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Ticiana De Francesco,1– 3 Iqbal Ike K Ahmed3,4 1Hospital de Olhos Leiria de Andrade, Fortaleza, Brazil; 2Clinica de Olhos De Francesco, Fortaleza, Brazil; 3John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 4Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, CanadaCorrespondence: Ticiana De Francesco, Email ticianadefrancesco@gmail.comAbstract: This review evaluates the impact of transient intraocular pressure (IOP) elevations during common ophthalmic surgical and diagnostic procedures on glaucoma patients. Elevated IOP is a key risk factor in glaucoma, and while transient IOP spikes are frequently encountered during surgeries like cataract extraction, laser in situ keratomileusis (LASIK), and femtosecond laser-assisted cataract surgery (FLACS), the clinical significance of these short-term elevations remains uncertain, particularly for eyes with compromised optic nerves. There is still a lack of data on which IOP level and duration of IOP insult the glaucoma damage occurs. Still, it is known that the combination of the degree of IOP elevation, duration of the insult and optic nerve susceptibility are important determinants of this event. While transient IOP elevations during these procedures are generally well tolerated, patients with advanced glaucoma and severely compromised optic nerves may be at greater risk for further damage. More research is needed to fully understand the long-term implications of acute IOP spikes, particularly in patients with advanced disease.Keywords: intraocular pressure, glaucomatous damage, transient intraocular pressure rise

Ticiana De Francesco,1,2 Tsontcho Ianchulev,3 Douglas J Rhee,4 Ronald C Gentile,3,5 Louis R Pasquale,3 Iqbal Ike K Ahmed1,6,7 1John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 2Clinica de Olhos De Francesco, Fortaleza, Brazil; 3Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 4Department of Ophthalmology and Visual Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA; 5NYU Long Island School of Medicine, Department of Ophthalmology, Mineola, NY, USA; 6Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; 7Prism Eye Institute, Mississauga, CanadaCorrespondence: Ticiana De Francesco, Tel +55 85 32192425, Email ticianadefrancesco@gmail.comAbstract: To review the latest surgical advances and evolving clinical use of scleral bio-tissue for reinforcement in the eye and review the published literature on novel surgical applications of scleral allograft bio-tissue. Conventional surgical procedures for scleral reinforcement using homologous scleral allograft have been traditionally ab-externo interventions comprising of anterior or posterior reinforcement of the sclera for clinical indications such as trauma, scleromalacia, glaucoma drainage device coverage, scleral perforation, buckle repair as well as posterior reinforcement for pathologic myopia and staphyloma. There have been a few novel ab-interno uses of scleral bio-tissue for reinforcement in both retina and glaucoma. Over the last decade, there has been an increase in peer-reviewed publications on scleral reinforcement, reflecting more interest in its clinical applications. With favorable biological and biomechanical properties, scleral allograft may be an ideal substrate for an array of new applications and surgical uses.Keywords: sclera, allograft, biotissue, glaucoma

Jason Bacharach,1 Iqbal Ike K Ahmed,2 Elizabeth D Sharpe,3 Michael S Korenfeld,4 Steven Zhang,5 Christophe Baudouin6 1North Bay Eye Associates, Sonoma County, CA, USA; 2John Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 3Glaucoma Consultants and Center for Eye Research, Mt. Pleasant, SC, USA; 4Comprehensive Eye Care, Washington, MO, USA; 5Thea Pharma, Inc, Lexington, MA, USA; 6Quinze-Vingts National Ophthalmology Hospital & Vision Institute, Paris Saclay-Versailles-Saint Quentin University, IHU Foresight, Paris, FranceCorrespondence: Jason Bacharach, Email jbacharach@northbayeye.comPurpose: To evaluate the safety and efficacy of a preservative-free latanoprost 0.005% formulation (T2345) in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT) compared to benzalkonium chloride–preserved latanoprost 0.005% (BPL) formulation in the United States (US).Patients and Methods: A prospective, randomized, multicenter, observer-masked, parallel-group study enrolled 335 patients diagnosed with POAG or OHT from 31 US sites who had adequately controlled intraocular pressure (IOP; ≤ 18 mm Hg) with latanoprost monotherapy. After a ≥ 72-hour washout period, patients were randomized to T2345 (n=165) or BPL (n=170) groups. Study drugs were dosed once-daily from Day 0 to Day 84 in one or both eyes. The study eye was the eye with lower IOP at baseline. The primary efficacy measure was the between-group comparison of the mean IOP values in the study eye at each time point (8 AM, 10 AM, and 4 PM on Days 15, 42, and 84). Safety measurements included ocular and systemic treatment-emergent adverse events (TEAEs).Results: Both T2345 and BPL adequately controlled IOP with 95% CIs within 1.5 mm Hg in the study eye at all assessed time points. The percentages of patients with diurnal IOP < 18 mm Hg at Day 84 were 73.1% vs 78.7% for the T2345 and BPL groups, respectively. Adverse events were generally mild-to-moderate and primarily ocular. Fewer patients in the T2345 group experienced ocular TEAEs (13.9% vs 22.5%, respectively) and TEAEs with a suspected relationship to the study medication compared with the BPL group (5.5% vs 11.8%, respectively). The most common ocular TEAEs were instillation site pain and conjunctival hyperemia.Conclusion: In patients with POAG or OHT, both T2345 and BPL maintained IOP at or below clinically meaningful values for the duration of the study. T2345 showed a favorable safety profile, with numerically lower incidences of ocular TEAEs than BPL.Keywords: glaucoma, ocular hypertension, intraocular pressure, benzalkonium chloride, latanoprost, preservative

Ticiana De Francesco,1– 3 Iqbal Ike K Ahmed3,4 1Clinica de Olhos De Francesco, Fortaleza, Brazil; 2Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil; 3John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 4Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, CanadaCorrespondence: Ticiana De Francesco, 499 Barao de Aracati, Fortaleza, Brazil, Tel +55 85 3219-24-25, Email ticianadefrancesco@gmail.comAbstract: Microinvasive glaucoma surgery (MIGS) has emerged as a safer method to lower IOP with minimal impact on patient quality of life compared to traditional glaucoma surgeries. With the advent of MIGS, there has been a renewed interest in exploring the suprachoroidal route. MIGS targeting the suprachoroidal space allow for a safe reduction in IOP while sparing conjunctiva and allowing “blebless” surgery, thus avoiding bleb-related complications. This article aims to review the rationale behind the suprachoroidal MIGS procedures and the literature surrounding the efficacy and safety of a novel suprachoroidal device, the MINIject. The available literature has shown promising IOP lowering results with the MINIject implant with a potentially safer and less invasive approach than traditional glaucoma surgeries.Keywords: suprachoroidal space, microinvasive glaucoma surgery, glaucoma

Sean Yonamine,1,&ast; Lauren Ton,2,&ast; Jennifer Rose-Nussbaumer,3 Gui-Shuang Ying,4 Iqbal Ike K Ahmed,5 Teresa C Chen,6 Asher Weiner,7 Steven J Gedde,8 Ying Han1 1Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA; 2School of Medicine, University of California San Francisco, San Francisco, CA, USA; 3Stanford Byers Eye Institute, Palo Alto, CA, USA; 4Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA, USA; 5Prism Eye Institute, Mississauga, Ontario, Canada; 6Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA; 7University at Buffalo, State University of New York, Buffalo, NY, USA; 8Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA&ast;These authors contributed equally to this workCorrespondence: Ying Han, Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA, Tel +1 415 514 6920, Fax +1 415 353 4250, Email ying.hang@ucsf.eduPurpose: To assess practice patterns and opinions of glaucoma specialists regarding glaucoma drainage device tube shunt placement and post-operative anti-inflammatory medication use. We also assess the perceived need for a randomized control trial to compare them.Patients and Methods: An online survey was distributed to a group of glaucoma specialists from the American Glaucoma Society via the American Glaucoma Society forum from April to August 2021.Results: One hundred and twenty-eight responses were included. Ninety percent placed tubes in the anterior chamber. Sixty-one percent reported that evidence suggested the superiority of sulcus tube placement over the anterior chamber, whereas 34% reported there was not enough evidence to suggest superiority of either in preventing endothelial cell loss. Comparing these techniques for intraocular pressure control, 49% reported evidence suggested sulcus tube placement superiority whereas 46% reported there was not enough evidence. Over 40% of respondents reported that they were either unfamiliar with literature or that there was not enough evidence to support the superiority of difluprednate 0.05% over prednisolone 1% for post-operative use in preventing endothelial cell loss and for intraocular pressure control. Ninety percent and 81% of respondents respectively would benefit from randomized control trials comparing outcomes of anterior chamber vs sulcus tube placement and post-operative corticosteroid usage.Conclusion: Most glaucoma specialists surveyed place glaucoma drainage device tube in the anterior chamber over the sulcus. A randomized control trial to determine optimal tube placement and post-operative anti-inflammatory medication use for preventing endothelial cell loss would change current glaucoma drainage device practice patterns.Keywords: endothelial cell loss, sulcus, glaucoma drainage device

