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Purpose: Despite holding promise, reports of using MIGS in severe glaucoma are scarce, and none has described combining multiple MIGS in this population. To the best of our knowledge, this is the largest study to report outcomes of phacoemulsification and MIGS (Phaco/MIGS) in patients with severe glaucoma. Methods: This retrospective review comprised 327 clinical visits of 71 patients with severe glaucoma who underwent Phaco/MIGS with iStent, endocyclodestruction, Kahook Dual Blade, Hydrus Microstent, or a combination of these MIGS (cMIGS) performed between 2016 and 2021. Primary outcomes included intraocular pressure (IOP) and medication burden evaluated by Generalized Estimating Equations, as well as Kaplan–Meier Estimates. Further analyses compared the efficacy of cMIGS and single Phaco/MIGS (sMIGS), procedure duration, visual acuity, and complications. Results: Mean preoperative IOP was 16.7 mmHg ± 5.8 (SD) on 2.3 ± 1.9 medications overall (N = 71), 16.9 ± 6.3 mmHg on 1.7 ± 1.9 medications in the sMIGS group (N = 37), and 16.4 ± 5.3 mmHg on 2.9 ± 1.6 medications in the cMIGS group (N = 34). Throughout 12 months, Phaco/MIGS led to significant reduction patterns in IOP (p < 0.001) and medications (p = 0.03). At 12 months, 47.5%, 87.5%, and 64.7% of the patients achieved IOP ≤ 12 mmHg, 17 mmHg, or predetermined goal IOP, respectively, without additional medication or procedure. Mean 12-month IOP was 13.5 ± 3.1 mmHg on 1.8 ± 1.7 medications. After adjusting for baseline medication burden, the reduction pattern in IOP (p < 0.05) was different between cMIGS and sMIGS, favoring cMIGS, and the groups had similar reduction patterns in medications (p = 0.75). Conclusion: The use of Phaco/MIGS in patients with cataract and severe glaucoma may significantly reduce IOP and medication burden throughout 12 months and, thus, may serve as a stepping stone in severe glaucoma patients with visually significant cataract before proceeding with more invasive glaucoma surgery. This effect may be potentiated by the combination effect of cMIGS. Plain Language Summary: Many patients with cataract and mild or moderate glaucoma who undergo cataract surgery also benefit from microinvasive glaucoma surgery (MIGS) performed at the same time, but the role of MIGS in patients with severe glaucoma and cataract is not clear. We report that combined cataract surgery and MIGS were associated with significant reductions in eye pressure in patients with severe glaucoma for more than 12 months. [ABSTRACT FROM AUTHOR]

Purpose: To compare outcomes of ab-interno canaloplasty and trabeculotomy of the superior versus inferior angle. Patients and methods: This was a prospective, non-randomized, interventional comparison study done at the Veteran Affairs Hospital in Long Beach, California. All patients underwent cataract surgery with intraocular lens implantation combined with ab-interno canaloplasty and trabeculotomy with the OMNI Surgical System (SightSciences, Menlo Park, CA, USA), either superiorly or inferiorly. Pre- and post-operative intraocular pressure using Goldmann applanation tonometry and best corrected visual acuity were obtained and compared using paired t-tests. Patients were excluded if they had any prior intraocular surgery or prior laser trabeculoplasty procedures. Results: 38 eyes from 29 patients were analyzed. 19 eyes were included in the superior group and 19 eyes in the inferior group. Mean pre-operative IOP in the superior group was 17.6 ± 5.2 mmHg and in the inferior group was 17.6 ± 4.6 mmHg (p > 0.99). At 12 months, mean postoperative IOP for the superior group decreased 24% to 13.3 ± 2.8 mmHg while the inferior group decreased 26% to 13.1 ± 2.2 mmHg (p = 0.92). Mean preoperative medications in the superior group were 2.2 ± 1.3 and in the inferior group was 2.4 ± 1.3 (p = 0.88). At 12 months, this decreased to 1.3 ± 1.5 post-operatively in the superior group and 2.2 ± 1.6 post-operatively in the inferior group (p = 0.64). Conclusion: There was no statistical difference in efficacy between superior versus inferior canaloplasty/trabeculotomy with OMNI. Therefore, surgeons can perform the procedure in the direction that is most comfortable for them without affecting outcomes. [ABSTRACT FROM AUTHOR]

aime E Dickerson Jr,1,2 Alison E Harvey,1 Reay H Brown1,31Sight Sciences, Inc., Menlo Park, CA, USA; 2North Texas Eye Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA; 3Atlanta Ophthalmology Associates, Atlanta, GA, USA Correspondence: Jaime E Dickerson Jr, Email [email protected] Purpose: To determine if there was an association between severity of glaucoma and intraocular pressure (IOP) and medication (med) outcomes for patients in the ROMEO (R etrospective, O bservational, M ulticenter E valuation of O MNI) study. Setting: Eleven ophthalmology practices in 8 US states. Design: Post-hoc analysis of all eyes enrolled and treated with ab interno canaloplasty and trabeculotomy in the retrospective, multicenter ROMEO study. Methods: Eyes were grouped according to visual field mean deviation (MD): mild (MD better than − 6 dB), moderate (MD between − 6 and − 12 dB), advanced (− 12 dB or worse). IOP and med outcomes at 12 months were compared across groups. Least squares regression was used to assess the relationship of MD with month 12 IOP. Outcomes for 1st and last MD deciles were compared as a sensitivity analysis. Results: One hundred and twenty-seven eyes were available for analysis including 79 mild, 42 moderate, 6 advanced. Most eyes had a reduction in IOP at Month 12 (70%) with most at 18 mmHg or less. Percentage IOP reduction was similar across the groups (mild 16.9%, moderate 18.6%, advanced 18.0%) with mean month 12 IOP between 14 and 16 mmHg. Medications were also reduced in all three groups; − 0.8 (mild, P < 0.001), − 0.55 (moderate, P < 0.05), and − 1.0 (advanced, P = 0.139, ns). Regression analysis revealed no relationship between month 12 IOP and MD. Med reductions were observed for all groups with a reduction of 1 or more medications seen in (%, 95% CI) 69%, 59– 79 (mild), 50%, 35– 65 (moderate), and 60%, 21– 99 (advanced). Secondary interventions tended to have greater incidence with worse MD likely reflecting lower desired IOP targets. Conclusion: Analysis of data from the ROMEO study suggests that similar meaningful IOP and med reductions can be expected across the range of disease severity studied. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate outcomes of new adopters of the OMNI® Surgical System (Sight Sciences, Inc.) by prospectively evaluating intermediate-term outcomes of patients operated by trainees. Patients and Methods: This was a prospective study of surgeries performed by trainees on patients with open angle glaucoma undergoing simultaneous cataract surgery and ab interno canaloplasty and trabeculotomy using the OMNI Surgical System. Pre-operative intraocular pressure (IOP) and number of glaucoma medications were recorded. Only patients with a minimum of 6-month follow up were included. Baseline IOP was used to separate subjects into two groups: Group 1 (IOP ≥ 18 mmHg) and Group 2 (IOP < 18 mmHg). Mean decrease in IOP and medications was calculated and compared with paired t-tests for the overall sample as well as the subgroups. Success was defined as those with a ≥ 20% reduction from pre-operative IOP or with an IOP ≤ 18 mmHg and ≥ 6 mmHg and on the same or fewer number of medications while not requiring additional surgery. Adverse events were also recorded. Results: Forty-two eyes of 31 patients were included. Mean pre-operative IOP was 17.2 ± 4.8 mmHg and mean number of medications was 2.4 ± 1.2. The primary endpoint was reached in 83.3% of patients at 12 months. IOP was reduced by 22.3% to 13.4 ± 2.4 (p< 0.001). Mean number of medications decreased to 1.7 ± 1.6 (p< 0.001). Group 1 mean IOP decreased 35.4% from 22.2 ± 4.6 mmHg to 14.3 ± 2.8 mmHg (p< 0.001). Group 2 mean number of medications decreased from 2.3 ± 1.1 to 1.6 ± 1.5 (p< 0.001). Conclusion: When operated on by the novice MIGS surgeon, the OMNI device provides effective IOP and glaucoma medication reduction with minimal adverse events. Efficacy and safety of the device in the hands of trainees was comparable to experienced glaucoma surgeons suggesting its ease of adoption. [ABSTRACT FROM AUTHOR]

Topical glaucoma medications have favorable safety and efficacy, but their use is limited by factors such as side effects, nonadherence, costs, ocular surface disease, intraocular pressure fluctuations, diminished quality of life, and the inherent difficulty of penetrating the corneal surface. Although traditionally these limitations have been accepted as an inevitable part of glaucoma treatment, a rapidly-evolving arena of minimally invasive surgical and laser interventions has initiated the beginnings of a reevaluation of the glaucoma treatment paradigm. This reevaluation encompasses an overall shift away from the reactive, topical-medication-first default and a shift toward earlier intervention with laser or surgical therapies such as selective laser trabeculoplasty, sustained-release drug delivery, and micro-invasive glaucoma surgery. Aside from favorable safety, these interventions may have clinically important attributes such as consistent IOP control, cost-effectiveness, independence from patient adherence, prevention of disease progression, and improved quality of life. [ABSTRACT FROM AUTHOR]

aime E Dickerson Jr5,6 On behalf of the GEMINI 2 STUDY GROUP1Vance Thompson Vision, West Fargo, ND, USA; 2Omni Eye Services, Atlanta, GA, USA; 3Ophthalmology Associates, Fort Worth, TX, USA; 4Oklahoma Eye Surgeons, Oklahoma City, OK, USA; 5Sight Sciences, Menlo Park, CA, USA; 6North Texas Eye Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USACorrespondence: Jaime E Dickerson, Email [email protected] Purpose: To provide long-term intraocular pressure (IOP) and ocular hypotensive medication usage outcomes through 36 months for patients treated with canaloplasty and trabeculotomy (OMNI Surgical System) combined with cataract surgery as participants in the GEMINI study.Setting: Eleven ophthalmology practices in 10 US states.Design: Non-interventional 36-month extension of the 12-month, prospective, multicenter, GEMINI study.Methods: GEMINI patients had visually significant cataract, mild-to-moderate glaucoma (ICD-10 guidelines), medicated IOP < 33 mmHg, and unmedicated mean diurnal IOP (DIOP) (after washout) 21– 36 mmHg. Patients from GEMINI were eligible for inclusion. Outcome measures were reduction in mean unmedicated DIOP, reduction in mean IOP-lowering medications, percent of eyes with ≥ 20% reduction in unmedicated DIOP, and percent of eyes with unmedicated DIOP ≥ 6 and ≤ 18 mmHg.Results: A total of 66 patients provided consent and were enrolled. Mean (SD) unmedicated DIOP was 23.1 (2.7) mmHg at baseline, 16.7 (4.1), 16.3 (3.3) at 24 and 36 months; mean reductions of 6.2 (4.1) and 6.9 (3.4) mmHg. Twelve-month IOP at the end of GEMINI was 15.6 mmHg. The proportion of eyes with ≥ 20% reduction in IOP was 77% and 78% (months 24 and 36) compared to 87% at month 12 from GEMINI. About 68% of patients had an IOP between 6 and 18 mmHg at 24 months and 71% at 36 months. Mean IOP-lowering medications was 1.7 at baseline, which was reduced to 0.4 (24 months, − 1.3) and 0.3 (36 months, − 1.4). About 74% of patients (46 of 62) were medication free at 36 months.Conclusion: GEMINI demonstrated 12-month effectiveness of canaloplasty and trabeculotomy with OMNI combined with cataract surgery for IOP and medication reduction in mild-to-moderate glaucoma. However, longer-term data is key to the decision making in the selection of a surgical treatment. This GEMINI extension demonstrates that the 12-month outcomes from GEMINI were sustained through 36 months. [ABSTRACT FROM AUTHOR]

