Cyclodialysis Cleft and Hypotony Following Combined Phacoemulsification and Excisional Goniotomy with the Kahook Dual Blade

A 69-year-old woman with bilateral primary open-angle glaucoma who underwent cataract extraction with intraocular lens implantation and excisional goniotomy with the Kahook Dual Blade (KDB; New World Medical, Rancho Cucamonga, CA, USA) in both eyes one year prior was referred for evaluation of significant visual acuity loss and pain in the left eye. On initial examination, intraocular pressure in the left eye was 3 mmHg and slit lamp examination revealed normal anterior chamber depth. Gonioscopy revealed a cyclodialysis cleft that was confirmed by anterior segment optical coherence tomography. Prominent chorioretinal folds suggestive of long-standing hypotony maculopathy were observed during fundoscopic examination. The cyclodialysis cleft, thought to be created inadvertently during the KDB goniotomy, resolved after three sessions of argon laser photocoagulation and the patient’s symptoms and visual acuity partially improved

Micro-invasive glaucoma surgery – an interventional glaucoma revolution

Abstract The glaucoma surgical landscape has changed dramatically over the last decade with the introduction and integration of micro-invasive glaucoma surgery (MIGS) techniques. These modalities target physiologic outflow pathways or optimize previously utilized glaucoma surgical methods in order to deliver safety, efficacy, and individualized care to the patient. MIGS techniques can be classified based on anatomical location as well as method of intraocular pressure (IOP) reduction. This review will focus on MIGS optimizing the conventional outflow pathway via intervention at Schlemm’s canal, MIGS optimizing the uveoscleral outflow pathway via suprachoroidal shunting, and MIGS optimizing the transscleral or subconjunctival outflow pathway which has long been utilized by glaucoma surgeons performing traditional filtration procedures. The wide array of currently available MIGS modalities can be staggering to the glaucoma care provider, but an understanding of the landscape and the large classes of interventional strategies can allow for clinical decision making based on the specifics of the patient’s needs and the pathophysiology of their disease.https://deepblue.lib.umich.edu/bitstream/2027.42/152252/1/40662_2019_Article_154.pd

Bio-Interventional Cyclodialysis and Allograft Scleral Reinforcement for Uveoscleral Outflow Enhancement in Open-Angle Glaucoma Patients: One-Year Clinical Outcomes.

BACKGROUND: To evaluate the one-year safety and effectiveness of bio-interventional cyclodialysis and scleral reinforcement in open-angle glaucoma (OAG) patients undergoing cataract surgery. METHODS: An ab-interno approach was used to create a sectoral cyclodialysis in OAG patients who were prospectively followed in a consecutive case series. Subsequent visco-cycloplasty with scleral reinforcement using homologous minimally modified allograft scaffold was completed to maintain patency of the cyclodialysis reservoir and increase uveoscleral outflow. Outcomes were mean medicated IOP and mean number of IOP-lowering medications. Safety outcomes were adverse events (AEs) and best-corrected visual acuity (BCVA) changes. RESULTS: Successful cyclodialysis and allograft bio-scaffold reinforcement was achieved in 117 eyes. There was minimal intraoperatie bleeding and few post-operative adverse events. At baseline, mean BCVA was 0.48 (95% CI: 0.42‒0.54; 20/40 Snellen) and mean ± SD medicated IOP was 20.2 ± 6.0 mmHg on 1.4 ± 1.3 IOP-lowering medications. At 12 months, there was a 27.1% reduction from baseline mean medicated IOP. In eyes with medicated baseline IOP > 21 mmHg (n = 45), there was a 39.7% paired IOP reduction at 12 months with a concurrent reduction in the mean number of IOP lowering medications to 0.8 ± 0.9 which were statistically significant (p < 0.01). For all eyes, 81.9% achieved a medicated IOP ≤ 18 mmHg with no increase in medications at 12 months. To achieve target IOP control, secondary glaucoma surgery was performed in 3.2% of the cases. CONCLUSION: IOP lowering through uveoscleral outflow enhancement can be achieved by means of a bio-interventional cyclodialysis procedure with allograft scleral reinforcement