Jingyi Ma, Mariam Issa, Devesh Varma, Iqbal IK Ahmed Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, CanadaCorrespondence: Iqbal IK Ahmed, Ophthalmology and Vision Sciences, University of Toronto, 2201 Bristol Circle, Suite 100, Oakville, Ontario, L6H 0J8, Canada, Tel +1 (905) 456-3937, Email ikeahmed@mac.comPurpose: We aimed to evaluate the effectiveness and safety of a virtual eye assessment triage system implemented in response to COVID-19.Patients and Methods: We conducted a retrospective cross-sectional study using a consecutive sample of all virtual assessments conducted from March 24 to June 7, 2020 at a single ophthalmology center in Toronto, ON, Canada. Visual acuity and smartphone photographs were uploaded to an electronic assessment website. All patients were virtually triaged to an email or phone consult. Patient outcomes and satisfaction were assessed with a quality assurance survey. Primary outcome measures were the incidence of unplanned additional in-person visits and changes in treatment.Results: We performed 1535 virtual assessments. Of the triage pathways, 15% received an email consult only and 85% received a phone consult. Subsequently, 15% required an in-person assessment, 3% were referred elsewhere, and 0.1% were sent to the emergency. Presentations were most commonly cornea (52%) and retina (25%). They were non-urgent in 68% of cases and no pharmacologic treatment was required for 49%. Of 397 patients that responded out of 653 patients surveyed, 4% had an unplanned additional visit to the emergency, after which two patients underwent urgent retinal surgery and one patient underwent urgent glaucoma surgery. Two patients (0.5%) had a minor change in treatment.Conclusion: As routine regular in-person visits were not possible during the COVID-19 lockdown, virtual eye assessments provided an opportunity to triage patients. Virtual assessments have the potential to reduce in-person visits, but caution must be exercised to not miss vision-threatening conditions.Keywords: virtual care, telemedicine, COVID-19, medical education

Vanessa Vera,1 Sebastien Gagne,2 Jonathan S Myers,3 Iqbal Ike K Ahmed4 1Department of Ophthalmology, Unidad Oftalmologica de Caracas, Caracas, Venezuela; 2Départment d’ophthalmologie de, Université de Montréal, Montréal, Canada; 3Glaucoma Service, Wills Eye Hospital, Philadelphia, PA, USA; 4Department of Ophthalmology, University of Toronto, Toronto, CanadaCorrespondence: Vanessa Vera Email vanessaveramd@gmail.comAbstract: The XEN Gel Stent (Allergan Inc., an Abbvie company) is an implant that lowers intraocular pressure by creating a filtration pathway from the anterior chamber to the subconjunctival space, using the same pathway as trabeculectomy. While the primary method for implantation is via ab interno approach, it is also possible to implant the device ab externo. This technique paper details the surgical steps for closed conjunctival implantation of the Gel Stent and provides surgical pearls for enhancing outcomes.Keywords: XEN Gel Stent, glaucoma, filtration surgery, ab interno, ab externo, transconjunctival implantation

Tina M Roa,1 Peter A Netland,1 Vital P Costa,2 Steven R Sarkisian Jr,3 Lama A Al-Aswad,4 Marlene R Moster,5 Iqbal IK Ahmed6 1Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA 22908, USA; 2Department of Ophthalmology, University of Campinas, Campinas, Brazil; 3Oklahoma Eye Surgeons, PLLC, Oklahoma City, OK 73112, USA; 4Department of Ophthalmology, NYU Grossman School of Medicine, NYU Langone Health, New York, NY 10017, USA; 5Glaucoma Service, Wills Eye Hospital, Philadelphia, PA 19107, USA; 6Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, CanadaCorrespondence: Peter A NetlandUniversity of Virginia School of Medicine, PO Box 800715, Charlottesville, VA 22908, USATel +1 434 982-1086Email pan9c@virginia.eduPurpose: Our aim was to evaluate and compare the clinical outcomes after implantation of the silicone-plate (model FP7) and porous polyethylene-plate (model M4) Ahmed Glaucoma Valves.Patients and Methods: This was a prospective, multicenter, comparative series. A total of 52 eyes (52 patients) were treated with either the silicone or porous plate Ahmed Glaucoma Valve implant. Hypertensive phase was defined as intraocular pressure > 21 mmHg during the first 3 months postoperatively. Success was defined as 5 mmHg ≤intraocular pressure ≤ 21 mmHg (with or without additional glaucoma medications), without loss of light perception and without additional glaucoma procedures. Patients were monitored for 1 year after surgery.Results: The pre-operative intraocular pressure was 29.9 ± 6.6 mmHg and 33.8 ± 10.5 in the silicone-plate and porous-plate groups, respectively (P = 0.118). At 12 months after surgery, the mean intraocular pressure was 13.6 ± 4.7 mmHg in the silicone-plate group and 17.9 ± 10.9 mmHg in the porous-plate group (P = 0.141). The mean number of glaucoma medications at 12 months was 1.64 ± 1.40 mmHg and 1.89 ± 1.54 mmHg in the silicone- and porous-plate groups, respectively (P = 0.605). Hypertensive phase was not significantly different in the two groups (50.0% of the silicone-plate and 57.7% of the porous-plate groups, P = 0.578). At 12 months after surgery, the percent success for the silicone-plate and porous-plate groups was 88.5% and 53.8%, respectively (P = 0.005). Complications were similar in the two groups.Conclusion: The porous-plate Ahmed Glaucoma Valve showed similar average intraocular pressure reduction compared with the silicone-plate model. At 12 months after surgery, there was a significantly lower success rate in the porous-plate compared with the silicone-plate group.Keywords: Ahmed Glaucoma Valve, model FP7, model M4, glaucoma drainage implant, porous polyethylene, Medpor

Vanessa Vera,1 Arsham Sheybani,2 Dan Lindfield,3 Ingeborg Stalmans,4 Iqbal Ike K Ahmed5 1Department of Glaucoma, Unidad Oftalmologica de Caracas, Caracas, Venezuela; 2Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, MO, USA; 3Department of Ophthalmology, Royal Surrey County Hospital, Guildford, Surrey, UK; 4Glaucoma Unit, University Hospitals UZ Leuven, Leuven, Belgium; 5Glaucoma and Advanced Anterior Segment Surgery, University of Toronto, Toronto, ON, Canada Abstract: Surgical management of glaucoma offers a means of effective disease control. A gel stent that facilitates drainage to the subconjunctival space offers intraocular pressure (IOP) reduction similar to traditional glaucoma filtering surgeries in a less invasive manner. However, like all subconjunctival filtering procedures that result in a bleb, fibrosis can present as a cause of elevated IOP. The following proposed techniques and recommendations for managing elevated IOP due to bleb fibrosis after gel stent implantation are based on the clinical experience of the authors. The goal of this paper is to improve outcomes following gel stent surgery by providing guidance on assessment of bleb function and strategies for bleb enhancement. Keywords: glaucoma gel stent, bleb management, bleb fibrosis, glaucoma surgery, glaucoma filtering surgery, bleb needling