Purpose: To examine the potential risk factors affecting the long-term outcomes following a combination of phacoemulsification with ab interno trabeculotomy with the microhook (μLOT-Phaco) and goniotomy with the Kahook Dual Blade (KDB-Phaco).Methods: For 12 months, we retrospectively examined a total of 100 eyes of 100 patients with primary open-angle glaucoma (POAG) and exfoliation glaucoma (EG) who had previously undergone surgery between December 2016 and December 2020. Patients with a preoperative intraocular pressure (IOP) ˂12 mmHg were excluded. Probability of success was calculated using the Kaplan–Meier method, with surgical failure defined as an IOP > 18 mmHg, < 20% IOP reduction or additional glaucoma surgery. The Cox proportional hazards model was used to examine the potential risk factors for failure, which included age, gender, type of glaucoma, surgical techniques, preoperative IOP, number and type of preoperative IOP-lowering medications, preoperative visual field mean deviation (MD) value, and axial length.Results: For the 51 males and 49 females, mean preoperative age was 74.4 ± 9.0 years, with μLOT-Phaco performed in 44 and KDB-Phaco in 56 subjects. The type of glaucoma was POAG in 68 and EG in 32 eyes. Preoperative IOP was 20.5 ± 6.7 mmHg, while postoperative IOPs were 14.4 ± 4.2 mmHg, 13.7 ± 2.8 mmHg, and 14.6 ± 3.9 mmHg, respectively (P < 0.001). Significant decreases from the preoperative number of IOP-lowering medications (3.1 ± 1.2) were observed at 12, 24, and 36 months, respectively (1.2 ± 1.3, 1.6 ± 1.3, and 2.1 ± 1.4 (P < 0.001)). Probability of success at 12, 24, and 36 months postoperatively was 52.0%, 49.6%, and 47.7%, respectively. Lower preoperative IOP was shown to be a potential risk factor for surgical failure.Conclusion: Long-term follow-ups showed IOP decreased in μLOT-Phaco and KDB-Phaco patients. Results suggest that patients with higher preoperative IOP may have better postoperative outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To assess the effectiveness of XEN45, either alone or in combination with phacoemulsification, in open-angle glaucoma (OAG) patients in clinical practice. Methods: Retrospective and single-center study conducted on OAG patients who underwent XEN45 implant, either alone or in combination with cataract surgery. We compared the clinical outcomes of the eyes of thosewho underwent XEN-solo versus those who underwent XEN+Phacoemulsification. The primary endpoint was the mean change in intraocular pressure (IOP) from baseline to the last follow-up visit. Results: A total of 154 eyes, 37 (24.0%) eyes that underwent XEN-solo and 117 (76.0%) eyes that underwent XEN+Phacoemulsification, were included. The mean preoperative IOP was significantly lowered from 19.1± 5.0 mmHg to 14.9± 3.8 mmHg at month-36, p< 0.0001. Preoperative IOP was significantly lowered from 21.2± 6.2 mmHg and 18.4± 4.3 mmHg to 14.3± 4.0 mm Hg and 15.2± 3.7 mmHg at month-36 in the XEN-solo and XEN+Phacoemulsification groups, p< 0.0004 and p=0.0009; with no significant differences between them. In the overall study population, the mean number of antiglaucoma medications was significantly reduced from 2.1± 0.8 to 0.2± 0.6, p< 0.0001. There were no significant differences in the proportion of eyes with a final IOP ≤ 14 mmHg and ≤ 16 mmHg between XEN-solo and XEN+Phaco groups (p=0.8406 and 0.04970, respectively). Thirty-six (23.4%) eyes required a needling procedure. Conclusion: XEN implant significantly lowered IOP and reduced the need of ocular hypotensive medication, while maintaining a good safety profile. Beyond week-1, there were no significant differences in IOP lowering between XEN-solo and XEN+Phacoemulsification groups. [ABSTRACT FROM AUTHOR]

aime E Dickerson Jnr8,91The Williamson Eye Center, Baton Rouge, LA, USA; 2Vold Vision, Fayetteville, AR, USA; 3Grene Vision Group, Wichita, KS, USA; 4Mercy Eye Specialists, Springfield, MO, USA; 5Buffalo Ophthalmology, Williamsville, NY, USA; 6Morris Eye Group, Encinitas, CA, USA; 7Arthur M Cotliar Eye Care and Surgery, New York, NY, USA; 8North Texas Eye Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA; 9Sight Sciences, Inc., Menlo Park, CA, USACorrespondence: Jaime E Dickerson Jnr, Email [email protected] Purpose: To provide extended safety and effectiveness follow-up for eyes treated with circumferential canaloplasty and trabeculotomy (CP+TR) that were included in the 12-month ROMEO study. Setting: Seven multi-subspecialty ophthalmology practices located in 6 states (Arkansas, California, Kansas, Louisiana, Missouri, and New York). Design: Retrospective, multicenter, IRB approved. Subjects: Eligible eyes had mild–moderate glaucoma and were treated with CP+TR with cataract surgery or as a standalone intervention. Methods: Main outcome measures were mean IOP, mean number of ocular hypotensive medications, mean change in number of medications, proportion of patients with a ≥ 20% reduction in IOP or with IOP ≤ 18 mmHg, and proportion of patients medication free. Safety outcomes were adverse events and secondary surgical interventions (SSI). Results: Eight surgeons at 7 centers contributed 72 patients stratified by pre-operative intraocular pressure (IOP); > 18 mmHg (Grp1), ≤ 18 mmHg (Grp2). Mean follow-up of 2.1 years (min 1.4, max 3.5). 2-year IOP (SD) was 15.6 mmHg (− 6.1 mmHg, − 28% from baseline) on 1.4 medications (− 0.9, − 39%) for Grp1 with cataract surgery; 14.7 mmHg (− 7.4 mmHg, − 33% from baseline) on 1.6 medications (− 0.7, − 15%) for Grp1 standalone, 13.7 mmHg (− 0.6 mmHg, − 4.2%) on 1.2 medications (− 0.8, − 35%) for Grp2 with cataract surgery, 13.3 mmHg (− 2.3 mmHg, − 14.7%) on 1.2 medications (− 1.0, − 46%) for Grp2 standalone. The proportion of patients at 2 years with either a ≥ 20% IOP reduction or IOP between 6 and 18 mmHg and no increase in medication or SSI was 75% (54 of 72, 95% CI 69.9%, 80.1%). One-third of patients (24 of 72) were medication free whereas 9 of 72 were pre-surgical. No device-related adverse events during extended follow-up; 6 eyes (8.3%) required additional surgical or laser intervention for IOP control after 12 months. Conclusion: CP+TR provides effective IOP control that is sustained for 2 years or more. [ABSTRACT FROM AUTHOR]

aime E Dickerson Jr,4,5 Dan Q Nguyen61Eugene and Marilyn Glick Eye Institute, Indiana School of Medicine, Indianapolis, IN, USA; 2Royal Surrey County Hospital, Guildford, England, UK; 3Valid Insight, Macclesfield, England, UK; 4Sight Sciences, Menlo Park, CA, USA; 5North Texas Eye Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA; 6Mid-Cheshire Hospitals NHS Foundation Trust, Crewe, UKCorrespondence: Francesca Torelli, Valid Insight, Ropewalks, Newton St, Macclesfield, SK11 6QJ, UK, Tel +44 203 750 9833 Ext 703, Email [email protected] Introduction: Selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS) are increasingly used options for mild-to-moderate open-angle glaucoma (OAG) care. While most MIGS devices are indicated for use in combination with cataract surgery only, with phacoemulsification playing a role in lowering IOP, newer technologies can also be used as standalone glaucoma surgery. Methods: This systematic literature review (SLR) aimed to assess the clinical, economic, and humanistic outcomes of MIGS and SLT for the treatment of OAG and was conducted according to PRISMA guidelines. Studies that assessed MIGS or SLT in at least one treatment arm versus any other glaucoma treatment in adults with mild-to-moderate OAG were included. Clinical, humanistic (health-related quality of life [HRQoL] and patient burden), and economic data were extracted, and the methodological quality of included studies was evaluated. Results: A total of 2720 articles were screened, and 81 publications were included. Fifty-eight reported clinical outcomes. The majority assessed iStent or iStent inject (n=41), followed by OMNI (n=9), gonioscopy-assisted transluminal trabeculotomy (GATT) or the Kahook Dual Blade (KDB) (n=7), Hydrus (n=6), SLT (n=5), Xen Gel Stent (n=2), PreserFlo (n=1), and iTrack (n=1). IOP reduction was observed across prospective studies, varying from − 31% to − 13.7% at month 6 and from − 39% to − 11.4% at year 1 versus baseline. Most adverse events were transient and non-serious. Limited humanistic and economic data were identified. Conclusion: Given their established efficacy and safety, there is a rationale for wider use of MIGS in mild-to-moderate OAG. Of the MIGS devices, iStent and OMNI have the largest clinical evidence base supporting their sustained effectiveness. [ABSTRACT FROM AUTHOR]

