose

To evaluate the 2-year efficacy and safety of Kahook dual-blade (KDB) goniotomy in patients with medically uncontrolled glaucoma.

Methods

This was a retrospective case-series study of 90 consecutive patients with primary open-angle glaucoma (POAG) or pseudoexfoliation glaucoma (PEXG) that underwent KDB goniotomy alone (KDB-alone group) or KDB goniotomy in combination with phacoemulsification (KDB-phaco group) during 2019-2020. All patients were uncontrolled on three or more medications. Surgical success was defined as an IOP reduction ≥20% and/or a reduction of one or more medications at 24 months. We also report IOP levels and number of medications from baseline to 24 months, as well as the need for further glaucoma interventions.

Results

At 24 months, mean IOP had reduced from 24.8±8.3 to 15.0±5.3 mmHg in the KDB-alone group (P<0.001) and from 22.3±5.8 to 13.9±3.0 mmHg in the KDB-phaco group (P<0.001). Medications had reduced from 3.5±0.6 to 3.1±0.9 in the KDB-alone group (P=0.047) and from 3.3±0.5 to 2.3±1.1 in the KDB-phaco group (P<0.001). An IOP reduction ≥20% and/or a reduction with one or more medications was achieved by 47% of eyes in the KDB-alone group and by 76% of eyes in the KDB-phaco group. Eyes with PEXG and POAG responded equally well to the success criteria. During the 24-month follow-up, additional glaucoma surgery or transscleral photocoagulation was performed in 28% of eyes in the KDB-alone group and in 12% of eyes in the KDB-phaco group.

Conclusion

In patients with medically uncontrolled glaucoma, KDB had a significant IOP-lowering effect after 24 months, but success rates were higher when KDB was performed in combination with cataract surgery compared to stand-alone treatment.

Risk factors for intraocular pressure elevation in a six-month period after ab interno trabeculotomy using a Kahook Dual Blade

BACKGROUND

To examine the risk factors for an early postoperative intraocular pressure (IOP) increase after ab interno trabeculotomy using a Kahook Dual Blade (KDB trabeculotomy).

METHODS

A retrospective study was performed in 76 exfoliation glaucoma (EXG) eyes and 56 primary open angle glaucoma (POAG) eyes that underwent KDB trabeculotomy, with or without cataract surgery at Kumamoto University Hospital. Postoperative high IOP was classified as IOP≥20 mmHg (within three months after surgery, whether persistent or temporary), transient IOP≥20 mmHg (IOP≥20 mmHg after surgery, then dropped below 20 mmHg), and the presence of IOP spikes (≥ 10 mmHg from baseline). Risk factors were examined using logistic regression analysis.

RESULTS

The preoperative mean IOP (SD) was 24.98 (7.23) mmHg in patients with EXG and 21.28 (6.58) mmHg in patients with POAG. IOP was reduced by 32.1% in patients with EXG and by 17.7% in patients with POAG at 6 months after surgery. Postoperative IOP≥20 mmHg was observed in 56.6% of EXG patients and in 51.8% of POAG patients. IOP spikes occurred in 15.8% of EXG patients and in 14.3% of POAG patients. Logistic regression analysis showed that factors with significant odds ratios (ORs) were age (OR = 0.866, 95% CI = 0.793-0.945), preoperative medication use (OR = 2.02, 95% CI = 1.17-3.49), trabeculotomy in combination with cataract surgery (OR = 0.0674, 95% CI = 0.015-0.303), and IOP at day 1 (OR = 1.41, 95% CI = 1.18-1.68) for postoperative IOP≥20 mmHg, the IOP at day 1 (OR = 1.1, 95% CI = 1.03-1.17) for transient IOP≥20 mmHg, and age (OR = 0.948, 95% CI = 0.901-0.997) and preoperative IOP (OR = 0.83, 95% CI = 0.736-0.936) for IOP spikes.