Corneal endothelial cell density loss following glaucoma surgery alone or in combination with cataract surgery: a systematic review protocol

Objective: We aim to systematically assess and compare corneal endothelial cell density (ECD) loss in patients with glaucoma following glaucoma surgery and cataract surgery. / Introduction: Corneal ECD loss may occur due to intraoperative surgical trauma in glaucoma surgery or postoperatively with chronic endothelial cell trauma or irritation. Corneal oedema and decompensation after aqueous shunt glaucoma surgery has been reported but the long-term ECD loss is still unknown. / Inclusion criteria: Trabeculectomy, glaucoma filtration surgery or microinvasive glaucoma surgery in adults with ocular hypertension, primary and secondary open angle glaucoma, normal tension glaucoma and angle-closure glaucoma. Participants with pre-existing corneal disease will be excluded. Glaucoma laser treatments and peripheral iridotomy will be excluded. The outcomes include preoperative and postoperative corneal ECD, percentage change of corneal ECD and adverse events. / Methods: We will conduct an electronic database search for randomised controlled trials, prospective non-randomised studies, observational studies in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and The International Prospective Register of Systematic Reviews (PROSPERO). Eligibility criteria will include quantitative articles published after and including the year 2000, written in English and containing data on ECD loss. Two independent reviewers will screen titles and abstracts and extract data from full texts, reporting outcomes according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data extraction of key characteristics will be completed using customised forms. Methodological quality will be assessed using the Joanna Briggs Institute critical appraisal forms. / Ethics and dissemination: Ethics approval is not required for this review, as it will only include published data. Findings will be published in a peer-reviewed journal and disseminated across ophthalmic networks. / PROSPERO registration number: PROSPERO CRD42020192303

Long Term Efficacy of a Supraciliary Micro-stent Combined with Cataract Surgery in the Treatment of Glaucoma

Purpose: The purpose of this study is to evaluate the long-term efficacy of supraciliary micro-stent implantation in combination with phacoemulsification in the treatment of mild-moderate primary open angle glaucoma (POAG). Methods: Retrospective data of patients previously enrolled in the “Study of an Implantable Device for Lowering Intraocular Pressure in Glaucoma Patients Undergoing Cataract Surgery” (COMPASS trial), in which patients with mild-moderate POAG had undergone either cataract surgery alone or cataract surgery combined with implantation of a supraciliary micro-stent, were collected. Eligible patients had since exited the trial and had 5-8 years of postoperative data available. The primary outcome measure was the proportion of eyes with a “complete success” defined as an IOP ≤ 18 mmHg on no glaucoma medications and not having undergone any secondary surgical procedures for IOP control. Thirty-three eyes were in the treatment group and 12 eyes were in the control group. Device safety was also reviewed. Results: Significantly more eyes in the treatment group achieved a “complete success” (61%) versus those eyes in the control group (17%) (p\u3c0.05). When controlling for patient age, sex, preoperative visual field, preoperative IOP, and preoperative anti-glaucoma medication usage, eyes in the treatment groups were 9 times more likely to meet the primary outcome measure versus control group (p=0.004). Mean postoperative IOP was 17.7 ± 4.8 in the control group versus 15.0 ± 4.4 in the treatment group (p=0.08), while mean medication usage was 0.9 ± 0.7 in the control group versus 0.4 ± 0.7 in the treatment group (p=0.01). Average follow up was 6.38 years. No device related adverse events, such as corneal decompensation occurred. Conclusion: Implantation of a supraciliary micro-stent combined with cataract surgery in eyes with mild-moderate POAG demonstrates better long term IOP control than those eyes undergoing cataract surgery alone