Purpose: To report the early postoperative causes of intraocular pressure (IOP) spikes after complete circumferential gonioscopy-assisted transluminal trabeculotomy (GATT) using anterior segment optical coherence tomography (ASOCT). Methods: This was retrospective interventional case series of patients who underwent circumferential GATT by a single surgeon (APR) from 2021 to 2022 at a tertiary eye care in East India and who developed IOP spikes at 1 day-2 weeks (immediate) or early (> 2 weeks– 2 months) after GATT. The intraocular pressure (IOP), glaucoma medications, and angle evaluation by ASOCT at 1 week, and 1 month were compared between the two groups. Results: Thirty-two eyes of 32 consecutive patients, aged 40± 20.1 years (20 exfoliation glaucoma, 9 juvenile open-angle, and 3 developmental glaucoma), that developed IOP spikes between immediate (n=20) or early (n=12) IOP spikes after GATT, were included. Immediate postoperative spikes were seen in 20 eyes due to retained viscoelastic (n=8), hyphema (n=8) in uncontrolled hypertension, and peripheral anterior synechiae (PAS) (n=6) of which only one eye required medication at 2 months. Causes of immediate IOP spikes on ASOCT included an inverted/reattached trabecular shelf, iris strands in eyes with abnormal iris in developmental glaucoma, and PAS in 1– 2 quadrants. Causes of early IOP spikes included PAS > 3 quadrants (n=8), and hyperreflective fibrotic tissue over TM (n=4) with 50% requiring medications at 2 months. The ASOCT features predicting the need for medications were PAS > 3 quadrants (OR=8.4[2.2– 14.3], p=0.03) and fibrotic TM closure (OR=5.4, [3.6– 10.2], p=0.003). One eye with macrohyphema 3 days after surgery owing to uncontrolled hypertension (owing to the stoppage of medicines), required additional incisional trabeculectomy within 1 month of surgery. Conclusion: Immediate IOP spikes are mostly self-resolving as opposed to early IOP spikes > 2 weeks that require medications after GATT. Gonioscopic PAS > 3 quadrants, and fibrotic TM closure were the main identifiable ASOCT causes predicting the need for medications after GATT. [ABSTRACT FROM AUTHOR]

Purpose: We introduce a newly designed T-shaped internal trabeculotomy hook and compare its surgical outcomes with those of Kahook dual blade (KDB) surgery. Patients and Methods: One eye each of seventeen and sixty-one patients underwent T-hook and KDB surgeries, respectively. Post-surgical intraocular pressure (IOP), medications, visual acuity, and prevalence of IOP spikes and hyphema were compared between the two cohorts. Results: The utility of the T-hook was excellent and enabled the easy opening of the Schlemm's canal. The pre-surgical IOP of 25.6 ± 7.5 mmHg in the T-hook cohort decreased to 14.1 ± 4.3 (− 41.2% reduction) and 15.0 ± 3.1mmHg (− 39.3% reduction) at 3 (P< 0.001) and 6 months (P=0.003), respectively. Pre-surgical medications of 2.8 decreased to 2.3 and 2.0 medications, respectively, at 3 and 6 months. The best-corrected visual acuity (BCVA) improved from the pre-surgical logarithm of the minimum angle resolution (logMAR) of 0.148 to − 0.012 at three months (P=0.036,). While the pre-surgical IOP of 24.9± 4.3 mmHg in the KDB cohort decreased to 16.5± 5.7 mmHg (− 35.5%, P< 0.001) and 16.1± 3.4 mmHg (− 33.5%, P< 0.001) at 3 and 6 months, respectively. Reduction in medications at 3- and 12-month timepoints (from 2.8 to 1.7 and 1.7, respectively; P< 0.001) and improvement in BCVA at three months (from 0.106 to − 0.025 logMAR, P< 0.001) were also significant. There was no difference between the T-hook and KDB cohorts in terms of the pre-surgical IOP (P=0.15) and post-surgical IOP at 1 (P=0.27), 3 (P=0.17), 6 (P=0.47), and 12 months (P=0.11, Mann–Whitney U-test). The prevalence of a post-surgical IOP spike in the T-hook and KDB cohorts was 41.2% and 47.5%, and that of post-surgical hyphema was 17.6% and 26.2%, respectively. Conclusion: The novel T-hook was easy to use and was as useful as the KDB device in performing internal trabeculotomy. [ABSTRACT FROM AUTHOR]

Purpose: To describe the case of a monocular patient with ocular mucous membrane pemphigoid (MMP) and open angle glaucoma refractory to medical treatment, who was successfully managed with ab interno goniotomy at the time of cataract surgery. Methods: A 63-year-old woman with a history of severe MMP presented with exacerbation of the disease in both eyes. Vision was 20/80 in the right eye and light perception in the left eye. Symblepharon formation, trichiasis and forniceal foreshortening were present in the right eye, while the cornea of the left eye was completely conjunctivalized. Following aggressive systemic immunosuppressive therapy with corticosteroids and cyclophosphamide, the disease was brought under control. However, the patient developed a mature cataract and high intraocular pressure (IOP) of 28 mmHg on maximal medical therapy. Due to the high risk of ocular MMP exacerbation with glaucoma filtration surgery, the decision was made to proceed with cataract extraction combined with ab interno goniotomy with the Kahook Dual Blade. Results: There were no intraoperative complications. The IOP has remained in the 12– 14 mmHg range without any topical glaucoma medications over a total follow up of 3.5 years. Conclusion: Ab interno goniotomy using the Kahook Dual Blade can significantly reduce IOP and medication burden in MMP cases, where any type of conjunctival incisional surgery could induce disease flare up. In this case, it represented a safe and effective surgical procedure for ocular MMP with concomitant refractory open angle glaucoma. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate 3-year safety and efficacy of two second-generation trabecular micro-bypass stents. (iStent inject®) with phacoemulsification. Materials and Methods: This multicenter retrospective study of iStent inject implantation with phacoemulsification included data from eight surgeons across Australia. Eyes with cataract and mild to advanced glaucoma [predominantly primary open-angle (POAG), primary angle closure (PAC), or normal-tension (NTG) glaucoma] or ocular hypertension (OHT) were included. Study assessments included intraocular pressure (IOP); number of ocular hypotensive medications; proportions of eyes with 0, 1, 2, or ≥ 3 IOP-lowering medications; IOP ≤ 15 mmHg or ≤ 18 mmHg; visual fields (VF); retinal nerve fiber layer thickness (RNFL); central corneal thickness (CCT); intraoperative complications; adverse events; and secondary surgeries. Results: A total of 273 eyes underwent surgery and had 36-month follow-up. At 36 months versus preoperative, mean IOP decreased by 15.5% (16.4± 4.6 mmHg to 13.9± 3.5 mmHg; p< 0.001), and 70.3% of eyes achieved IOP of ≤ 15 mmHg (versus 49.1% preoperatively; p< 0.001). The mean medication burden decreased by 68.5% (from 1.51± 1.17 to 0.48± 0.89 medications; p< 0.001); 71.4% of eyes were medication-free (versus 21.6% preoperatively; p< 0.001), while 6.2% of eyes were on ≥ 3 medications (versus 22.3% preoperatively; p< 0.001); 96.3% of eyes maintained or reduced medications vs preoperative. Significant IOP and medication reductions occurred across glaucoma subtypes (POAG, PAC, NTG, OHT): 13– 22% for IOP (p< 0.05 for all) and 42– 94% for medication (p< 0.05 for all). Favorable safety included few adverse events; stable VF, RNFL, and CCT; and filtering surgery in only 8 eyes (2.9%) over 3 years. Conclusion: In this multicenter cohort from 8 surgeons across Australia, significant IOP and medication reductions were sustained through 3 years after iStent inject implantation with phacoemulsification. Results were favorable across different glaucoma subtypes (including POAG, PAC, NTG, OHT), severities, and surgeons, thereby underscoring the real-world relevance and efficacy of iStent inject implantation for glaucoma treatment. [ABSTRACT FROM AUTHOR]

Purpose: After tube shunt surgery, many factors may contribute to insufficient filtration over time, prompting further intervention to achieve optimal intraocular pressure (IOP) control. This study explores whether ab interno XEN gel stent implantation could be a viable approach in eyes that need further IOP reduction after tube shunt surgery. Methods: This is a retrospective, single-surgeon case series on ab interno XEN45 gel stent implantation in eyes that had previous tube shunt surgery. Main outcome measures were IOP and number of glaucoma medications at the pre-operative visit, post-operative week (POW) 1, and post-operative month (POM) 1, 3, 6, and 12. Adverse events and further interventions were noted. Surgery outcome was qualified as absolute success (IOP ≤ 18mmHg or ≥ 20% IOP reduction without glaucoma medications), qualified success (IOP ≤ 18mmHg or ≥ 20% IOP reduction with glaucoma medications), or failure (IOP > 18mmHg and < 20% IOP reduction with maximum tolerated glaucoma medications). Results: 7 eyes from 6 patients were included in this study. IOP was reduced from 23.9 ± 5.3 mmHg (mean ± standard deviation) pre-operatively to 14.0 ± 5.3 mmHg at POM12 (p < 0.05). Number of glaucoma medications was reduced from 4.3 ± 1.3 pre-operatively to 1.6 ± 1.6 at POM12 (p < 0.05). Hypotony and choroidal effusion were noted in one case which resolved before POM1. Bleb needling was required in 3 of the 7 eyes (43%), with one eye requiring needling twice. By POM12, 2 of 7 eyes (29%) achieved absolute success, 4 eyes (57%) qualified success, and 1 eye (14%) was qualified as failure. Conclusion: Ab interno XEN gel stent can effectively reduce IOP and number of glaucoma medications after failed tube shunt surgery. Nonetheless, further interventions such as bleb needling may still be required to optimize IOP control. [ABSTRACT FROM AUTHOR]

Purpose: To determine the change in Humphrey visual field and clinical parameters after minimally invasive glaucoma surgery combined with cataract surgery. Patients and Methods: Patients undergoing minimally invasive glaucoma surgery combined with cataract surgery in a multicenter retrospective case series between 2013 and 2021 with reliable preoperative and 12 to 18 month postoperative visual field measurements were included. Devices included iStent, XEN, and Hydrus. Clinical parameters were compared with a generalized linear model with generalized estimating equations between preoperative and postoperative visits including best corrected visual acuity, intraocular pressure, number of glaucoma medications and visual fields. Visual field metrics included mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), and Collaborative Initial Glaucoma Treatment Study (CIGTS) score of total deviation probability and pattern deviation probability. Results: Forty-four eyes from 39 patients were included. During the follow up period, visual acuity improved from 0.23± 0.17 to 0.10± 0.14 logMAR (mean ± standard deviation, p< 0.001), number of glaucoma medications was reduced from 2.68± 1.06 to 1.46± 1.32 (p< 0.001), and intraocular pressure decreased from 17.08± 4.23 mmHg to 14.92± 3.13 mmHg (p=0.003). Differences across devices were negligible. The only significant difference was a greater reduction in number of glaucoma medications in the XEN group (p< 0.001). There were no significant changes in the global parameters of VFI, MD, PSD, or CIGTS. Conclusion: Overall, minimally invasive glaucoma surgery combined with cataract surgery appears to be effective at stabilizing visual field function, reducing intraocular pressure, reducing number of glaucoma medications, and improving visual acuity over a 12 to 18 month follow-up period across MIGS devices. [ABSTRACT FROM AUTHOR]