Sarah Farukhi Ahmed,1 Kyle C McDermott,2 Wesley K Burge,2 I Ike K Ahmed,3,4 Devesh K Varma,3 Y Joyce Liao,5 Alan S Crandall,4 S Khizer R Khaderi2,61Shiley Eye Institute of Ophthalmology, University of California, San Diego, CA, USA; 2Vizzario, Inc., Venice, CA, USA; 3Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada; 4Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 5Ophthalmology and Neurology, Stanford University Medical Center, Stanford, CA, USA; 6Ophthalmology, Stanford University Medical Center, Stanford, CA, USAAbstract: Historically, visual acuity has been the benchmark for visual function. It is used to measure therapeutic outcomes for vision-related services, products and interventions. Quantitative measurement of suboptimal visual acuity can potentially be corrected optically with proper refraction in some cases, but in many cases of reduced vision there is something else more serious that can potentially impact other aspects of visual function such as contrast sensitivity, color discrimination, peripheral field of view and higher-order visual processing. The measurement of visual acuity typically requires stimuli subject to some degree of standardization or calibration and has thus often been limited to clinical settings. However, we are spending increasing amounts of time interacting with devices that present high-resolution, full color images and video (hereafter, digital media) and can record our responses. Most of these devices can be used to measure visual acuity and other aspects of visual function, not just with targeted testing experiences but from typical device interactions. There is growing evidence that prolonged exposure to digital media can lead to various vision-related issues (eg, computer vision syndrome, dry eye, etc.). Our regular, daily interactions (digital behavior) can also be used to assess our visual function, passively and continuously. This allows us to expand vision health assessment beyond the clinic, to collect vision-related data in the whole range of settings for typical digital behavior from practically any population(s) of interest and to further explore just how our increasingly virtual interactions are affecting our vision. We present a tool that can be easily integrated into digital media to provide insights into our digital behavior.Keywords: vision education, visual acuity, vision assessment, technology, video games, mobile gaming, software applications, mobile applications

Mark J Gallardo,1,2 Richard A Supnet,1 Iqbal Ike K Ahmed3 1El Paso Eye Surgeons, PA, El Paso, TX, USA; 2Department of Ophthalmology, University of Texas Health Sciences Center in San Antonio, San Antonio, TX, USA; 3Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada Purpose: To compare the efficacy of minimally invasive ab-interno canaloplasty (ABiC) vs ab-externo canaloplasty (CP) in reducing intraocular pressure (IOP) and glaucoma medication dependence.Patients and methods: This nonrandomized, retrospective, single-center, paired eye study assessed the 12-month outcomes of 12 patients with primary open-angle glaucoma who underwent ABiC in one eye and CP in the other eye, either as stand-alone procedures or combined with cataract extraction. Primary endpoints included mean IOP and number of glaucoma medications at 12 months postoperative. Secondary endpoints included surgical complications and secondary interventions.Results: Four males and eight females with a mean age of 73.8±12.6 years were included. In the CP group, the mean preoperative IOP was 18.1±3.9 mmHg on 2.4±0.5 medications, which reduced to 13.5±2.2 mmHg (P

Mark J Gallardo,1,2 Richard A Supnet,1 Iqbal Ike K Ahmed3 1El Paso Eye Surgeons, PA, El Paso, TX, USA; 2University of Texas Health Sciences Center, San Antonio, TX, USA; 3Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada Purpose: The aim of this study was to compare the 1-year efficacy and safety profile of ab-interno canaloplasty (ABiC) when performed as a stand-alone procedure or as an adjunct to cataract extraction in reducing IOP and glaucoma medication dependence.Patients and methods: This retrospective, comparative, consecutive case series included patients with uncontrolled primary open-angle glaucoma (POAG) who underwent ABiC as a stand-alone procedure or in conjunction with cataract extraction. Data were collected over a 12-month period. Primary outcome measures were mean lower IOP and mean number of glaucoma medications. Secondary endpoints included surgical and postsurgical complications and secondary interventions.Results: The study included 75 eyes of 68 patients (mean age: 73.7±9.9 years) with a mean baseline IOP of 20.4±4.7 mmHg on 2.8±0.9 medications, which reduced to 13.3±1.9 mmHg (n=73) on 1.1±1.1 medications at 12 months postoperative (both P

David F Chang,1 Eric D Donnenfeld,2 L Jay Katz,3 Lilit Voskanyan,4 Iqbal Ike K Ahmed,5 Thomas W Samuelson,6 Jane Ellen Giamporcaro,7 Dana M Hornbeak,7 Kerry D Solomon8 1Altos Eye Physicians, Los Altos, CA, 2Ophthalmic Consultants of Long Island, Rockville Centre, NY, 3Department of Ophthalmology, Wills Eye Hospital, Jefferson Medical College, Philadelphia, PA, USA; 4S.V. Malayan Ophthalmology Centre, Yerevan, Armenia; 5Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada; 6Minnesota Eye Consultants, Minneapolis, MN, 7Glaukos Corporation, San Clemente, CA, 8Carolina Eyecare Physicians, Mount Pleasant, SC, USA Purpose: To evaluate the long-term intraocular pressure (IOP)-lowering effect and safety parameters following treatment with two trabecular micro-bypass stents and topical prostaglandin in phakic eyes with open-angle glaucoma (OAG) not controlled on two preoperative medications. Methods: This prospective, single-arm, unmasked study enrolled 39 qualified phakic eyes with OAG not controlled on 2 medications, preoperative medicated IOP of 18–30 mmHg, and IOP following medication washout of 22–38 mmHg. Two trabecular micro-bypass stents were implanted as a standalone procedure, and travoprost was started on postoperative day 1. Evaluations included IOP, best-corrected visual acuity, medication use, fundus and slit-lamp examinations, visual field, cup:disc ratio, central corneal thickness, and ocular complications. Data through 18 months were summarized previously. Thirty-seven of the original 39 subjects have been followed for 3 years postoperatively; follow-up is continuing for 5 years. Results: At 3 years postoperative, 97% of eyes had achieved an IOP reduction of ≥20% from baseline with a reduction of 1 medication. Eighty-six percent of eyes had IOP of ≤18 mmHg with a reduction of 1 medication. Mean medicated IOP decreased to 14.0±2.6 mmHg on 1 medication versus 22.4±2.3 mmHg on 2 medications preoperatively. The mean unmedicated IOP decreased to 17.7±1.7 mmHg at 37 months from 25.3±1.9 mmHg preoperatively. Long-term postoperative adverse events included cataract surgery in 3 eyes due to cataract progression, and trabeculectomy in 1 eye due to uncontrolled IOP of 23 mmHg. No intraoperative or device-related adverse events occurred. Conclusion: Significant and sustained reduction in IOP and medications with a favorable safety profile was shown through 3 years after implantation of 2 trabecular micro-bypass stents combined with postoperative travoprost in phakic OAG eyes uncontrolled on 2 preoperative medications. These findings demonstrate the long-term performance and safety of trabecular bypass stents in combination with topical prostaglandin for OAG patients. Keywords: glaucoma, trabecular micro-bypass, MIGS, IOP, medication