CONCLUSION

Although KDB trabeculotomy is an effective treatment for patients with EXG and POAG, patients who take multiple preoperative medications and have a high IOP on day 1 require careful follow-up to prevent postoperative IOP elevation.

A novel use of the endoscopic cyclophotocoagulative probe for the management of excisional goniotomy induced chronic recurrent hyphema

Purpose

To describe the management of a case of chronic, recurrent hyphema following excisional goniotomy with the Kahook Dual Blade.

Observations

One week following uncomplicated surgery, the patient presented with eye pain, elevated intraocular pressure, and layered hyphema. The hyphema resolved with conservative measures but recurred several times with similar symptoms over the next several months. An attempt to stenose the "oozing" collector channel using the argon laser was unsuccessful. Treatment of the angle with an endoscopic semi-conductor diode laser (endoscopic cyclophotocoagulative or ECP) probe successfully altered the angle preventing further episodes of recurrent hyphema. The primary glaucoma procedure failed necessitating a filtering procedure.

Conclusions and importance

Clinician should be aware of this potential complication, its treatment options, and outcomes.

Long-Term Outcomes of a Kahook Dual Blade Procedure Combined with Phacoemulsification in Japanese Patients with Open-Angle Glaucoma

We retrospectively evaluated the long-term surgical outcomes of phacoemulsification combined with a Kahook dual blade (KDB) procedure in Japanese patients with open-angle glaucoma. The primary outcome was surgical success or failure. Surgical failure was indicated by a <20% reduction in preoperative intraocular pressure (IOP) or IOP > 18 mmHg (criterion A), IOP > 14 mmHg (criterion B), or requirement for reoperation. Glaucoma medications after surgery and postoperative complications were recorded. Surgical outcomes were compared between primary open-angle glaucoma (POAG) and exfoliation glaucoma (ExG) groups. The probability of success at 36 months postoperation was 52.5% using criterion A and 36.9% using criterion B. Mean IOP decreased significantly from 19.5 ± 6.9 mmHg preoperatively to 11.9 ± 2.7 mmHg at 36 months, and the mean number of glaucoma medications from 2.4 ± 1.4 to 1.6 ± 1.4 (both p < 0.01). IOP spikes were significantly more common in the ExG group (23.7% vs. 9.1%; p = 0.045), as was the need for additional glaucoma surgery (10.5% vs. 1.8%; p = 0.038). A KDB procedure combined with cataract surgery resulted in significant long-term decreases in IOP and the number of glaucoma medications. The complication rate was higher in eyes with ExG. Therefore, these eyes require more careful management after a KDB procedure.

Gonioscopy-assisted transluminal trabeculotomy versus goniotomy with Kahook dual blade in patients with uncontrolled juvenile open-angle glaucoma: a retrospective study

Background

To compare the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) and Kahook Dual Blade (KDB) excisional goniotomy in patients with uncontrolled juvenile open-angle glaucoma (JOAG).

Methods

Thirty-three patients (46 eyes) were included in this single-center, retrospective, comparative study and treated with GATT (36 eyes) or KDB goniotomy (13 eyes). Intraocular pressure (IOP), number of glaucoma medications, adverse events, and additional anti-glaucoma procedures were collected during pre- and postoperative visits. Surgical success was defined as 6 mmHg ≤ IOP ≤ 18 mmHg and ≥ 20% IOP reduction from baseline with (partial success) or without (complete success) IOP-lowering medications.