aime E Dickerson Jr4,6 On behalf of the ROMEO Study Group1Ophthalmology, Yale New Haven Hospital, New Haven, CT, USA; 2Vance Thompson Vision, Sioux Falls, SD, USA; 3Morris Eye Group, Encinitas, CA, USA; 4Clinical Research, Sight Sciences, Menlo Park, CA, USA; 5Mahatma Gandhi Medical College and Research Center, Wardha, India; 6North Texas Eye Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USACorrespondence: Jaime E Dickerson Jr, Email [email protected] Purpose: Twelve-month safety and effectiveness results for canaloplasty combined with trabeculotomy using the OMNI surgical system in pseudophakic eyes or combined with cataract surgery in mild-to-moderate open-angle glaucoma (OAG). Setting: Sixteen centers in 11 US states (AL, AR, CA, CT, KS, LA, MO, NY, SD, TN, TX). Design: Retrospective, case series, open-label. Methods: A total of 136 eligible patients from 20 surgeons: mild-to-moderate OAG (visual field mean deviation (MD) not worse than − 12 dB), 12-month follow-up, preoperative medicated IOP > 18 mmHg and ≤ 36 mmHg on ≤ 5 medications. One eye per patient enrolled. Endpoints included proportion with ≥ 20% reduction in IOP or IOP between 6 and 18 mmHg (inclusive) and on the same or fewer medications without secondary surgical intervention (SSI) (primary success), mean IOP, change in IOP, ocular hypotensive medication use, and proportion of patients with a 20% or greater reduction in IOP at 12 months. Safety: adverse events (AE) and best corrected visual acuity (BCVA). Results: Primary success was met by 71%. Mean IOP was reduced (22.3– 15.9 mmHg, p < 0.0001). Medications went from 1.9 ± 1.3 to 1.3 ± 1.2 (p < 0.001). AE were mild and as expected for angle surgery. The most frequent AE were BCVA loss (6%), mild inflammation (4%), IOP elevation (3%), and clinically significant hyphema (3%). There were 4 (3%) SSI. Conclusion: The OMNI system provides effective IOP reduction, sustained IOP control, and meaningful medication reduction for up to 12 months postoperative. The present study confirms and extends the results from ROMEO. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate short-term outcomes of combined ab interno canaloplasty and trabeculotomy in pseudophakic eyes with open-angle glaucoma. Patients and Methods: Series included all pseudophakic eyes with open-angle glaucoma treated with up to 360° ab interno canaloplasty and up to 360° ab interno trabeculotomy using a purpose-engineered device (OMNI, Sight Sciences Inc). Data collected prior to surgery and out to 6-months postoperative. Surgical success defined as a 20% reduction in intraocular pressure (IOP) without increase in glaucoma medication, or discontinuation of at least one glaucoma medication without increase in IOP. Other primary endpoints included mean IOP and number of glaucoma medications. Results: The study included 67 eyes of 52 patients with a mean age of 76.5 ± 8.9 years. Preoperative mean IOP was 22.1± 8.0 mmHg on 2.3± 1.4 glaucoma medications. Pressure lowering effects were sustained out to 6 months postoperative with a mean IOP of 15.2± 4.9 mmHg (p < 0.001) and mean medication reduction of 0.7± 1.4 (p < 0.001). Surgical success rate was 69.8% (30 eyes) and correlated with preoperative IOP. Two patients required a secondary surgical intervention. Conclusion: Combined ab interno canaloplasty and trabeculotomy as a standalone procedure is an effective means of reducing IOP and medication burden in pseudophakic eyes with open-angle glaucoma. [ABSTRACT FROM AUTHOR]

Background: We report the real-world distribution of glaucoma types and glaucoma surgeries in each age or sex group in our department. Methods: The department database of Matsue Red Cross Hospital, a tertiary care hospital, for eyes surgically treated to manage glaucoma between April 2014 and March 2018 was searched. Patient age, sex, disease type, and surgical procedure were collected from the database. The age was stratified by ≤ 64 years (young), 65– 74 years (pre-old), 75– 89 years (old), and ≥ 90 years (oldest-old or super-old). Results: In the database, 2036 consecutive surgeries (70.3 ± 14.4 years; 1015 males) were identified. Among all subjects, primary open-angle glaucoma (POAG) (42.7%) was the most frequent identifiable glaucoma type followed by primary angle-closure disease (PACD) (18.8%) and exfoliation glaucoma (17.9%). The glaucoma types differed significantly among the age groups (P < 0.0001); POAG was the most frequent type of glaucoma in young and pre-old groups, while PACD and exfoliation glaucoma were the most frequent glaucoma types in the oldest-old group. Among all subjects, trabeculotomy or other goniotomy/gonio-bypass surgery (41.7%) was the most frequent glaucoma surgery followed by long-tube shunt (22.1%) and trabeculectomy (16.2%). The glaucoma surgeries performed differed significantly among the age groups (P < 0.0001). The frequency of trabeculectomy was the highest in the young group (27.8%), trabeculotomy was the highest in the pre-old (42.6%) and old (46.6%) groups, and long tube shunt (41.3%) and cataract extraction + goniosynechialysis (32.6%) were the highest in the oldest-old group. The glaucoma type (P < 0.0001) and surgeries performed (P < 0.0001) differed significantly between sex groups; the rates of PACD and cataract extraction + goniosynechialysis were remarkably higher in female than male group. Conclusion: The types of glaucoma and required glaucoma surgeries differ among the different age groups and sexes. Primary angle-closure disease and exfoliation glaucoma are the major glaucoma types in the old and oldest-old age groups. [ABSTRACT FROM AUTHOR]

PRESERFLO™ MicroShunt is a new minimally invasive glaucoma surgical (MIGS) device, implanted with an ab externo approach, which drains the aqueous humor to the subconjunctival space. It has been designed as a safer and less invasive approach for treating medically uncontrolled primary open-angle glaucoma (POAG) patients. The classic way of MicroShunt implantation involves different key steps, which includes creating a small scleral pocket with a 1mm blade; passing a 25-gauge (25G) needle through the scleral pocket into the anterior chamber (AC); and subsequently flushing the stent with a 23-gauge (23G) thin-wall cannula. However, sliding the needle into the scleral pocket can create false passages, thus making the device's threading more difficult. The purpose of the current paper is to propose a simplified implantation approach. Our method proposes to make the scleral tunnel by using directly the 25G needle and, at the limbus, this 25G needle is used to slightly depress the sclera and enter into the AC. The MicroShunt is subsequently assembled on a 23G cannula mounted on a 1mL syringe. The syringe can then be used to flush the device. Outflow can thus be confirmed immediately by seeing drops of aqueous humor leaking from the external opening of the stent. This new approach may have different potential advantages, such as better control of the site of entry, avoids wrong passages, reduces or eliminates the risk of aqueous humor sideway flow, facilitates a parallel path to the iris plane, and it is faster. [ABSTRACT FROM AUTHOR]

Purpose: To characterize the clinical outcomes of a novel ab interno minimally invasive procedure with the STREAMLINE® Surgical System for creation of incisional goniotomies and canal of Schlemm viscodilation in eyes with mild to severe primary open-angle glaucoma (POAG). Methods: In a prospective, single-arm, first-in-human case series, 20 eyes of 20 subjects with mild to severe POAG underwent creation of incisional goniotomies and canal of Schlemm viscodilation following phacoemulsification cataract extraction after washout of all intraocular pressure (IOP)-lowering medications. The angle surgery portion was performed with a single-use handpiece tipped with a microcannula that creates precise goniotomies through the trabecular meshwork into the canal of Schlemm and delivers a small volume of ophthalmic viscosurgical device directly into the canal via precise catheterization. Outcomes in this interim analysis included mean reduction in IOP and medications through 6 months of follow-up, as well as the proportion of eyes achieving IOP reduction ≥ 20% from baseline. Results: At month 6, mean IOP reduction of ≥ 20% from baseline was achieved in 89.5% of eyes (17/19). Mean (standard deviation) medicated IOP at screening was 16.3 (3.6) mmHg and unmedicated baseline IOP (after washout) was 23.5 (2.5) mmHg. Mean IOP was significantly reduced from baseline through 6 months of follow-up to 14.7 (2.4) mmHg (p< 0.001), representing an IOP reduction of 8.8 mmHg (36.9%). Overall, 57.9% (11/19) of eyes decreased dependence on IOP-lowering medications by at least one medication, and 42.1% (8/19) were medication free. Mean medication use was reduced from 2.0 (0.8) at screening to 1.1 (1.1) at 6 months (p< 0.001). Three eyes had transient IOP spikes treated with topical medications. Conclusion: The creation of incisional goniotomies and canal of Schlemm viscodilation safely and effectively reduced IOP and the need for IOP-lowering medications by both clinically and statistically significant magnitudes in eyes with mild to severe POAG undergoing concomitant phacoemulsification cataract extraction through the first 6 months of follow-up. [ABSTRACT FROM AUTHOR]

Purpose: To report 12-month efficacy outcomes of 360° canaloplasty and 180° trabeculotomy using the OMNI surgical system in combination with phacoemulsification in patients with mild-moderate open-angle glaucoma (OAG) and visually significant cataract. Setting: Fifteen multi-subspecialty ophthalmology practices and surgery centers located in 14 US states. Design: Prospective, multicenter, IRB approved study of patients treated with canaloplasty (360°) and trabeculotomy (180°). Eligible patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤ 33 mmHg on 1 to 4 hypotensive medications. Unmedicated post-washout mean diurnal IOP (DIOP) ≥ 21 and ≤ 36 mmHg. Methods: Medication washout preoperatively and prior to month 12 DIOP. Effectiveness outcomes were IOP and IOP lowering medication use. Safety outcomes included adverse events and secondary surgical interventions (SSIs). Evaluations at 1, 3, 6, and 12 months. Results: A total of 149 subjects underwent surgery and 120 were included in the final effectiveness analysis. Mean (standard deviation) unmedicated diurnal IOP was reduced from 23.8 (3.1) mmHg at baseline to 15.6 (4.0) at month 12 (− 35%) and medications (before washout) were reduced from 1.8 (0.9) at baseline to 0.4 (0.9) at month 12 (− 80%). At month 12, 84.2% of eyes achieved IOP reductions > 20% from baseline, 80% of eyes were medication-free, and 76% of eyes achieved IOP between 6– 18 mmHg inclusive. Adverse events were uncommon. Most were mild and self-limited including transient hyphema (9 of 149; 6%) and transient IOP elevations (3 of 149; 2.0%). No eyes required SSIs or experienced loss of VA that was attributable to the device or procedure. Conclusion: Canaloplasty and trabeculotomy performed with the OMNI surgical system at the time of phacoemulsification significantly reduces unmedicated mean diurnal IOP and medication use 12 months postoperatively, with an excellent safety profile. This procedure should be considered for eyes with mild-moderate OAG to reduce IOP, medication burden, or both. [ABSTRACT FROM AUTHOR]

Glaucoma continues to be a leading cause of blindness worldwide for the same reasons as in the past several decades, including the lack of early detection, improper treatment, and non-adherence to therapy. Medical therapy continues to be the first-line therapy even as surgical techniques are improving in their safety and efficacy. To turn the tide in preventing blindness from glaucoma, attention must be focused on targeted patient education, screening, effective treatment, and addressing health disparities. To achieve this, early safer cataract surgery and microinvasive glaucoma surgery must be considered as a first-line therapy in addition to medical therapy to best lower both intraocular pressure and the medication burden. [ABSTRACT FROM AUTHOR]