Ahmad M Mansour,1,2 Rafic S Antonios,1 Iqbal Ike K Ahmed3 1Department of Ophthalmology, American University of Beirut, Beirut, Lebanon; 2Department of Ophthalmology, Rafic Hariri University Hospital, Beirut, Lebanon; 3Department of Ophthalmology, University of Toronto, Toronto, ON, Canada Background: Complete removal of the cortex has been advocated to prevent posterior capsular opacification but carries the risk of zonular dehiscence, hence there is a need for a safe maximal cortical cleanup technique in eyes with severe diffuse zonulopathy in subjects above age 90. Methods: We used bimanual central cortical cleaning by elevating central fibers and aspirating them toward the periphery. Peripheral cortical fibers were removed passively only when they became loose due to copious irrigation. A one-piece foldable implant was inserted without a capsular tension ring. Postoperative corticosteroid drops were used. Results: This technique was safely performed in a dozen eyes with severe pseudo-exfoliation or brunescent cataract with weak zonules. Posterior capsular rupture, iritis, vitreous loss, and lens subluxation were not observed. Moderate capsular phimosis occurred but with maintained central vision. Conclusion: The dogma of “complete cortical cleanup” in severe zonulopathy needs to be revisited in favor of a clear visual axis with maximal preservation of the damaged zonules. This technique is ideal in patients above age 90 where posterior capsular opacification and late dislocation of intraocular lens–capsule bag complex are unlikely to occur until several years postoperatively. Keywords: brunescent cataract, cortex aspiration, phacoemulsification, pseudo-exfoliation, weak zonules

Purpose: To compare the effectiveness and adverse event profile of standalone polystyrene-isobutylene-styrene (SIBS) microshunt implantation with adjunct mitomycin C (MMC) 0.2 mg/ml and MMC 0.4 mg/ml., Design: Mega-analysis using individual patient data from international prospective and retrospective clinical studies., Participants: Patients with glaucoma who underwent implantation of a SIBS microshunt with MMC as a standalone procedure., Methods: A comparison of eyes that received MMC 0.2 mg/ml or 0.4 mg/ml., Main Outcomes Measures: Primary outcome was complete success defined as the proportion of eyes at 1 year with all of the following: (1) no 2 consecutive intraocular pressures (IOPs) > 17 mmHg; (2) no clinical hypotony; (3) ≥ 20% IOP reduction from baseline; and (4) no use of glaucoma medications. Secondary outcomes included IOP thresholds of 12 mmHg, 14 mm Hg, and 21 mmHg, median IOP, number of medications, risk factors for failure, interventions, adverse events, and reoperations., Results: At 1 year, the complete success rate was significantly higher (71.3% vs. 50.46%; P < 0.001) and the median IOP was significantly lower (13.0 vs 14.2 mmHg; P < 0.05) in the MMC 0.4 mg/ml group. Mitomycin C 0.2 mg/ml was found to be a significant risk factor for failure (hazard ratio 1.75; 95% confidence interval 1.14-2.67). Needling and surgical revision occurred at a lower rate in the MMC 0.4 mg/ml group (7% vs 18.8%; P = 0.002 and 4.3% vs 13.7% P = 0.0087, respectively). Adverse events occurred at a similar frequency in both groups (26.6% MMC 0.2 mg/ml vs 29.6% MMC 0.4 mg/ml; P = 0.46), most of which were early and transient., Conclusion: Polystyrene-isobutylene-styrene microshunt implantation with MMC 0.4 mg/ml resulted in a higher success rate with greater IOP reduction compared with MMC 0.2 mg/ml. Higher MMC concentration was not associated with increased serious adverse events., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare effects of glucagon-like peptide 1 (GLP-1) receptor agonists and metformin on the risk of primary open-angle glaucoma (POAG), ocular hypertension, and the need for first-line glaucoma treatments in patients with type 2 diabetes mellitus (T2DM)., Design: A retrospective cohort study was conducted using electronic medical records data from an international electronic health record network, covering a period from May 2006-2024., Participants: Patients with a diagnosis of T2DM who were treated with either GLP-1 receptor agonists or metformin., Methods: Data from 120 health care organizations across 17 countries were analyzed. Patient outcomes were assessed at 1, 2, and 3 years. Propensity score matching (PSM) was used to balance covariates such as demographics, comorbidities, and medication use. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated., Main Outcome Measures: Incidence of POAG, ocular hypertension, and the need for first-line treatments including topical drops and laser trabeculoplasty., Results: After PSM, both groups included 61 998 patients at the 1-year follow-up, 27 414 patients at the 2-year follow-up, and 14 100 patients at the 3-year follow-up. Patients treated with GLP-1 receptor agonists showed a significantly decreased risk of POAG development compared with those receiving metformin at 1 year (RR, 0.59; 95% CI, 0.39-0.88), 2 years (RR, 0.50; 95% CI, 0.32-0.78), and 3 years (RR, 0.59; 95% CI, 0.37-0.94). Similar protective effects were observed for ocular hypertension at 1 year (RR, 0.44; 95% CI, 0.31-0.62), 2 years (RR, 0.43; 95% CI, 0.30-0.62), and 3 years (RR, 0.51; 95% CI, 0.34-0.75). The risk of first-line therapy initiation also was lower in the GLP-1 receptor agonists group at 1 year (RR, 0.63; 95% CI, 0.53-0.74), 2 years (RR, 0.71; 95% CI, 0.59-0.85), and 3 years (RR, 0.75; 95% CI, 0.62-0.91)., Conclusions: Glucagon-like peptide 1 receptor agonists are associated with a significantly lower incidence of POAG, ocular hypertension, and the need for first-line glaucoma treatments compared with metformin in patients with T2DM. These findings highlight the potential ocular benefits of GLP-1 receptor agonists and their expanding role in the clinical management of patients with diabetes., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the association between social determinants of health (SDH) in the domains of social and community context, education access, environmental context, economic stability, and healthcare access, with glaucoma prevalence., Design: Cross-sectional study., Methods: The study population consisted of adult participants who answered glaucoma-related questions on the 2017 National Health Interview Survey (NHIS), the most recent iteration that includes glaucoma-related questions. The main outcome measures included the relationships between SDH-related factors and self-reported glaucoma diagnosis as well as self-reported glaucomatous vision loss were examined using univariable and multivariable regression models., Results: In total, 26,696 of 26,742 (99.83%) NHIS respondents were included, of whom 880 (3.30%) reported a glaucoma diagnosis and 275 (1.03%) reported glaucomatous vision loss. Participants were predominantly middle-aged (50.95 ± 18.60 years), female (54.75%), and non-Hispanic White (70.49%). In age-adjusted multivariable regression (n = 25,456), non-Hispanic Black race (odds ratio [OR] = 1.87, 99% CI = [1.37, 2.55], P < .001, compared to non-Hispanic White race) and poor health status (OR = 1.54, 99% CI = [1.00, 2.37], P = .01, compared to good health status) were significant predictors of glaucoma diagnosis. For glaucomatous vision loss, having an income below the poverty threshold (OR = 2.41, 99% CI = [1.12, 5.20], P = .003, compared to income ≥5 times the poverty threshold) was the only significant predictor in univariable analyses. No SDH-related factors were significantly associated with glaucomatous vision loss in multivariable analysis (n = 848). Multicollinearity was minimal (variation inflation factor<1.6 for all independent variables)., Conclusions: Non-Hispanic Black race and poor health status were associated with self-reported glaucoma diagnosis. Physicians and policymakers may consider SDH when assessing clinical risk and designing public health interventions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: To investigate the effect of perioperative intraocular pressure (IOP) lowering medications on controlling postoperative IOP following uncomplicated phacoemulsification., Methods: Ovid MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched up until November 2022. Randomised controlled trials (RCTs) that assessed IOP change via applanation tonometry in medicated and control arms following uncomplicated cataract surgery in healthy eyes were included. The primary outcome was the weighted mean difference (WMD) of IOP at 2-8 h, 12-24 h, and 1-7 days postoperatively within each medication class or common fixed-combination formulations. Risk of bias was assessed using the revised risk of bias in randomised trials (RoB-2). Level of evidence was rated using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) RESULTS: From 702 screened articles, 30 RCTs involving 2986 eyes were included. There was a statistically significant reduction in IOP favouring treatment arms at 2-8 h (WMD = -3.87 mmHg; 95% CI [-4.75, -3.00]; p < 0.001) and 12-24 h (WMD = -2.69 mmHg; 95% CI [-3.36, -2.02]; p < 0.001), with the effect wearing off beyond 1 day (p = 0.18). Between medication classes, the largest effect at both 2-8 h and 12-24 h was observed with intracameral cholinergics or fixed-combination carbonic anhydrase inhibitor-beta-blocker (FCCB) formulations. Conversely, the smallest effect was observed with prostaglandin analogues, alpha-agonists, and topical carbonic anhydrase inhibitors (CAIs)., Conclusion: Prophylaxis against acute IOP elevations following uncomplicated cataract surgery is effective. FCCB and intracameral cholinergics are the most effective ocular antihypertensive agents, while alpha-agonists, prostaglandin analogues, and topical CAIs were found to be the least effective. These findings may inform future surgical guidelines., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: Risk communication is an integral aspect of shared decision-making and evidence-based patient choice. There is currently no recommended way of communicating risks and benefits of cataract surgery to patients. This study aims to investigate whether the way this information is presented influences patients' perception of how risky surgery will be., Methods and Analysis: Two-arm parallel randomised study and patients referred for cataract surgery were assigned to receive information framed either positively (99% chance of no adverse effects) or negatively (1% chance of adverse effects). Subsequently, patients rated their perceived risk of experiencing surgical side effects on a 1-6 scale., Results: This study included 100 patients, 50 in each study group. Median (IQR) risk perception was 2 (1-2) in the positive framing group and 3 (1-3) in the negative framing group (p<0.0001). Risk framing was the only factor that was significant in risk perception, with no differences found by other patient clinical or demographic characteristics., Conclusion: Patients who received positive framing reported lower risk scores for cataract surgery than patients who received negative framing. Patient factors were not identified as significant determinants in patients' perceived risk. Larger longitudinal studies are warranted to further investigate., Competing Interests: Competing interests: All authors have completed and submitted the ICMJE disclosures form. DLM: None. IKA: Consultant—Aequus, Ace Vision, Aerie Pharmaceuticals, Akorn, Alcon, Allergan, Aquea Health, Inc, ArcScan, Avellino Lab USA, Inc, Avisi, Bausch Health, Beaver Visitec, Belkin Vision, Beyeonics, Bionode, Carl Zeiss Meditec, Centricity Vision, Inc, CorNeat Vision, Custom Surgical, Elios Vision, ElutiMed, Equinox, eyeFlow, Inc, EyedMed, EyeQ Technologies, Exhaura Limited, Genentech, Glaukos, Gore, Heine, Heru, Hexiris Pharma, Iantrek, InjectSense, Iridex, iStar, Ivantis, Johnson & Johnson Vision, Labtician Thea, LayerBio, Leica Microsystems, Life Long Vision, Long Bridge Medical, Inc, MicroOptx, MST Surgical, Myra Vision/Shifamed LLC, New World Medical, NovaEye, Ocular Instruments, Ocular Therapeutix, Oculo, Oculus Surgical, Omega Ophthalmics, PolyActiva, PulseMedica, Radiance Therapeutics, Inc, Radius XR, Rheon Medical SA, Ripple Therapeutics, Samsara Vision, Sanoculis, Santen, Sight Sciences, Smartlens, Inc, Stroma, Thea Pharma, TFS Health Science, ViaLase, Visus Therapeutics, Vizzario, VSY Biotechnology, Zilia, Inc; Honoraria—Alcon, Allergan, Carl Zeiss Meditec, Heine, Johnson & Johnson Vision, MST Surgical; Research Support—Aerie Pharmaceuticals, Alcon, Allergan, Bionode, Glaukos, iCare, Ivantis, Johnson & Johnson Vision, New World Medical, Santen. MBS: Consultant—AbbVie, Alcon, Bausch Health, Santen, Zeiss; Honoraria—AbbVie, Alcon, Bausch Health, Johnson & Johnson Vision, Labtician Théa, Santen, Zeiss; Research support—Glaucoma Research Society, Canadian Institute for Health Research, Alcon, Bausch Health, Johnson & Johnson Vision., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The purpose of this study was to measure intraocular pressure (IOP) elevation while applying standard gonioscopy, selective laser trabeculoplasty (SLT), and laser iridotomy procedural lenses., Methods: Twelve cadaver eyes were mounted to a custom apparatus and cannulated with a pressure transducer which measured IOP. The apparatus was mounted to a load cell which measured the force on the eye. Six ophthalmologists performed simulated gonioscopy (Sussman 4 mirror lens), SLT (Latina lens), and laser iridotomy (Abraham lens) while a computer recorded IOP (mm Hg) and force (grams). The main outcome measures were IOP and force applied to the eye globe during ophthalmic diagnostics and procedures., Results: The average IOP's during gonioscopy, SLT, and laser iridotomy were 43.2 ± 16.9 mm Hg, 39.8 ± 9.9 mm Hg, and 42.7 ± 12.6 mm Hg, respectively. The mean force on the eye for the Sussman, Latina, and Abraham lens was 40.3 ± 26.4 grams, 66.7 ± 29.8 grams, and 65.5 ± 35.9 grams, respectively. The average force applied to the eye by the Sussman lens was significantly lower than both the Latina lens (P = 0.0008) and the Abraham lens (P = 0.001). During gonioscopy indentation, IOP elevated on average to 80.5 ± 22.6 mm Hg. During simulated laser iridotomy tamponade, IOP elevated on average to 82.3 ± 27.2 mm Hg., Conclusions: In cadaver eyes, the use of standard ophthalmic procedural lenses elevated IOP by approximately 20 mm Hg above baseline.