Results

The mean ± SD preoperative IOP was 30.48 ± 12.9 mmHg and 26.08 ± 13.1 mmHg (P = 0.164) on 3.71 ± 0.46 and 3.08 ± 0.86 (P = 0.023) glaucoma medications in GATT and KDB group, respectively. At 3 months, the mean ± SD IOP was 15.48 ± 5.93 mmHg and 20.0 ± 10.8 mmHg after GATT and KDB, respectively (P = 0.072). The percentage of IOP lowering from baseline was 44.4 in the GATT group and 14.1 in the KDB group (P = 0.011). The mean reduction in medications was 2.6 ± 1.7 and 0.8 ± 1.2 three months after GATT and KDB, respectively (P < 0.001). Cumulative proportion of partial and complete success were 65.6 and 44.7% in the GATT group, 30.8 and 15.4% in the KDB group at 6 months. Additional procedures were required in 13.9% of cases after GATT and in 61.5% after KDB (P = 0.001). Patients in the GATT group with prior anti-glaucoma procedures and postoperative IOP spikes were more likely to fail, while those with complete trabeculotomy had a better prognosis.

Conclusions

Reduction of IOP and medications were greater after GATT in uncontrolled JOAG eyes. Whereas, more additional IOP-lowering procedures were required after KDB goniotomy.

Trial registration

This study was registered under the Chinese Clinical Trial Registry (ChiCTR2000034172, 27/06/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02159-z.

Comparison of Surgical Outcomes Between Microhook Ab Interno Trabeculotomy and Goniotomy with the Kahook Dual Blade in Combination with Phacoemulsification: A Retrospective, Comparative Case Series

PURPOSE

To study surgical outcomes of patients with a minimum of 6 months of follow-up after undergoing combined phacoemulsification with either microhook ab interno trabeculotomy (μLOT-Phaco) or goniotomy using the Kahook Dual Blade (KDB-Phaco).

METHODS

This retrospective comparative case series examined 22 μLOT-Phaco eyes and 81 KDB-Phaco eyes that underwent surgery between December 2016 and October 2018. Data collected from medical records included pre- and postoperative intraocular pressure (IOP), number of IOP-lowering medications and complication occurrence. Potential risk factors for failure were determined by Cox proportional hazards regression analysis. Surgical failure was defined as an IOP of > 20 mmHg, < 20% reduction in preoperative IOP or additional glaucoma surgery. Kaplan-Meier survival analysis was used to assess success rates. Score matching used a genetic algorithm consisting of type of glaucoma.

RESULTS

Of 81 KDB-Phaco eyes, 22 eyes were matched to 22 μLOT-Phaco eyes. Mean IOP in the μLOT-Phaco group decreased from 24.7 ± 6.4 mmHg at baseline to 14.4 ± 3.0 mmHg (P < 0.01) and 13.0 ± 2.5 mmHg (P < 0.01) at 6 and 12 months, respectively. Mean IOP in the KDB-Phaco group decreased from 23.2 ± 5.4 mmHg to 15.8 ± 3.3 mmHg (P < 0.001) and 16.7 ± 2.1 mmHg (P < 0.001), respectively. Mean number of preoperative IOP-lowering medications in the μLOT-Phaco group at baseline was 3.7 ± 1.0, which decreased to 1.4 ± 1.5 (P < 0.01) at 12 months, while in the KDB-Phaco group it decreased from a baseline value of 3.3 ± 1.2 to 1.1 ± 1.4 (P < 0.01). Probability of qualified success at 12 months in the μLOT-Phaco and KDB-Phaco groups was 71.8% and 62.2%, respectively (P = 0.75). Similar postoperative complications were found between the groups.

CONCLUSIONS

Use of μLOT-Phaco and KDB-Phaco resulted in comparable IOPs and reductions in the number of medications.

Turn Back Elevation of Once Reduced IOP After Trabeculotomy Ab Externo and Kahook Dual Blade Surgeries Combined with Cataract Surgery

Purpose

To evaluate the surgical outcome of internal trabeculectomy by Kahook dual blade (KDB) with that of external trabeculotomy, each combined with phaco-lensectomy and intraocular lens implantation (Phaco).

Patients and Methods

This is a retrospective comparative study. The primary and secondary outcome measures are postsurgical intraocular pressure and postsurgical hyphema. One eye each of 76 primary open angle glaucoma (POAG), pseudoexfoliation glaucoma (PEG) and ocular hypertension (OH) patients underwent external phaco-trabeculotomy, and that of 40 POAG, PEG and OH patients underwent phaco-KDB surgery.