Purpose: To assess the effectiveness and safety of primary-needling in eyes who underwent a XEN45 implant. Methods: Retrospective and single center study. Consecutive patients with early-to-moderate open-angle glaucoma (OAG) or ocular hypertension, who underwent XEN45 surgery, either alone or combined with phacoemulsification, and had at least a valid 12-month post-operative visit, were included in the study. Primary needling was performed by using a 30-gauge needle without viscoelastic. Subjects were divided in two groups: Eyes who underwent XEN+primary-needling (needling) and those who underwent XEN without primary-needling (no-needling). The primary end-point was the mean change in IOP from baseline to the last follow-up visit. Results: Sixty-three eyes, 19 (30.2%) in the needling group and 44 (69.8%) in the no-needling one, were included in the study. There were not significant differences in mean IOP lowering between needling and no-needling groups at month-12 (mean difference − 2.5± 5.3 mm Hg, p=0.0926). No significant differences in mean reduction of ocular-hypotensive medications were observed between needling and no-needling groups, p=0.8690. At month-12, 50 (80.6%) had blebs considered as functioning, with no difference between groups, p = 0.5631. At month-12, 59 (93.7%) eyes were classified as success, with no significant differences between needling (17/19) and no-needling (42/44) groups, p=0.3754. Secondary needling was performed in 8 (12.7%) eyes, without differences between groups (p=0.6333). Conclusion: Primary needling, at the time of surgery, was a safe procedure in OAG patients who underwent a XEN implant, although it was not associated with a lower postoperative IOP or less ocular hypotensive medications. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to determine whether ReSure hydrogel sealant is superior to standard suture for closure of clear corneal incisions in the setting of combined glaucoma procedures. Setting: Glaucoma Department, Duke University Eye Center. Design: This is a retrospective case series. Subjects studied were patients in a 6-year period undergoing combined phacoemulsification and glaucoma surgery. All cases were performed by the same surgeon. Wound closure methods correlated with discrete timeframes, as ReSure replaced suture midway through the study period, thereby establishing sutured closure as an analogous control group. Methods: All cases included a phacoemulsification procedure requiring a 2.4 mm clear corneal incision. Upon completion of the phacoemulsification portion of the case, the wound was closed with either ReSure hydrogel or standard 10– 0 suture closure. The researchers assessed the rate of Seidel-positive corneal wound leak on postoperative day one. Results: In all cases employing ReSure, no wound leak was observed at postoperative day one. Within the suture group, 3 cases showed Seidel positivity of the corneal incision. This equates to a statistically significant difference in wound leak frequency of 2.04% (P = 0.012); confidence interval, 0.21 to 5.82. Conclusion: ReSure was able to maintain closure 100% of the time over hundreds of combined cases. Suture, though the standard of practice, did not perform to this level, presenting with 3 cases of spontaneous wound leak. We conclude that ReSure is highly effective and superior to suture in closure of clear corneal incisions in combined glaucoma procedures. [ABSTRACT FROM AUTHOR]

Purpose: To compare the outcomes of ab interno suture trabeculotomy (AbI-TLO) and ab externo metal trabeculotomy (AbE-TLO) in adult patients with glaucoma aged over 40 years. Patients and Methods: A retrospective chart review was conducted, including adult patients with glaucoma who underwent AbI-TLO or AbE-TLO between January 2015 and June 2019. A single surgeon (YO) performed all the operations. Eighty-one patients (81 eyes) were included in this study. Surgical success was defined as a postoperative intraocular pressure (IOP) of ≤ 18 mmHg and an IOP reduction of ≥ 20% from the preoperative IOP, without requiring additional glaucoma surgery. Success rates were assessed using Kaplan–Meier survival curves and log-rank (Mantel–Cox) tests, while risk factors were analyzed using the Cox proportional hazards model. Results: Forty-nine patients who underwent AbI-TLO and 32 patients who underwent AbE-TLO were studied; the preoperative IOPs were 27.9 ± 7.3 (mean ± standard deviation) mmHg and 25.6 ± 8.1 mmHg in the AbI-TLO and AbE-TLO groups, respectively (p=0.217). The 12-month postoperative IOPs were 15.8 ± 4.0 mmHg and 16.3 ± 4.2 mmHg in the AbI-TLO and AbE-TLO groups, respectively (p=0.724). The surgical success rates at 12 months were 77.6% and 62.5% in the AbI-TLO and AbE-TLO groups, respectively (p=0.144). Postoperative hyphema with level formation and ocular hypertension over 30 mmHg were observed in 22.4% and 26.5% of patients in the AbI-TLO group and 18.8% and 12.5% of those in the AbE-TLO group, respectively. Stepwise multivariate Cox regression analysis showed that a longer axial length was a risk factor for surgical failure (hazard ratio: 2.030; p=0.042). Conclusion: AbI-TLO and AbE-TLO had similar surgical outcomes and postoperative complications. A longer axial length was associated with an insufficient IOP reduction. [ABSTRACT FROM AUTHOR]

Background/Aims: Surgical procedures in ophthalmology underlie variations over different time periods and are strongly dependent on the technical process and the invention of innovative surgical techniques. Especially, in glaucoma surgery a lot of surgical devices and techniques have been introduced during the last years. Until now, the use of these newer techniques has not been shown on a robust data basis. We herein present the numbers of different types of glaucoma surgeries performed at German hospitals between 2006 and 2018. Methods and Design: The quality reports of hospitals in Germany from 2006 to 2018 were analyzed concerning all procedural codes for glaucoma surgery and intervention. Especially, the change in usage of "classical" and "modern" surgical techniques (MIGS: "minimally invasive glaucoma surgery") or devices was compared. Results: The number of glaucoma procedures performed increased by 75% from 27,811 in 2006 to 48,794 in 2018. Absolute numbers of trabeculectomies, goniotomies, ab externo trabeculotomies and to a certain level cyclodestructive procedures decreased during the examined years while use of MIGS has increased in absolute and relative numbers since 2012. From 2015 a strong increase in the usage of XEN implants could be seen. Drainage implants (such as Baerveldt/Ahmed) showed stable absolute numbers over the time period covered. Absolute numbers of laser trabeculoplasty peaked in 2014 and decreased afterwards. Iridotomies and iridectomies increased by 120%/248% over the whole period. Conclusion: Our data show a trend towards the modern surgical options and especially MIGS during the recent years. Classical procedures showed a decrease in total numbers emphasized from 2013. These numbers confirm the assumption that modern glaucoma surgery is becoming more and more popular and established in German hospitals. [ABSTRACT FROM AUTHOR]

Introduction: This retrospective comparative study assessed real-world effectiveness and safety of first-generation (iStent®) and second-generation (iStent inject®) trabecular micro-bypass stents with cataract surgery in patients with open-angle glaucoma (OAG). Material and Methods: Through a 24-month postoperative follow-up, the effectiveness was quantified by intraocular pressure (IOP) reduction; mean glaucoma medication reduction; proportional analysis of eyes meeting IOP cutoffs (< 18, < 15, < 12 mmHg) either with or without medications; and proportional analysis of medication burden. Safety measures included visual acuity, adverse events, and secondary surgery. Results: A total of 82 consecutive eyes (39 iStent, 43 iStent inject) with a 24-month follow-up were analyzed. Most eyes (74.4%) had primary open-angle glaucoma, with the remainder having pseudoexfoliative or pigmentary glaucoma; all eyes had mild-to-moderate disease. At 24 months postoperative, the mean IOP was lower, and the percent reduction from baseline was greater, in iStent inject eyes (26.0% reduction, 17.7mmHg to 13.1mmHg) than in iStent eyes (9.8% reduction, 16.4mmHg to 14.8mmHg) (between-groups comparison, p=0.019). Within each group, the postoperative IOP reduction was greater in eyes with higher baseline IOP (p< 0.001). Medication burden decreased significantly in both groups, from 1.74 to 0.51 mean medications for iStent (70.7% reduction, p< 0.0001), and 2.19 to 0.65 for iStent inject (70.3% reduction, p< 0.0001). Both groups exhibited excellent safety. Conclusion: iStent or iStent inject with phacoemulsification produced significant IOP and medication reductions, with effects enduring for two years. IOP reductions were greater for iStent inject than for iStent. Within each group, higher preoperative IOP was associated with greater postoperative IOP reduction. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to compare the effect of trabectome surgery in patients with and without intolerance to their medication and with preoperatively sufficiently controlled, insufficiently controlled, and uncontrolled intraocular pressure (IOP) on the surgical outcome. Patients and Methods: A total of 155 eyes (133 patients) with different forms of open angle glaucoma with or without intolerance to their glaucoma medication undergoing trabectome surgery alone (AIT) or combined with phacoemulsification (phaco-AIT) were included in this retrospective monocentric study. Patients were corresponding to IOP ≤ 18 mmHg (controlled but glaucoma progression or intolerance, group 1), 19– 26 mmHg (insufficiently controlled, group 2), and ≥ 26 mmHg (not controlled, group 3), respectively. Pre- and postoperative IOP and the number of IOP-lowering medications were registered over 12 months. Surgical success was defined as a postoperative IOP of ≤ 18mmHg and/or reduction of the topical treatment demand after 1 year. Results: Of the 155 included eyes, 79 received AIT and 76 received phaco-AIT. Sixty-nine eyes had a preoperatively sufficiently controlled IOP, 63 had an insufficiently controlled IOP, and 23 had an uncontrolled IOP. In all groups, the IOP significantly dropped by 6 and 12 months after surgery (p < 0.001). Surgical success war similar in all groups [47.8% (group 1), 38.1 (group 2) and 34.8% (group 3); p= 0.47]. The effect of AIT on IOP and glaucoma medication independent of intolerance to the anti-glaucoma medication and type of surgery (AIT/phaco-AIT). Conclusion: Independently of the preoperative IOP, a satisfying surgical success was achieved using AIT. In instances that do not qualify for filtrating surgery, trabectome surgery alone or in combination with phacoemulsification thus represents a safe and effective minimally invasive glaucoma surgery technique regardless of an intolerance to the topical medication. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to evaluate the 24-month efficacy of viscodilation of Schlemm's canal and the distal outflow system with iTrack ab-interno canaloplasty in reducing intraocular pressure (IOP) and antiglaucoma medication use in patients with primary open-angle glaucoma (POAG). Patients and Methods: This retrospective, comparative, and consecutive case series assessed the 24-month outcomes of iTrack as a standalone procedure (iTrack-alone) or in conjunction with cataract surgery (iTrack+phaco), in cases of mild, moderate or severe POAG. Data were collected at baseline and the 12- and 24-month follow-up visits. Results: The study included 53 patients (60 eyes) with a mean age of 73.6± 9 years. For all eyes, a significant reduction in mean IOP was seen at 12 and 24 months, reducing from 20± 4.9 mmHg at baseline to 13.6± 1.9 mmHg and 13.5± 2.6 mmHg, respectively (P< 0.001). The reduction in medications was also significant, reducing to 1.12± 1.09 and 1.7± 1.29 medications at 12 months and 24 months, respectively, from a baseline of 2.77± 0.91 (P< 0.001). Similar results were achieved whether iTrack was performed as a standalone procedure, or in conjunction with cataract surgery. While the iTrack-alone group started with a higher IOP at baseline, both groups experienced similar and stable IOP reduction of more than 30% from baseline. The reduction in medication use was also significant in both groups, decreasing from 3± 0.7 for iTrack-alone and 2.5± 1.1 for iTrack+phaco at baseline to 2.1± 1.3 and 1.3± 1.2 at 24 months, respectively (P< 0.001). The 24-month efficacy outcomes were similar in cases of mild–moderate versus severe glaucoma. No serious adverse events were recorded. Conclusion: Twenty-four-month follow-up data demonstrate that iTrack ab-interno canaloplasty can effectively reduce IOP and medication dependence, with a good safety profile. These results also demonstrate that iTrack can be effectively performed as a standalone procedure or in combination with cataract surgery, and in all grades of glaucoma severity. [ABSTRACT FROM AUTHOR]