New devices in glaucoma

Glaucoma remains a leading cause of blindness globally. Minimally invasive treatment techniques are rapidly expanding the availability of therapeutic options for glaucoma. These include devices aimed at enhancing outflow through the subconjunctival space, Schlemm\u27s canal, and suprachoroidal space, sustained-release drug delivery devices, and extraocular devices aiming to reduce glaucomatous progression through other novel means. In this review, we provide an overview of several novel devices either newly available or in development for the medical and surgical management of glaucoma. Further studies are required to determine the long-term efficacy of these devices and how they will integrate into the current landscape of glaucoma management

Инновационные технологии при комбинированной хирургии глаукомы и осложненной катаракты

The review considers possible treatment tactics for patients with open-angle glaucoma and coexisting cataract. Combined treatment is recommended in the case of subcompensation of intraocular pressure (IOP) and a significant decrease in visual functions, because it allows achieving a more pronounced hypotensive effect, versus the phacoemulsification alone. The advantage of one-step intervention lies in the optimization of economic, social, psychological aspects, and shortening the patient's period of rehabilitation. In recent years, the methods of minimally invasive glaucoma surgery (MIGS) have become most relevant and common. The safety and technical simplicity of MIGS procedures, as well as their success in combination with phacoemulsification, ensured a widespread dissemination of these interventions. According to a number of scientific studies, the implementation of MIGS-technologies simultaneously with phacoemulsification contributes to the achievement of optimal results. The review considers the main groups of MIGS methods, presents the results of clinical studies devoted to their effectiveness. It presents the data on the efficacy of combined MIGS technologies with phacoemulsification and MIGS methods alone. There is a great interest in studying modern microinvasive methods of laser treatment in the combined treatment of patients with POAG and cataract. These operations have a minimal damaging effect on the trabecular tissue and have a pathogenetic orientation. The development of microinvasive-combined methods of treatment of POAG and complicated cataract remains an actual and promising direction.В обзоре рассмотрены возможные варианты тактики лечения пациентов с открытоугольной глаукомой и осложненной катарактой. При субкомпенсации внутриглазного давления (ВГД) и значительном снижении зрительных функций показано комбинированное лечение, т. к. оно позволяет добиться более выраженного гипотензивного эффекта, в отличие от операции факоэмуль-сификации катаракты. Преимуществом одномоментного вмешательства является оптимизация экономических, социальных, психологических аспектов, сокращение периода реабилитации пациента. Методики минимально инвазивной хирургии глаукомы — MIGS (minimally invasive glaucoma surgery) в последние годы становятся наиболее актуальными и распространенными. Безопасность и техническая простота методик MIGS, а также успешность при комбинации с факоэмульсификацией обеспечили широкое распространение данных вмешательств. Согласно ряду научных исследований, выполнение MIGS-технологий одномоментно с факоэмульсификацией катаракты способствует достижению оптимальных результатов. В обзоре рассмотрены основные группы методик MIGS, представлены результаты клинических исследований, посвященных изучению их эффективности. Приведены сравнительные данные о гипотензивном эффекте MIGS-технологий, проведенных изолированно, а также в сочетании с факоэмульсификацией катаракты. Большой интерес вызывают современные малоинвазивные методики лазерного лечения в комбинированном лечении больных первичной открытоугольной глаукомой (ПОУГ) и катарактой. Данные операции оказывают минимальное повреждающее действие на трабекулярную ткань и обладают патогенетической направленностью. Разработка микроинвазивных комбинированных способов лечения ПОУГ и осложненной катаракты остается актуальным и перспективным направлением