Results

Reduction of the intraocular pressure (IOP) by phaco-KDB at one and two years was 28.4 and 27.8%, respectively, and was not significantly different from that by external phaco-trabeculotomy of 32.7% (P=0.256) and 31.5% (P=0.468), respectively. Three months postsurgical IOP after phaco-KDB and external phaco-trabeculotomy was 16.1 and 15.9 mmHg, respectively. There was a significant turn back elevation of once reduced IOP to 17.1 (P=0.0207) and 17.0 mmHg (P=0.0096) at 24 months, respectively. There were no differences in success probability to achieve IOP below 17 mmHg (P=0.120), 21 mmHg (P=0.719) and >20% IOP reduction (P=0.309) with medication(s) at two years between the phaco-KDB and external phaco-trabeculotomy cohorts. Younger age was a significant (P<0.001) risk factor for failure; however, presurgical IOP (P=0.466), the type of surgery (P=0.219) and presence of postsurgical IOP spike (P=0.737) were not significant risk factors by the Cox proportional hazard model. Hyphema and spike of the IOP in phaco-KDB and external phaco-trabeculotomy cohorts were 40% and 88% (P<0.001), and 53% and 41% (P=0.238), respectively.

Conclusion

The IOP reduction by the phaco-KDB was equivalent to that by external phaco-trabeculotomy up to two years. In both cohorts, once reduced postsurgical IOP tend to increase up to 24 months.

Effectiveness and limitations of minimally invasive glaucoma surgery targeting Schlemm's canal

Glaucoma surgery is performed to lower intraocular pressure (IOP); ideally, the IOP reduction is safely maintained for an extended period of time. Although trabeculectomy was considered the gold standard for glaucoma surgery for many years because of its effective IOP reduction, yet now it is considered unsafe because of serious complications. In recent years, minimally invasive glaucoma surgery (MIGS), which emphasizes safety and can be performed rapidly, has become widespread. Because MIGS does not involve conjunctival incisions, patients can undergo future trabeculectomy. If IOP reduction can be maintained safely, the number of anti-glaucoma drops can be reduced and visual function maintained, good outcomes for patients with glaucoma. Currently, many types of MIGS approved in Japan are reported to yield relatively good results, with targets of approximately 15-19 mmHg. However, the IOP-lowering effects of MIGS are limited. In procedures targeting Schlemm's canal, it is difficult to lower IOP beyond episcleral venous pressure. In some instances, a beneficial effect cannot be achieved if function is reduced beyond the collector channel. There are many unclear aspects regarding long-term outcomes following MIGS. Notably, investigation is ongoing to determine which patients are likely to benefit most from surgery. Based on previous reports, this review describes the characteristics and results of MIGS, approved in Japan, as well as underlying factors that affect the preoperative predictions and outcomes of the surgical procedure.

Primary outcomes of combined cataract extraction technique with Ab-Interno trabeculectomy and endoscopic Cyclophotocoagulation in patients with primary open angle Glaucoma

BACKGROUND

Glaucoma surgery have been developed to lower intraocular pressure in a less invasive manner than traditional glaucoma surgery. The purpose of this article is to determine the outcome of using combined phacoemulsification technique, ab-interno trabeculectomy dual blade and endoscopic cyclophotocoagulation (ECP) surgeries in patients with primary open angle glaucoma.

METHODS

A retrospective case series was performed on 27 consecutive eyes with both primary open-angle glaucoma (POAG) and cataract; each eye was treated with combined phacoemulsification, ab-interno trabeculectomy-Kahook Dual Blade and Endocyclophotocoagulation at Instituto de ojos Oftalmosalud, Lima, Peru, between April 2017 and May 2017.