Purpose: Efficacy and safety evaluation of Kahook Dual Blade (KDB) goniotomy vs iStent inject implantation. Materials and Methods: Retrospective study in patients that underwent goniotomy with KDB or iStent inject implantation, stand-alone or combined with cataract surgery. Main outcome parameters were intraocular pressure (IOP), number of glaucoma medications, proportion of eyes achieving > 20% IOP reduction and number of eyes with postoperative IOP < 19 mmHg at last follow-up. Results: A total of 29 patients (30 eyes) were included in the iStent inject group and 30 patients (32 eyes) in the KDB group. Mean follow-ups were 20.9± 6.5 (KDB-alone) to 29.5± 7.6 (phaco-iStent inject) months. Pre- and post-operative IOPs were 22.2± 5.8 mmHg and 15.9± 4.3 mmHg (P=0.004) in the KDB-alone, 24.2± 6.8 mmHg and 16.2± 6.7 mmHg (P=0.001) in the phaco-KDB, 20.6± 5.4 mmHg and 20.9± 6.8 mmHg (P=0.598) in the iStent inject-alone as well as 20.9± 5.5 mmHg and 15.6± 3.4 mmHg (P=0.003) in the phaco-iStent inject subgroups. No major complications occurred. Conclusion: All KDB and iStent subgroups except the stand-alone iStent inject subgroup showed a clinically significant IOP-lowering effect as a stand-alone procedure or combined with cataract surgery. Goniotomy with KDB in this setting seems to offer an advantageous IOP reduction compared to iStent inject. [ABSTRACT FROM AUTHOR]

Purpose: To report interim 6-month safety and efficacy outcomes of 360° canaloplasty and 180° trabeculotomy using the OMNI® Surgical System concomitantly with phacoemulsification in patients with open-angle glaucoma (OAG). Setting: Fifteen multi-subspecialty ophthalmology practices and surgery centers located in 14 states (Alabama, Arizona, Arkansas, Florida, Georgia, Iowa, Kansas, Montana, Nebraska, North Dakota, Oklahoma, Pennsylvania, Texas, and Wisconsin). Design: Prospective, multicenter, IRB approved study of patients treated with canaloplasty (360°) and trabeculotomy (180°). Eligible patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤ 33 mmHg on 1 to 4 hypotensive medications. Methods: Medication washout prior to baseline diurnal IOP (Goldmann). Effectiveness outcomes included mean IOP and medications. Safety outcomes included adverse events (AE), best corrected visual acuity (BCVA) and secondary surgical interventions (SSI). Analysis includes descriptive statistics and t-tests evaluating change from baseline. Results: A total of 137 patients were enrolled and treated. Mean diurnal IOP after washout was 23.8 ± 3.1 mmHg at baseline. At month 6, 78% (104/134) were medication free with IOP of 14.2 mmHg, a mean reduction of 9.0 mmHg (38%). 100% (104/104) had a ≥ 20% reduction in IOP and 86% (89/104) had IOP ≥ 6 and ≤ 18 mmHg. The mean number of medications at screening was 1.8 ± 0.9 and 0.6 ± 1.0 at month 6. AE included transient hyphema (4.6%) and IOP elevation ≥ 10 mmHg (2%). There were no AE for loss of BCVA or recurring hyphema. There were no SSI. Conclusion: Canaloplasty followed with trabeculotomy and performed concomitantly with phacoemulsification has favorable intra and perioperative safety, significantly reduces IOP and anti-glaucoma medications through 6 months in eyes with mild-moderate OAG. [ABSTRACT FROM AUTHOR]

Purpose: To compare the safety and efficacy of two different techniques for implantation of the XEN Gel Stent, a minimally invasive surgical device for the treatment of refractory glaucoma. Methods: A retrospective chart review of eyes that received ab interno or ab externo XEN Gel Stent placement from February 2017 to October 2019 was conducted. A single surgeon (NMR) performed all operations. Eyes that received the XEN implant concomitant with a glaucoma drainage device insertion or that were lost to 6-month follow-up were excluded. Intraocular pressure (IOP) change, change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes compared between groups. Results: Fifty eyes that underwent ab interno placement and 30 eyes that underwent ab externo placement were studied. The ab interno cohort demonstrated a mean IOP reduction of 8.4 ± 1.7 mmHg (28.6% decrease) by 12 months, compared to a mean reduction of 12.8 ± 3.0 mmHg (40.1% decrease) in the ab externo group (p = 0.208). Mean reduction in medication use was 1.81 ± 0.29 medications in the ab interno group and 1.86 ± 0.37 in the ab externo group (p = 0.913). By 12 months, 58% of ab interno eyes had required 5-fluorouracil injection compared to 36.7% of ab externos (p = 0.105). Bleb needling was applied to 42% and 26.7% of the eyes, respectively (p = 0.231). A second glaucoma surgery was necessary for 20% of the ab interno cohort and 10% of the ab externo cohort (p = 0.351). Conclusion: There were no differences in outcomes between ab interno and ab externo placement of the XEN Gel Stent. Both approaches are safe and effective for lowering IOP. [ABSTRACT FROM AUTHOR]

Purpose: The present study aimed to compare the outcomes of combined phacoemulsification and 360-degree endocyclophotocoagulation with and without goniotomy using a Kahook Dual Blade in patients with glaucoma. Patients and Methods: We enrolled 37 patients, 21 of whom underwent combined phacoemulsification with 360-degree endocyclophotocoagulation and goniotomy using a Kahook Dual Blade (tri-modal therapy (T-MT) group). The remaining 16 patients underwent phacoemulsification with endocyclophotocoagulation (bi-modal therapy (B-MT) group). Visual acuity, intraocular pressure, and number of glaucoma medications were recorded before the study and postoperatively on the first day, at week 1, and at 1, 3, 6, 9, and 12 months. Surgical success was defined as an IOP ≤ 12 mmHg and ≥ 6 mmHg or an at least 20% reduction in IOP from baseline with (qualified success) or without medications (complete success). Results: Forty-nine eyes were included. Baseline mean IOP was 16.96± 3.66 mmHg and 15.64± 4.88 mmHg in the T-MT and B-MT groups (p=0.122), respectively. At the 12-month follow-up, mean IOP values were 11.44± 2.15 mmHg and 12.45± 1.90 mmHg (p=0.031) in the T-MT and B-MT groups, respectively. Complete success rates were 37% in the T-MT group and 31% in the B-MT group, while qualified success rates were 74% and 50%, respectively. Glaucoma medications decreased from 2.0± 1.4 to 0.8± 1.0 (p< 0.001) in the T-MT group and from 1.5± 1.3 to 1.0± 1.5 in the B-MT group (p=0.032). Similar improvements in visual acuity were observed in both groups. Complications were mild and resolved without intervention. Conclusion: The tri-modal treatment is safe and may be more effective in reducing IOP and glaucoma medication requirements than bi-modal treatment. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: To determine the effect of Kahook Dual Blade goniotomy with phacoemulsification (Phaco-KDB) compared to phacoemulsification alone (Phaco) on surgically induced astigmatism (SIA). Design: Prospective study. Participants: Forty eyes of 28 patients treated with Phaco-KDB and 20 eyes of 13 patients treated with Phaco between 12/27/16 and 7/23/19 with a minimum 1 month follow-up were prospectively enrolled. Methods: Corneal astigmatism was assessed pre- and post-operatively using the simulated K (simK) values from the Pentacam Holladay report. Main Outcome Measures: SIA was compared between Phaco-KDB and Phaco groups using mean magnitude SIA, rate of ≥ 0.50 D SIA, and SIA centroids. Results: The difference in mean magnitude SIA was not statistically significant between Phaco-KDB and Phaco (mean = 0.28 D and 0.25 D, respectively, P = 0.621). The difference in the rate of ≥ 0.50 D SIA was not statistically significant between Phaco-KDB and Phaco (11.6% and 10.0%, respectively, P = 1.00). The SIA centroid for Phaco-KDB was 0.05 D @ 51° ± 0.40 D and 0.07 D @ 3° ± 0.32 D for Phaco. Conclusion: Neither the mean magnitude SIA nor the rate of astigmatic change ≥ 0.50 D was significantly different between Phaco-KDB and Phaco groups. SIA centroids between groups showed comparable and negligible effect on corneal astigmatism. KDB combined with phacoemulsification may not significantly affect SIA compared to phacoemulsification alone based on postoperative topography and is likely an astigmatically neutral procedure. [ABSTRACT FROM AUTHOR]

Purpose: Evaluation of 1-year-outcome of XEN 45 gel stent surgery in a Swedish cohort with regard to clinical success, complications, and learning curve. Patients and Methods: This was a retrospective study of glaucoma patients undergoing glaucoma XEN-stent surgery alone or combined with phacoemulsification between December 2015 and May 2017. Intraocular pressure (IOP), number of medical agents, and adverse events were assessed. Clinical success rate was defined as achieving individual target pressure with/without medication. Results: A total of 113 eyes were included in the final statistics. Mean age was 70.8± 11.8 years. Primary open angle glaucoma (POAG) accounted for 46.9% and exfoliative glaucoma (PEXG) for 40.7%. Mean preoperative IOP was 23.8± 6.2 mmHg and mean number of agents 3.4. After 1 year, mean IOP was reduced to 16.1± 4.7 mmHg and medication to 1.34 substances on average. Failure rate at 1-year follow-up was 34% with no significant difference between POAG and PEXG. There was a trend of higher success rate for combined cases (P=0.116). Stents with malpositioned or curved appearance had significantly worse outcome. The failure rate of the most productive surgeon dropped from 33% to 10% from the first implantations. Temporary hypotony (19.5%) and choroidal detachment (9.7%) were the most common complications. Blockage of the inner stent lumen was common (8.8%), with a high proportion of failure. Conclusion: XEN-stent surgery is a surgical option in uncontrolled glaucoma in both POAG and PEXG. A XEN-stent can reduce both IOP and the number of antiglaucoma medications needed. The learning curve is significant and stent positioning is crucial for optimal results. Combined XEN-cataract surgery is not inferior to stand-alone procedures. The long-time effectiveness is still to be proven. [ABSTRACT FROM AUTHOR]