Purpose: To evaluate the performance and safety of minimally invasive glaucoma surgery with a supraciliary drainage device (MINIject; iSTAR Medical, Wavre, Belgium) in primary open-angle glaucoma (POAG) as a stand-alone procedure., Design: Meta-analysis., Methods: At 11 sites in Colombia, France, Germany, India, Panama, and Spain, 82 patients were treated in 3 prospective, multicenter, interventional, nonrandomized trials (STAR-I, II, III). Data were pooled in a meta-analysis of up to 2 years of follow-up postimplantation. The main outcome measures were mean relative and absolute reduction in diurnal intraocular pressure (IOP) compared to baseline. Secondary outcomes included patients with IOP ≤18 mmHg, patients with IOP reduction ≥20%, number of IOP-lowering medications, adverse events, and endothelial cell density loss., Results: At the 2-year follow-up (n = 66), mean IOP was reduced from 23.8 ± 3.3 mmHg at baseline to 14.4 ± 4.5 mmHg (-39.3%; P < 0.0001). An IOP reduction of ≥20% was achieved in 89.4% of patients, with 84.8% having an IOP ≤18 mmHg. IOP-lowering medications were reduced from a mean of 2.4 ± 1.1 to 1.4 ± 1.4 (P < 0.0001), with 37.9% of patients being medication-free at 2 years. Mean endothelial cell density loss at 2 years was 6.2 ± 9.1% compared to baseline and no patient had a loss >30%., Conclusions: This meta-analysis demonstrates the favorable safety and efficacy profile of a supraciliary device implanted in a stand-alone, ab-interno procedure in patients with mild-to-moderate POAG. The data demonstrate that MINIject is a safe and effective, bleb-free treatment option for patients requiring low target IOP up to 2 years., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare 5-year corneal endothelial safety of 3 minimally invasive glaucoma surgery (MIGS) devices (iStent inject , Hydrus Microstent, CyPass Micro-Stent)., Setting: U.S. multicenter trials., Design: Post hoc 5-year analysis from prospective randomized single-masked pivotal trials., Methods: Mild to moderate open-angle glaucoma subjects received a MIGS implant with phacoemulsification (implant + phaco) or phaco alone (control). In addition, 5-year end points comparing the implant and control groups included proportion of eyes with significant endothelial cell loss (ECL) (>30% or ≥30% vs baseline) and mean endothelial cell density (ECD)., Results: Comparable proportions of eyes in the iStent inject + phaco and control groups had significant 60-month ECL (9.4% vs 6.3%, respectively, diff: 3.2%, 95% CI, -5.0% to 11.3%, P = .77). Hydrus (20.8% vs 10.6%, diff: 10.2%, 95% CI, 3.2% to 17.2%, P = .01) and CyPass (27.2% vs 10.0%, diff: 17.2%, 95% CI, 5.6% to 28.7%, P = .02) had more eyes with ECL vs controls (iStent inject 1.49X, Hydrus 1.96X, CyPass 2.72X vs controls). Mean ECD over 60 months for iStent inject was indistinguishable vs control, whereas greater ECL was observed primarily 3 months postoperative (Hydrus) or accelerated after 2 years (CyPass). No iStent inject or Hydrus subjects developed persistent corneal edema, whereas 7 CyPass-implanted eyes developed ECL-related complications., Conclusions: Through 5 years postoperative, there were no differences in proportion of eyes with significant ECL or mean ECD between the iStent inject and control groups. There was greater 5-year ECL and lower ECD in the Hydrus and CyPass groups vs controls. The Hydrus ECL rate mirrored control after 3 months; the CyPass ECL rate accelerated vs control., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS.)