INCLUSION CRITERIA

1) Patients with uncontrolled mild to advanced POAG (according to Glaucoma Grading Scale HODAPP) 2) cataract condition 3) treatment with two or more glaucoma medications due to rapid progression in the visual fields (at least two in a short period of time). Intraocular pressure (IOP), best corrected visual acuity (BCVA) logMAR and number of glaucoma medications were recorded prior to the study, at day 1, week 1, and 1,3,6 and 9 months after surgery. Primary outcome measure was surgical success defined in terms of IOP < 14 mmHg either with no medications (complete success) or with medications (qualified success).

RESULTS

A total of 27 eyes from 27 patients were included. The mean basal IOP was 17.0 ± 3.7 mmHg and postoperatively was 11.6 ± 1.9 mmHg and 11.4 ± 1.8 mmHg (P < 0.001) at 6 and 9 months respectively. Glaucoma medications decreased from 1.9 ± 1.4 to 0.56 ± 1.05 at 9 month follow-ups (P < 0.001). Preoperative best corrected visual acuity (BCVA) showed and improvement from 0.4 ± 0.4 LogMAR to 0.2 ± 0.4 logMAR at 9 months. The main complication was blood reflux intra-operatively (66.7%), which resolved without re-operation. The mean IOP was reduced by 32.9% from baseline and the surgical success was 92,6%, (complete success 70,3% and qualified success 29,6%) at 9 months.

CONCLUSIONS

In patients with POAG, combined treatment with phacoemulsification, ab-interno trabeculectomy and endoscopic cyclophotocoagulation effectively reduced IOP and glaucoma medication dependence.

Kahook Dual Blade goniotomy in post penetrating keratoplasty steroid-induced ocular hypertension

PURPOSE

Steroid-induced ocular hypertension (OHTN) after penetrating keratoplasty (PKP) may cause irreversible damage to the optic nerve and graft failure. The purpose of this study is to report the first case of a post PKP patient with poorly controlled IOP, successfully treated with Kahook Dual Blade (KDB) goniotomy in both eyes.

OBSERVATIONS

The patient was a 62-year old male with prior PKP in both eyes for lattice corneal degeneration. After an uncomplicated phacoemulsification in the left eye, his IOP increased to 32 mmHg on maximum tolerated IOP lowering therapy, including oral acetazolamide. This patient was dependent on scleral contact lenses for his irregular astigmatism post PKP to achieve his best-corrected visual acuity. Thus, we needed to consider a conjunctival sparing procedure and decided to proceed with performing a KDB goniotomy in the left eye. At 29 months follow up the visual acuity (VA) remained at 20/20 and IOP 13 mmHg on dorzolamide/timolol combination drop. A year following, his right eye also required KDB goniotomy combined with cataract surgery to treat his cataract and elevated IOP of 28 mm Hg. At 18 months post KDB goniotomy, the right eye VA was 20/50 and IOP 13 mmHg on dorzolamide/timolol combination drop.

CONCLUSIONS

This case demonstrates KDB goniotomy may be a good surgical alternative for post PKP steroid-induced OHTN or glaucoma, especially in patients requiring scleral contact lens for their visual rehabilitation.

Twelve-Month Outcomes of Stand-Alone Excisional Goniotomy in Mild to Severe Glaucoma

PURPOSE

To describe 12-month intraocular pressure (IOP) and medication use outcomes following excisional goniotomy (EG) as a stand-alone procedure in eyes with medically uncontrolled glaucoma.

METHODS

This was a retrospective analysis of data from surgeons at 8 centers (6 US, 2 Mexico). Eyes with glaucoma undergoing standalone EG with a specialized instrument (Kahook Dual Blade, New World Medical, Rancho Cucamonga, CA) for IOP reduction and followed for 12 months postoperatively were included. Data were collected preoperatively, intraoperatively, and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. The primary outcome was reduction from baseline in IOP, and key secondary outcomes included IOP-lowering medication reduction as well as adverse events.