Purpose: This multicenter study evaluated 2-year effectiveness and safety following implantation of two second-generation trabecular micro-bypass stents (iStent inject®) with phacoemulsification. Materials and Methods: This was a retrospective study of iStent inject implantation with phacoemulsification by nine surgeons across Australia. Eyes had mild to advanced glaucoma (predominantly primary open-angle/POAG, appositional angle-closure/ACG, or normal-tension/NTG) or ocular hypertension (OHT), and cataract. Evaluations included intraocular pressure (IOP); medications; proportions of eyes with 0 or ≥ 2 medications, reduced/stable medications versus preoperative, and IOP ≤ 15 mmHg; visual acuity; cup-to-disc ratio (CDR); visual fields (VF); adverse events; and secondary surgery. Results: A total of 340 eyes underwent surgery and had 24-month follow-up data. At 24 months, mean IOP decreased by 16% from 16.4± 4.7 mmHg preoperatively to 13.7± 3.1 mmHg (p< 0.001), and 77% of eyes achieved IOP of ≤ 15 mmHg versus 49% preoperatively (p< 0.001). Mean number of medications decreased by 67% to 0.49± 0.95 versus 1.49± 1.20 preoperatively (p< 0.001), with 74% of eyes medication-free versus 25% preoperatively (p< 0.001), and 14% of eyes on ≥ 2 medications versus 46% preoperatively (p< 0.001). Medication burden was reduced or stable in 98% of eyes versus preoperative. Stratified analyses showed significant IOP and medication reductions across glaucoma subtypes (POAG, ACG, NTG, OHT): 13– 22% for IOP (p< 0.01 for all) and 62– 100% for medication (p< 0.001 for all). Favorable safety included few adverse events; stable CDR, VF, and visual acuity; and filtering surgery in only 8 eyes (2.4%) over 2 years. Conclusion: This 340-eye multicenter dataset provides robust evidence of the safety and efficacy of iStent inject implantation with phacoemulsification, with significant and sustained IOP and medication reductions through 2 years. Results were similarly favorable across glaucoma subtypes (including POAG, ACG, NTG, OHT) and were attained across various glaucoma severities, clinical sites, and surgeons, highlighting the real-world versatility and utility of this treatment modality. [ABSTRACT FROM AUTHOR]

Purpose: To determine the quality of life (QOL) in glaucoma patients undergoing combined cataract and minimally invasive glaucoma surgery from various perspectives ranging from personal, social, occupational life, and economic status. Settings and Design: A cross-sectional study design at King Fahd Hospital of the University, Khobar, Saudi Arabia. Methods: Patients undergoing phacoemulsification in conjunction with various forms of minimally invasive glaucoma surgery (MIGS) for each patient, including either Kahook Dual Blade (KDB) goniotomy, iStent, iStent inject and gonioscopy-assisted transluminal trabeculotomy (GATT), were included in the study between 2018 and 2019. Data were collected through a self-administered questionnaire based on the Visual Function Questionnaire (VFQ-25) for the 25-item National Eye Institute. Results: The study included 93 eyes of 78 patients (40 males and 38 females) who had MIGS: 50 KDB, 13 iStent, 23 iStent inject, and 7 GATT. An overall reduction in the number of anti-glaucoma medications (p< 0.001) was statistically significant. In the study, 36.6% of patients had a better social life, but 85.2% had no change in occupational life. Eventually, 86% were satisfied with the operation's outcome, and 79% confirmed that the overall quality of life improved after the procedure. Conclusion: Evaluating QOL is a crucial component of glaucoma treatment. More research is needed on MIGS and their relationship to QOL. In the future, MIGS may provide the desired outcomes in controlling glaucoma and improving the QOL. [ABSTRACT FROM AUTHOR]

Purpose: To report treatment outcomes of ab interno canaloplasty using the Visco360 and Omni system devices as a standalone procedure or combined with cataract surgery in patients with open-angle glaucoma (OAG). Design: Retrospective, single-center, consecutive case series. Study Patients: Eighty-nine eyes of 64 patients aged 43 to 91 with open-angle glaucoma treated with ab interno canaloplasty between January 2018 and September 2019. Eyes with previous incisional glaucoma surgery and eyes with less than 90 degrees of viscodilation were excluded. Intervention: Patients underwent ab interno canaloplasty as a stand-alone procedure or in conjunction with cataract surgery. Ab interno canaloplasty was performed with either the Visco360 or Omni System devices (Sight Sciences, Menlo Park, CA). Treatment consisted of viscodilation without trabeculotomy. Main Outcome Measures: Primary outcome measures were mean IOP and mean number of glaucoma medications. Additional analysis included the impact of degrees of treatment on treatment outcomes. Results: Preoperative mean IOP was 24.5 ± 8.3; the number of preoperative glaucoma medications was 2.5 ± 1.3. At 18 months postoperative, the mean IOP was reduced 36% to 15.8 ± 2.5 (P< 0.001) and glaucoma medications were reduced 32% to 1.7 ± 1.5 (P< 0.05). Higher preoperative IOP was significantly correlated with increased IOP lowering. Reduction of mean IOP and medications were not significantly different between standalone ab interno canaloplasty vs cataract surgery/ab interno canaloplasty. Reduction of mean IOP and medications were not significantly different between patients with 180 degrees of treatment vs 360 degrees of treatment. Conclusion: Ab interno canaloplasty reduces IOP and glaucoma medication use in patients with OAG whether as a standalone surgery or in combination with cataract surgery. [ABSTRACT FROM AUTHOR]

Purpose: To understand the distribution of trabeculectomies, glaucoma drainage implants (GDI) and micro-invasive glaucoma surgeries (MIGS) performed in the United States through geospatial mapping. Methods: We performed an observational cohort study to evaluate glaucoma surgeries in patients age ≥ 65. The most recently released data from Centers for Medicare Part B Carrier Summary Files were queried to determine the number of glaucoma surgeries performed per state during the year of 2017. We created choropleth maps, titled "GlaucoMap", to characterize the rates of various surgeries performed across the United States, defined as the number of procedures performed per 10,000 individuals. A chi-squared analysis was further used to evaluate differences in surgical preferences across geographic region. Standardized residuals (SR) were calculated to determine regional influences on surgical distribution. Results: There were 174,788 glaucoma surgeries performed: 22,862 trabeculectomies (13.1%), 19,991 GDI (11.4%) and 131,935 (75.5%) MIGS. The Northeast had the highest trabeculectomy rate, GDI was highest in the Southeast and MIGS were highest in the Southwest. There was a statistically significant difference in proportional use of conventional surgeries versus MIGS across various regions in the United States (p < 0.0001). Given the high trabeculectomy and GDI rates and relatively low MIGS adoption in the Southeast, we observed a +7.03 SR for conventional surgeries and − 4.01 SR for MIGS. The Southwest and Western states had the highest MIGS rate and contributed +3.29 and +3.24 SR toward disproportional MIGS preference, respectively. The preference for conventional surgeries in the Northeast (SR = +2.93) and MIGS in the Midwest (SR = +0.99) also contribute to the overall differences in glaucoma surgeries across the United States. Conclusion: GlaucoMap is useful for visualizing the distribution of glaucoma surgeries in the United States. The heterogeneity in surgical preferences points to regional differences in glaucoma management. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the long-term safety and efficacy of an iStent trabecular microbypass stent in combination with cataract surgery in eyes with primary open-angle glaucoma (POAG). Setting: Private practice; Sioux Falls, South Dakota. Design: Retrospective, consecutive case series. Methods: This case series included eyes implanted with a single trabecular microbypass stent in combination with phacoemulsification in patients with mild to severe POAG. Data were collected preoperatively and at day 1, week 1, month 1, and up to 6 years postoperatively. Primary outcome measures included mean intraocular pressure (IOP) and number of glaucoma medications. Safety was noted by assessing the incidence of IOP spikes and need for additional surgery. Results: The study comprised 411 eyes. Mean IOP was reduced to 14.9± 4.2 mmHg compared to 18.8± 5.6 mmHg at baseline at 6 years postoperative. The mean number of medications was reduced to 1.2± 1.0 from 1.4± 1.1 at baseline. In eyes with severe stage of disease, there was a mean IOP reduction > 6 mmHg at 6 years postoperative. Eyes with baseline IOP ≥ 18 mmHg achieved a more robust reduction in IOP. Fifteen eyes underwent a secondary glaucoma procedure. There were no intra- or postoperative complications. Conclusion: Trabecular microbypass stent implantation in combination with cataract surgery provides a sustained IOP reduction in eyes with mild-to-severe POAG. The degree of IOP reduction was more significant in eyes with higher baseline IOP and severe stage of disease. [ABSTRACT FROM AUTHOR]

Purpose: The emergence of microinvasive glaucoma surgeries (MIGS) has expanded glaucoma management options. Resident experience with these novel procedures is unclear as no residency minimums exist for them, nor are they part of Accreditation Council for Graduate Medical Education (ACGME) procedure logs. The purpose of this study was to assess resident experience with MIGS in ACGME ophthalmology residency programs across the United States. Methods: This was a cross-sectional survey study of resident MIGS experience. A survey was mailed to program directors of ACGME-accredited ophthalmology residency programs (N = 118) in January 2017. Descriptive analyses were used to characterize the respondent demographics. Chi-square, paired t-tests, and McNemar's tests were used to analyze the geographical distribution and frequency of MIGS experience. Results: A total of 30 out of 118 (25%) residency program directors across all geographic regions responded. Most incorporated both MIGS lecture (87%) and wet lab (73%) didactics into their curriculum. Only 27% felt that MIGS should be part of ACGME requirements. The most common MIGS taught were iStent (70%), endoscopic cyclophotocoagulation (50%), and trabectome (40%). Few residents had completed MIGS procedures as the primary surgeon by graduation. Eleven out of 30 program directors (37%) did not feel that the experience was adequate for independent practice. Conclusion: This study suggests that residents are exposed to some MIGS procedures during training, but program directors did not feel that the experience was adequate for independent practice. Further research is necessary to understand the barriers to integrating MIGS training into residency programs. [ABSTRACT FROM AUTHOR]