Экспериментальное исследование дренажа из нитинола

One of the relevant tasks in glaucoma treatment is development of a drainage implant (microstent) and a technique for its implantation during minimally invasive surgery with the aim of forming a channel for aqueous humor outflow to maintain patients’ intraocular pressure level within the tolerable range.We proposed a novel microstent for minimally invasive glaucoma surgery consisting of a drainage tube in the form of a self-expanding frame with dimensions significantly lower than similar devices used in clinical practice. The purpose of this work was to study the safety of the microstent made of nitinol when implanted in the eyes of experimental animals.The study included 10 grey Chinchilla rabbits divided into two groups. The drainage implant was installed into one eye of an animal, while its second eye was used as control for evaluation of the effectiveness and safety of the microstent. The difference between the groups was conjunctival access; in the second group implantation was done through punctures, moving the knife towards the limbus area.No inflammatory reactions were observed in cases with implantation of the stent under the conjunctiva and the limbal area. Biomicroscopy showed no differences between animal eyes. No local irritation was found according to morphological criteria.Microstenting is a promising glaucoma treatment approach, and the present study shows prospects for its continued development and modification of the drainage implant and its delivery system.Актуальной является задача разработки дренирующего имплантируемого устройства (микростента) и способа его имплантации в ходе малоинвазивного вмешательства, в результате которого создается канал для оттока водянистой влаги и поддержания ВГД у больных глаукомой в пределах толерантного уровня.Нами предложен микростент, устройство для малоинвазивной хирургии глаукомы, которое представляет собой дренажную трубку в виде саморасширяющегося каркаса по размеру значительно меньший наиболее распространенных в клинической практике. Целью работы было исследование безопасности микростента из нитинола при имплантации в глаза экспериментальных животных.Исследование проведено на 10 кроликах породы шиншилла серый, которые были разделены на 2 группы. Имплантацию выполняли в один глаз животного, второй являлся контролем для оценки эффективности и безопасности микростента. Отличие между группами заключалось в конъюнктивальном доступе: первой группе туннель формировали после разреза и отсепаровки конъюнктивы; во второй группе имплантацию проводили через прокол, проводя нож до зоны лимба.Клинических проявлений воспалительной реакции не выявлено во всех случаях имплантации под конъюнктиву и в зону лимба. Биомикроскопически правый и левый глаз животного не отличались. Каких-либо данных о наличии местно-раздражающего действия по морфологическим критериям не обнаружено.Микростентирование является перспективным направлением в лечении глаукомы, а проведенное исследование открывает перспективы дальнейших модификаций самого дренажного устройства и его системы доставки

Three-year findings of the HORIZON trial: a Schlemm canal microstent for pressure reduction in primary open angle glaucoma and cataract

OBJECTIVE: To report 3-year outcomes of the HORIZON study comparing cataract surgery with Hydrus Microstent versus cataract surgery alone. DESIGN: Multicenter randomized clinical trial. PARTICIPANTS: Five hundred fifty-six eyes from 556 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: Following phacoemulsification, eyes were randomized 2:1 to receive a Hydrus® Microstent (Ivantis, Inc.) or no stent. Follow-up included comprehensive eye examinations through 3 years postoperatively. MAIN OUTCOME MEASURES: Outcome measures included IOP, medical therapy, reoperation rates, visual acuity, adverse events, and changes in corneal endothelial cell counts. RESULTS: 369 eyes were randomized to microstent treatment (HMS) and 187 to cataract surgery only (CS). Preoperative IOP, medication usage, washed out DIOP, and glaucoma severity did not differ between the two treatment groups. At 3 years, IOP was 16.7 ± 3.1 in the HMS group and 17.0 ± 3.4 in the CS group (p=0.85). The number of glaucoma medications was 0.4 ± 0.8 in the HMS group and 0.8 ± 1.0 in the CS group (p<0.001), and 73% of eyes in the HMS group were medication free compared to 48% in the CS group (p<0.001). The HMS group had a higher proportion of eyes with IOP ≤18 mmHg without medications compared to CS (56.2% vs. 34.6%, p<0.001) as well as IOP reduction of at least 20, 30 or 40 percent compared to CS alone. The cumulative probability of incisional glaucoma surgery was lower in the HMS group (0.6% vs. 3.9%, hazard ratio = 0.156, 95% CI 0.031 to 0.773, p=0.020). There was no difference in postoperative corneal endothelial cell loss between groups. There were no procedure or device related serious adverse events resulting in vision loss in either group. CONCLUSIONS: Combined cataract surgery and microstent placement for mild to moderate POAG is safe, more effective in lowering IOP with fewer medications, and less likely to result in further incisional glaucoma filtrations surgery than cataract surgery alone at 3 years