RESULTS

A total of 42 eyes were analyzed, of which 36 (85.7%) had mild to severe primary open-angle glaucoma (POAG). Mean (standard error) IOP at baseline was 21.6 (0.8) mmHg, and mean number of medications used at baseline was 2.6 (0.2). At 3, 6, and 12 months postoperatively, mean IOP reductions from baseline were 4.6 mmHg (22.3%), 5.6 mmHg (27.7%), and 3.9 mmHg (19.3%) (p≤0.001 at each time point). At the same time points, mean medications reductions of 0.7 (25.8%), 0.9 (32.6%), and 0.3 (12.5%) medications were seen (p<0.05 at months 3 and 6, not significant at month 12). Six eyes (14.3%) underwent additional glaucoma surgery during the 12-month follow-up period.

DISCUSSION

Standalone EG with KDB can reduce IOP, and in many cases reduce medication use, through up to 12 months in eyes with mild to severe glaucoma. Statistically significant and clinically relevant reductions in IOP were seen at every time point. While the goal of surgery was not to reduce medication burden, mean medication use was significantly reduced at all but the last time point. In the majority of eyes, the need for a bleb-based glaucoma procedure was delayed or prevented for at least 12 months.

Cyclodialysis Cleft Associated with Kahook Dual Blade Goniotomy

Aim

The aim of this study is to report cyclodialysis cleft creation during Kahook dual blade (KDB) goniotomy.

Background

No known reports of cyclodialysis clefts have been published to the authors’ knowledge after KDB goniotomy.

Case description

A 55-year-old myopic male with primary open angle glaucoma in both eyes (OU) underwent routine cataract extraction and intraocular lens implant with KDB goniotomy in the right eye (OD). Preoperative intraocular pressures (IOP) OD were in the low 20 mm Hg range on timolol and bimatoprost. Postoperative IOP was 4 mm Hg, with a moderate depth anterior chamber. Gonioscopy was slit in all quadrants, with no structures visible, and no improvement on indentation. Mild macular choroidal folds were present OD. Ultrasound biomicroscopy (UBM) revealed an area of supraciliary fluid. Anterior chamber reformation with viscoelastic was performed and repeat gonioscopy revealed a cyclodialysis cleft from 2:00 to 3:00. Treatment with multiple sessions of argon laser photocoagulation successfully closed the cleft.

Conclusion

KDB goniotomy may be complicated by cyclodialysis cleft formation and hypotony maculopathy. Visualization of a cleft on gonioscopy may require anterior chamber reformation.

Clinical significance

With an increasing use of KDB for goniotomy, previously unreported complications may arise including cyclodialysis cleft and resultant hypotony maculopathy. Because cleft following KDB goniotomy is rare, suspicion may be low and diagnosis could be delayed in the setting of postoperative hypotony with closed angles.

How to cite this article

Shue A, Levine RM, et al. Cyclodialysis Cleft Associated with Kahook Dual Blade Goniotomy. J Curr Glaucoma Pract 2019;13(2):74–76.

Reversal of Toric Intraocular Lens-corrected Corneal Astigmatism after Kahook Dual Blade Goniotomy

A 79-year-old man underwent phacoemulsification (phaco) with TORIC intraocular lens (IOL) insertion combined with Kahook dual blade (KDB) goniotomy of the right eye several months after a stand-alone phaco in the fellow eye. He had significant against-the-rule astigmatism in both eyes (2.41D @ 10° right, 2.40D @ 160° left) preoperatively. Postoperatively, nearly all corneal astigmatism disappeared in the right eye (0.60D @ 37°), while it remained the same in the left eye (2.00D @ 167°). Ophthalmologists should be aware that KDB may have an unreported effect of altering corneal astigmatism, which should be considered when inserting TORIC IOL.

HOW TO CITE THIS ARTICLE

Hirabayashi MT, McDaniel LM, et al. Reversal of Toric Intraocular Lens-corrected Corneal Astigmatism after Kahook Dual Blade Goniotomy. J Curr Glaucoma Pract 2019;13(1):42-44.