Background: Glaucoma surgical management has evolved significantly with the introduction of minimally invasive glaucoma surgery. Our aim was to evaluate trends in Canadian glaucoma surgery billing code usage as a surrogate index of the current impact of this new technology in Canada's publicly funded health-care system. Methods: Retrospective administrative health records analysis of all patients who underwent a publicly funded glaucoma filtration procedure from January 2003 to December 2016 in the 6 largest Canadian provinces. The frequency of glaucoma-related procedures was adjusted against primary open-angle glaucoma prevalence data. Frequency of all glaucoma filtration procedures with and without implantation of a drainage device in each province per year is reported. Results: Nationwide, glaucoma filtration procedures per 1000 primary open-angle glaucoma patients per year remained constant, with increased drainage device implantation over time (P< 0.0001). Ontario and Nova Scotia mirrored the overall population. British Columbia and Saskatchewan showed increased rates of glaucoma filtration surgery, with increased drainage device implantations. In Quebec, overall filtration surgery decreased, while the rate of device implantation increased (p< 0.0001). Alberta showed a decline in filtration surgery and device implantations from 2003 to  2008, and then increased thereafter. Conclusion: Over the study period, there was a distinct trend towards billing code usage for implanted devices. Challenges encountered during this investigation highlight the need for identifiers in provincial health databases to accommodate the introduction of novel technologies. The absence of specific billing codes for newer technologies prevents accurate analyses of impact, utilization, efficacy and cost implications in contemporary patient management. [ABSTRACT FROM AUTHOR]

Glaucoma is a common blinding disease; while there is no cure, effective treatments include medications, laser, and incisional surgery. There is significant interest from patients and doctors to develop safer surgical options throughout the spectrum of disease, to minimize treatment burden in mild glaucoma patients and to minimize risk of complications in patients needing more aggressive treatment. Surgical procedures called Minimally or Micro-Invasive Glaucoma Surgery (MIGS) are growing in popularity. Eighty-seven prospective studies on MIGS were identified and assessed for quality. Most (74%) did not have a control group. Twelve of the highest quality were reviewed. MIGS procedures appeared to have fewer complications, and lowered intraocular pressure, and reduced medication use. Studies were limited by small sample size, narrow spectrum of glaucomatous disease, and/or conflicts of interest. There is a need for high quality, independently funded and performed, comparative studies on the MIGS to help make treatment decisions. [ABSTRACT FROM AUTHOR]

Introduction: This study evaluated long-term reductions in intraocular pressure (IOP) and medication following implantation of 2 second-generation trabecular micro-bypass stents (iStent inject®) in eyes with open-angle glaucoma (OAG) not controlled on 1 preoperative medication. Material and Methods: In this prospective interventional multi-surgeon study, standalone implantation of 2 iStent inject stents was performed in 57 eyes of 57 subjects with OAG, preoperative IOP of 18– 30 mmHg on 1 medication, and preoperative post-washout IOP of 22– 38 mmHg. The main outcome measures included the proportions of eyes achieving medication-free IOP ≤ 18 mmHg, IOP ≤ 15 mmHg, or ≥ 20% IOP reduction versus preoperative unmedicated IOP. Assessments included IOP, medications, visual acuity, visual field, pachymetry, complications, and interventions. Subjects were followed for 48 months with follow-up continuing in all eyes. Results: At Month 48 (n=57), 95% of eyes achieved an IOP reduction of ≥ 20% without medication versus preoperative washout IOP; and although they had eliminated medication, 81% of eyes still had an IOP reduction of ≥ 20% versus preoperative IOP on 1 medication. Mean 48-month unmedicated IOP decreased by 46% to 13.2± 1.6 mmHg vs 24.4± 1.3 mmHg preoperatively (p< 0.0001), with 95% of medication-free eyes having IOP ≤ 18mmHg and 82% having IOP ≤ 15mmHg. Over the course of follow-up, 3 eyes had medication added and 1 eye underwent a secondary glaucoma surgery, and safety parameters were favorable. Discussion: Standalone iStent inject implantation in OAG patients on 1 preoperative medication resulted in average IOP reduction to ≤ 15 mmHg with the elimination of medication and favorable safety through 48 months. Trial Registration: ClinicalTrials.gov identifier, NCT02868190. [ABSTRACT FROM AUTHOR]

Purpose: To compare reductions in intraocular pressure (IOP) and IOP-lowering medication use following sectoral excisional goniotomy with the Kahook Dual Blade (KDB) or 360° trabeculotomy (via either Trab360 or gonioscopy-assisted transluminal trabeculotomy [GATT]) in eyes with open-angle glaucoma (OAG) undergoing phacoemulsification cataract surgery. Methods: A retrospective review was conducted to collect data from adult subjects with early to advanced primary or secondary OAG undergoing phacoemulsification combined with either KDB or 360° trabeculotomy (Trab360 or GATT) between August 1, 2016 and July 30, 2018 for which 6-month follow-up was available. Data collected included IOP, glaucoma medications, adverse events, and additional IOP-lowering procedures. The primary outcome measure was surgical success (≥20% IOP or ≥1 medication reduction without additional IOP-lowering procedures) at 6 months. Results: Data were collected from 74 eyes of 61 subjects undergoing KDB excisional goniotomy and 27 eyes of 25 subjects undergoing 360° trabeculotomy (19 eyes of 17 subjects undergoing Trab360 and 8 eyes of 8 subjects undergoing GATT). At 6 months, 81.7% (58/71) of KDB eyes and 84.6% (22/26) of 360° trabeculotomy eyes achieved surgical successes (P=0.737). Mean IOP reductions and medication reductions were similar between groups at 6 months. However, more eyes undergoing KDB than Trab360/GATT achieved target IOP ≤18 mmHg (80.0% [56/70] vs 59.3% [16/27], P=0.040) and ≤15 mmHg (61.4% [43/70] vs 25.9% [7/27], P=0.003) without further IOP-lowering interventions at 6 months. The nature and frequency of adverse events were similar between groups. Conclusions: Both KDB and Trab360 or GATT procedures similarly lowered both IOP and the need for IOP-lowering medications during the first 6 postoperative months. More eyes undergoing KDB excisional goniotomy than 360° trabeculotomy attained target IOP ≤18 mmHg and ≤15 mmHg at 6 months. A full 360° trabecular bypass may not be necessary to achieve maximal efficacy from this class of micro-invasive glaucoma procedures. [ABSTRACT FROM AUTHOR]

Purpose: To characterize clinical outcomes following Kahook Dual Blade (KDB)-assisted goniosynechialysis and excisional goniotomy combined with phacoemulsification in eyes with angle-closure glaucoma and cataract. Setting: Two clinical practices. Methods: In this retrospective analysis of existing health records, data were collected from 42 eyes of 24 subjects from preoperative, operative, and postoperative encounters through 12 months of follow-up. Outcomes included changes in mean IOP, IOP-lowering medications, and logMAR best-corrected visual acuity (BCVA), as well as the proportions of patients achieving IOP reductions ≥20%, IOP ≤18 mmHg, and a reduction of ≥1 medication. Results: Preoperative, mean (standard error) IOP was 25.5 (0.7) mmHg and at Month 12 was reduced by 12.3 (0.73) mmHg (−47.2%; p<0.0001). The mean number of IOP-lowering medications used was 2.3 (0.1) preoperatively and was reduced at Month 12 by 2.2 (0.12) (−91.7%; p<0.0001). At Month 12, 92.9% of eyes achieved IOP ≤18 mmHg, 100% achieved IOP reduction of ≥20%, 95.2% required ≥1 fewer medications for IOP control, and 85.7% (36/42) were medication-free. Mean LogMAR BCVA improved from 0.547 (0.06) at baseline to 0.159 (0.07) at Month 12. Conclusion: KDB-assisted goniosynechialysis and excisional goniotomy at the time of phacoemulsification safely provide significant reductions in both IOP and IOP-lowering medication burden in eyes with angle-closure glaucoma, while simultaneously improving visual acuity. [ABSTRACT FROM AUTHOR]

Purpose: To compare postsurgical anterior chamber flare (ACF) among conventional (trabeculectomy, LEC) and novel (EX-PRESS Shunt, EXP) filtration surgeries and microhook ab interno trabeculotomy (μLOT), a novel minimally invasive glaucoma surgery (MIGS). Subjects and methods: This retrospective study included 125 primary open angle glaucoma eyes (89 consecutive subjects) treated with μLOT (n=38), LEC (n=12), or EXP (n=75). The intraocular pressure (IOP), numbers of antiglaucoma medication, and ACF at preoperatively and 2 weeks; 1, 3, and 6 months postoperatively were compared among the surgical groups using a mixed-effects regression model. Results: The postoperative IOP (p<0.0001) and medication use were significantly (p<0.0001) lower in the LEC and EXP groups than with μLOT for up to 6 months postoperatively. The ACF differed significantly (p=0.0004) among groups; the ACF was significantly higher (p=0.0097, post-hoc Student's t-test) with μLOT (33.6±52.8 pc/msec) than the EXP (15.7±19.9 pc/msec) at 2 weeks and was significantly (p=0.0111, post-hoc t-test) lower with μLOT (7.9±2.0 pc/msec) than LEC (12.0±6.1 pc/msec) at 6 months. Conclusion: Considering our observation, although its clinical significance is unclear, not all MIGS are minimally invasive regarding early postsurgical inflammation. [ABSTRACT FROM AUTHOR]

Purpose: Evaluate outcomes of trabecular meshwork (TM) bypass (iStent® GTS100) with cataract extraction (CE) and TM-bypass + ab interno canaloplasty (CP) (VISCO360®) with CE in patients with primary open-angle glaucoma (POAG). Setting: Private surgical center for a comprehensive ophthalmology practice Design: Retrospective analysis of 186 eyes from 130 consecutive patients with 6 months follow-up. Methods: Eligible eyes had POAG, indicated for CE, and had received CE + TM-bypass or CE + TM-bypass + CP. Exclusions: glaucomas not POAG, SLT within 6 months, or previous ALT. IOP, visual acuity, and medication use assessed at baseline, months 1, 3, and 6. Endpoints were mean reduction in IOP from baseline at 6 months, proportion with IOP reduction at 6 months of ≥20% and IOP <18 mmHg on same or fewer medications, mean medication reduction, and proportion medication independent. Results: Eighty-six eyes comprised the CE + TM-bypass + CP group; 100 eyes in the CE + TM-bypass group. At 6 months: mean IOP reduction was 2.9±3.6 mmHg for CE + TM-bypass + CP and 1.7±3.1 mmHg for CE + TM-bypass group (P<0.05); the proportion with IOP reduction of ≥20% and an IOP <18 mmHg on the same or fewer medications was 46% for CE + TM-bypass + CP and 35% for CE + TM-bypass; for both CE + TM-bypass + CP and CE + TM-bypass, mean number of medications was decreased (0.9 and 0.7, P<0.0001) with 56% and 48% off all medication. The most common AE were inflammation (6%) for CE + TM-bypass + CP group and VA loss (8%) for CE + TM-bypass. Conclusion: At six months, a greater proportion of CE + TM-bypass + CP patients achieved IOP reduction of ≥20% and an IOP <18 mmHg on the same or fewer medications than for TM-bypass + CE. [ABSTRACT FROM AUTHOR]