Background: To evaluate the safety and efficacy of the Minimally Invasive Micro Sclerotomy (MIMS) procedure in the management of uncontrolled open-angle glaucoma., Methods: A prospective, open-label, single-arm clinical evaluation with intra-subject comparisons performed at the Ophthalmologic Center after S.V. Malayan, Yerevan, Armenia. Included were adults with primary open-angle glaucoma (OAG) (N = 114) or exfoliative glaucoma (N = 6) who were uncontrolled (IOP > 21) on tolerated topical medication. Mild (N = 7), moderate (N = 66) and severe (n = 47) cases were prospectively included without preselection. Following subconjunctival Mitomycin C, an ab-interno MIMS procedure was performed alone (N = 100) or combined with phacoemulsification (N = 20). Patients were followed for 52 weeks. Procedure-related complications and adverse events were recorded. Success criteria were defined as -5 < IOP ≤ 21mmHg OR a reduction in IOP of ≥ 20% from baseline with (qualified success) or without (complete success) hypotensive medications., Results: Mean patient age was 69 ± 10.1 years. The mean duration of the procedure was 2:01 ± 0:41 min:sec. Scleral drainage channels were achieved in all cases. No device malfunctions, intraoperative complications, or serious adverse events were reported. Iris plugging of the sclerostomy site and early spikes in IOP were the most common adverse events. The only reason for failure was final IOP > 21 mmHg on tolerated medication. At 52 weeks (n = 93), mean IOP decreased by 38% from baseline (P < 0.001), from 27.9 ± 3.7 to 17.5 ± 5.3 mmHg, a difference of 10.5 mmHg (95% CI: -11.7, -9.3). One-year qualified success was documented in 82.1% (95% CI: 72.9%,89.2%) of the patients and complete success, in 70.5% (60.3-79.4%). 60% (95 CI:49.4%,69.9%) of the patients achieved maximum IOP level of 14 mmHg or at least 30% reduction in IOP., Conclusions: MIMS procedure is a relatively simple, short and safe minimally invasive bleb-forming procedure. Its efficacy, as found in this short-term evaluation, lends it suitable for mild and moderate uncontrolled open-angle glaucoma patients., Trial Registration: ClinicalTrials.gov ID: NCT04503590 2019-05-29., (© 2024. The Author(s).)

A 78-year-old woman with an ocular history of cataract surgery with a diffractive intraocular lens (IOL) in each eye has developed fluctuating vision, greater in the right eye than the left eye, after 4 years. She has a history of inactive central serous retinopathy and a vision potential of 20/25 + 2 in the right eye and 20/25 in the left eye. She has well-controlled diabetes, hypertension, and hypercholesterolemia. She has enjoyed her spectacle independence for some time and wishes to have her vision restored. On examination, her uncorrected distance visual acuity (UDVA) was 20/50 in the right eye and 20/25 in the left eye and her uncorrected near visual acuity (UNVA) was J3 in the right eye and J1 in the left eye. Intraocular pressures (IOPs) measured 22 mm Hg in the right eye and 18 mm Hg in the left eye. Pupils had limited reactivity with irregularity in the right eye but no obvious relative afferent pupillary defect. Motility and confrontation visual fields were unremarkable in both eyes. Retinal acuity meter was 20/20 in both eyes, and manifest refraction was plano -1.25 × 105 20/40, J3 in the right eye and +0.50 × 20/25, J1 in the left eye. Pertinent findings on slitlamp examination included temporal iris atrophy and transillumination defects greater in the right eye than the left eye, peripupillary pseudoexfoliative changes in both eyes, significant inferior subluxation of a diffractive 3-piece posterior chamber IOL in the capsular bag with lens-pitting peripherally and few central, moderate pseudophacodonesis, and an open posterior capsule in the right eye. In the left eye, she had mild inferior subluxation of a single-piece acrylic diffractive IOL in the capsular bag with moderate pseudophacodonesis and an open posterior capsule (Figure 1JOURNAL/jcrs/04.03/02158034-202403000-00019/figure1/v/2024-02-20T193212Z/r/image-tiff). All other anterior segment findings were unremarkable. On dilated posterior examination, she had a cup-to-disc ratio of 0.50 in the right eye and 0.65 in the left eye without edema hemorrhage or pallor. There were attenuated vessels in both eyes, posterior vitreous detachment in both eyes, and a few small drusen peripherally in both eyes. There was retinal pigment epithelium irregularity and dropout parafoveal in the right eye and subfoveal in the left eye (Figure 2). There was no evidence of macular edema, subretinal fluid, choroidal thickening, or neovascular membranes. The periphery was unremarkable in both eyes.JOURNAL/jcrs/04.03/02158034-202403000-00019/figure2/v/2024-02-20T193212Z/r/image-tiff What testing would you obtain preoperatively to help guide your decision-making? How would you counsel the patient regarding comorbid conditions and expectations?, (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: Compare estimated sensitivities of SITA-Standard to the RATA-Standard algorithm of the Radius virtual reality perimeter (VRP), and measure concordance in glaucoma staging., Methods: One hundred adult glaucoma patients-half with suspect or mild glaucoma, and half with moderate or severe-from five clinics performed four 24-2 visual field tests during a single visit, two with the Humphrey Field Analyzer (HFA) and two with Radius, in randomized order: HRHR or RHRH. Only one eye was tested per participant. We used the Wilcoxon rank sum test with Bonferroni correction to compare distributions of estimated sensitivities across all 54 test locations over the 15 to 40 dB measurement range of the Radius. Weighted kappa measured concordance in glaucoma staging between two masked glaucoma experts using Medicare definitions of severity., Results: A total of 62 OD and 38 OS eyes were tested. Estimated sensitivities for SITA-Standard and RATA-Standard were not significantly different for OD, but were for OS-likely because of SITA-Standard OD and OS being significantly different in our sample, but not for RATA-Standard. Low agreement was observed between 15 to 22 dB. Concordance in glaucoma staging was high for both graders: kappa = 0.91 and kappa = 0.93. Average test duration was 298 seconds for RATA-Standard and 341 seconds for SITA-Standard. The correlation in mean deviation was 0.94., Conclusions: Estimated sensitivities of RATA-Standard are comparable to SITA-Standard between 23 to 40 dB with high concordance in glaucoma staging., Translational Relevance: Radius VRP is statistically noninferior to HFA when staging glaucoma using Medicare definitions.

Competing Interests: A. Gupta, T. Tejpal, R. A. Sharma report no conflicts of interest; I. I. K. Ahmed—Consultant—Aequus, Aerie Pharmaceuticals, Akorn, Alcon, Allergan, Aquea Health, Inc, ArcScan, Bausch Health, Beaver Visitec, Beyeonics, Carl Zeiss Meditec, Centricity Vision, Inc, CorNeat Vision, Costum Surgical, ELT Sight, ElutiMed, Equinox, Genentech, Glaukos, Gore, Iantrek, InjectSense, Iridex, iStar, Ivantis, Johnson & Johnson Vision, LayerBio, Leica Microsystems, Long Bridge Medical, Inc, MicroOptx, MST Surgical, New World Medical, Ocular Instruments, Ocular Therapeutix, Oculo, Omega Ophthalmics, PolyActiva, Radiance Therapeutics, Inc, Ripple Therapeutics, Sanoculis, Santen, Shifamed, LLC, Sight Sciences, Smartlens, Inc, Stroma, Thea Pharma, ViaLase, Vizzario; Financial support—Aerie Pharmaceuticals, Alcon, Allergan, Glaukos, Ivantis, Johnson & Johnson Vision, New World Medical, Santen; Lecturer—Alcon, Allergan, Carl Zeiss Meditec, Johnson & Johnson Vision, MST Surgical, Mundipharma.

A 70-year-old man had progressive and severe glaucoma in each eye. He was intolerant to dorzolamide, brimonidine, and netarsudil. Each eye had prior selective laser trabeculoplasty (SLT) as well as phacoemulsification plus minimally invasive glaucoma surgery (MIGS) 6 years before current presentation (iStent [Glaukos Corp.] in the right eye and Cypass [Alcon Laboratories, Inc.] in the left eye). Postoperative acuities were 20/20 and 20/25 in the right and left eyes, respectively. When his left eye progressed with loss of central acuity despite peak intraocular pressures (IOPs) in the middle to upper teens, neuro-ophthalmology consultation was obtained (Figure 1JOURNAL/jcrs/04.03/02158034-202401000-00017/figure1/v/2023-12-22T124801Z/r/image-tiff). That workup included magnetic resonance imaging scan and hematologic screening, but all results were negative, and the neuro-ophthalmic consultant concluded that the vision loss was likely on the basis of glaucoma. Accordingly, a trabeculectomy was performed in the left eye achieving consistent IOPs in the range of 7 to 10 mm Hg without medications, rending the left eye stable since the filtration surgery nearly 2 years previously. The right eye continued to progress both subjectively and objectively, and on recent examination, the IOP measured 20 mm Hg and 09 mm Hg in the right and left eyes, respectively (Figure 2JOURNAL/jcrs/04.03/02158034-202401000-00017/figure2/v/2023-12-22T124801Z/r/image-tiff). Medications included timolol and latanoprostene bunod in the right eye only. Central corneal thickness was 526 μm and 527 μm in the right and left eyes, respectively. The visual acuity now measured 20/25 in the right eye and 20/250 in the left eye. The vertical cup-to-disc ratio was 0.9 in the right eye and 1.0 in the left eye. Gonioscopy revealed a wide open angle in each eye with a patent sclerostomy superiorly in the left eye. The conjunctiva and sclera were healthy and without scarring in the right eye. The bleb in the left eye was diffuse, lightly vascularized, and seidel negative. Axial length (AL) was 26.88 μm in the right eye and 26.77 μm in the left eye. The patient was in good health and was not anticoagulated. An extensive discussion ensued about the best course of action for the right eye. How would you proceed in managing definite progression in this individual's right eye, knowing that he had lost fixation in his left eye at similar pressures?, (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To present the effectiveness, risk factors for surgical failure, and adverse events over 12 months in a consecutive diverse cohort of glaucoma patients who underwent solo or combined ab externo SIBS microshunt with mitomycin C (MMC) with or without previous subconjunctival surgery., Design: Retrospective, consecutive, interventional case series., Methods: Consecutive glaucomatous eyes on maximally tolerated medical therapy received ab externo SIBS microshunt with MMC implantation as a solo or combined procedure with phacoemulsification from July 2015 to January 2020. The primary outcome was the proportion of eyes at 12-months with the following: (1) no 2 consecutive intraocular pressures (IOPs) >17 mm Hg or clinical hypotony, without (complete success) or with (qualified success) glaucoma medications; and (2) ≥20% reduction from baseline IOP. Secondary outcomes included upper IOP thresholds of 14 and 21 mm Hg with and without a 20% IOP reduction from baseline, median IOP, medications, risk factors for failure, postoperative interventions, complications, and reoperations., Results: A total of 436 eyes underwent surgery; 86 (20%) combined with phacoemulsification, 127 (29%) in eyes with refractory glaucoma, and 234 (51%) stand-alone procedures in non-refractory eyes. Complete success (6-17 mm Hg with no medications) was achieved in 64.0% of combined eyes, 58.1% of refractory eyes, and 74.8% of stand-alone non-refractory eyes; and qualified success rates (6-17 mm Hg with medications) were 90.7%, 84.7%, and 92.4% of eyes, respectively. At 12 months, 67% of eyes were medication free. Significant risk factors for failure included combined procedures in refractory eyes (hazard ratio [HR] = 3.2; 95% CI = 1.4-7.4), receiving <0.4 mg/mL of MMC (HR = 2.2; 95% CI = 1.6-3.1), refractory eyes (HR = 1.7; 95% CI = 1.2-2.5), combined procedures (HR = 1.6; 95% CI = 1.0-2.5), and each additional baseline medication class (HR = 1.3; 95% CI = 1.1-1.5). Postoperative complications occurred in 31% of eyes, and more often in those receiving ≥0.4 mg/mL MMC (odds ratio [OR] = 2.2, 95% CI 1.2-3.8). Needling occurred in 12% of eyes, with significantly higher frequency in refractory eyes (23%) and combined procedures (13%) compared to stand-alone (7%; P < .001). Revisions and reoperations occurred in 4% and 1.4% of eyes, respectively., Conclusions: The 1-year follow-up data from this large and diverse cohort support promising rates of qualified and complete surgical success with decreased medication burden and few postoperative complications and interventions. Combined phacoemulsification, refractory glaucoma, and receiving <0.4mg/mL MMC were associated with reduced surgical success rates., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To determine intermediate intraocular pressure (IOP)-lowering and adverse event profile of the 63-μm gelatin microstent (Xen63) with mitomycin C (MMC) compared with the 45-μm gelatin microstent (Xen45) with MMC., Design: Single center, consecutive, retrospective cohort study., Participants: Eighty-four glaucomatous eyes (42 63-μm gelatin microstent and 42 45-μm gelatin microstent) with or without previous subconjunctival glaucoma surgery., Methods: Consecutive eyes that underwent 63-μm gelatin microstent implantation with MMC from February 2020 to June 2021 were compared with eyes that underwent 45-μm gelatin microstent implantation with MMC. Standalone and combined cases with phacoemulsification were included., Main Outcome Measures: Primary outcome was the hazard ratio of failure of 45-μm gelatin microstent vs. 63-μm gelatin microstent eyes at 12 months, with failure defined as 2 consecutive IOPs, (1) >17 mmHg, (2) <6 mmHg with 2 lines of vision loss, or (3) <20% reduction from baseline IOP, without (complete) or with (qualified) glaucoma medications. Secondary outcomes included IOP thresholds of 14 mmHg and 21 mmHg, postoperative IOP, medications, adverse events, interventions, and reoperations., Results: The complete success rate was higher in the 63-μm gelatin microstent group (59.5% vs. 28.6%, P = 0.009) at the primary IOP threshold of 6 to 17 mmHg but did not differ significantly for qualified success (66.7% vs. 45.2%, P = 0.08). The crude hazard ratio of failure of 45-μm gelatin microstent relative to 63-μm gelatin microstent was 2.28 (95% confidence interval [CI], 1.21-4.32), and the adjusted hazard ratio was 7.90 (95% CI, 2.12-29.43). 63-μm gelatin microstent eyes had significantly lower mean IOP (12.7 ± 4.8 vs. 15.5 ± 5.1 mmHg, P = 0.001) and fewer medication classes (0.6 ± 1.1 vs. 1.7 ± 1.6 medications, P = 0.0005), with the degree of reduction in IOP and medication count being significantly greater in 63-μm gelatin microstent eyes. There were 28 and 21 distinct interventions in 63-μm gelatin microstent and 45-μm gelatin microstent eyes respectively, with 11.9% of eyes undergoing needling in each group. There were 34 and 19 distinct adverse events, in 63-μm gelatin microstent and 45-μm gelatin microstent eyes, respectively, most of which were early and transient. Nine Xen63 eyes (21.4%) and 6 45-μm gelatin microstent eyes (14.3%) underwent reoperation., Conclusions: 63-μm gelatin microstent resulted in higher surgical success rates and fewer medications compared with 45-μm gelatin microstent. This was tempered by more postoperative interventions and adverse events, although most were transient., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Glaucoma remains a leading cause of blindness globally. Minimally invasive treatment techniques are rapidly expanding the availability of therapeutic options for glaucoma. These include devices aimed at enhancing outflow through the subconjunctival space, Schlemm's canal, and suprachoroidal space, sustained-release drug delivery devices, and extraocular devices aiming to reduce glaucomatous progression through other novel means. In this review, we provide an overview of several novel devices either newly available or in development for the medical and surgical management of glaucoma. Further studies are required to determine the long-term efficacy of these devices and how they will integrate into the current landscape of glaucoma management., (© 2023. The Author(s).)

Purpose: To determine the effectiveness, risk factors for surgical failure, and adverse events in a large cohort of patients receiving stand-alone ab externo poly(styrene-block-isobutylene-block-styrene) (SIBS) microshunt implantation with mitomycin C (MMC) over 3 years of follow-up., Design: Retrospective, interventional case series., Participants: Glaucomatous eyes on maximally tolerated medical therapy with no previous subconjunctival glaucoma surgery., Methods: Records of eyes that underwent ab externo SIBS microshunt with MMC between July 2015 and November 2017 were reviewed. Data from all follow-up visits were utilized and included intraocular pressure (IOP), medication use, postoperative interventions, complications, and reoperations., Main Outcome Measures: The primary outcome was proportion of eyes at 3 years with (1) no 2 consecutive IOPs > 17 mmHg (or < 6 mmHg with > 2 lines of vision loss from baseline); (2) ≥ 20% reduction from baseline IOP; and (3) using no glaucoma medications (complete success). Secondary outcomes included 14 and 21 mmHg upper IOP thresholds with and without ≥ 20% IOP reduction from baseline, qualified success (with glaucoma medications), risk factors for failure, median IOP/medications, postoperative interventions, complications, and reoperations., Results: One hundred fifty-two eyes from 135 patients were included. Complete and qualified success was achieved in 55.6% and 74.8% of eyes, respectively. Time to first glaucoma medication use was a median of 16.9 (interquartile range [IQR], 12.1-34.1) months; however, 59.4% of eyes remained medication free at 3 years. Significant risk factors for failure included receiving < 0.4 mg/ml of MMC (adjusted hazard ratio [HR], 2.42; 95% confidence interval [CI], 1.44-4.05) and baseline IOP < 21 mmHg (adjusted HR, 1.79; 95% CI, 1.03-3.13). The most common complications were choroidal detachment, hyphema, and anterior chamber shallowing, occurring in 7%, 5%, and 5% of eyes, respectively. The needling rate was 15.1%, with significantly higher frequency for baseline IOP > 21 mmHg (HR, 3.21; 95% CI, 1.38-7.48). Revisions occurred in 7% of eyes and reoperations in 2.6%. Eyes receiving < 0.4 mg/ml of MMC underwent more revisions (odds ratio, 4.9; 95% CI, 1.3-18.3)., Conclusions: Three-year follow-up data from this large cohort continues to support promising rates of qualified and complete success, with decreased medication burden postoperatively and few postoperative complications and interventions. Comparisons to other filtering surgeries will further facilitate integration of the SIBS microshunt into the surgical treatment paradigm., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report 5-year postoperative safety data of iStent inject, including overall stability, endothelial cell density (ECD), and endothelial cell loss (ECL) in patients with mild-to-moderate primary open-angle glaucoma (POAG)., Design: 5-year follow-up safety study of the prospective, randomized, single-masked, concurrently controlled, multicenter iStent inject pivotal trial., Methods: In this 5-year follow-up safety study of the 2-year iStent inject pivotal randomized controlled trial, patients receiving iStent inject placement and phacoemulsification or phacoemulsification alone were studied for the incidence of clinically relevant complications associated with iStent inject placement and stability. Corneal endothelial endpoints were mean change in ECD from screening and proportion of patients with >30% ECL from screening, from analysis of central specular endothelial images by a central image analysis reading center at several time points through 60 months postoperatively., Results: Of the 505 original randomized patients, 227 elected to participate (iStent inject and phacoemulsification group, n = 178; phacoemulsification-alone control group, n = 49). No specific device-related adverse events or complications were reported through month 60. No significant differences were observed in mean ECD, mean percentage change in ECD, or proportion of eyes with >30% ECL between the iStent inject and control groups at any time point; mean percentage decrease in ECD at 60 months was 14.3% ± 13.4% in the iStent inject group and 14.8% ± 10.3% in the control group (P = .8112). The annualized rate of ECD change from 3 to 60 months was neither clinically nor statistically significant between groups., Conclusions: Implantation of iStent inject during phacoemulsification in patients with mild-to-moderate POAG did not produce any device-related complications or ECD safety concerns compared to phacoemulsification alone through 60 months., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To compare visual field (VF) progression between glaucoma patients receiving cataract surgery alone (CS) or with a Hydrus microstent (CS-HMS)., Design: Post hoc analysis of VF data from the HORIZON multicenter randomized controlled trial., Methods: A total of 556 patients with glaucoma and cataract were randomized 2:1 to either CS-HMS (369) or CS (187) and followed up for 5 years. VF was performed at 6 months and then every year after surgery. We analyzed data for all participants with at least 3 reliable VFs (false positives < 15%). Average between-group difference in rate of progression (RoP) was tested using a Bayesian mixed model and a 2-sided Bayesian P value <.05 (main outcome). A multivariable model measured the effect of intraocular pressure (IOP). A survival analysis compared the probability of global VF sensitivity dropping by predefined cutoffs (2.5, 3.5, 4.5, and 5.5 dB) from baseline., Results: Data from 352 eyes in the CS-HMS arm and 165 in the CS arm were analyzed (2966 VFs). The mean RoP was -0.26 dB/y (95% credible interval -0.36, -0.16) for CS-HMS and -0.49 dB/y (95% credible interval -0.63, -0.34) for CS. This difference was significant (P = .0138). The difference in IOP only explained 17% of the effect (P < .0001). Five-year survival analysis showed an increased probability of VF worsening by 5.5 dB (P = .0170), indicating a greater proportion of fast progressors in the CS arm., Conclusions: CS-HMS has a significant effect on VF preservation in glaucoma patients compared with CS alone, reducing the proportion of fast progressors., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: To assess the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in uveitic glaucoma (UG)., Methods: A retrospective interventional case series in which 33 eyes of 32 patients with UG underwent GATT with or without concomitant cataract extraction and intraocular lens implantation (CE/IOL) at three Canadian treatment centres from October 2015 to 2020. The main outcome measure was surgical success defined as an intraocular pressure (IOP) ≤18 mm Hg and at least one of the following: IOP within one mm Hg of baseline on fewer glaucoma medications as compared with baseline or a 30% IOP reduction from baseline on the same or fewer medications. Secondary outcome measures were IOP, medication usage and surgical complications., Results: Mean patient age (mean±SD) was 49±16 years (range: 18-79) and 44% were female. GATT was performed as a standalone procedure in 52% of cases and the remainder were combined with CE/IOL. Surgical success was achieved in 71.8% (SE: 8.7%) of cases. Mean preoperative IOP (±SD) was 31.4±10.8 mm Hg on a median of 4 medications. 59% of patients were on oral carbonic anhydrase inhibitors (CAIs) prior to surgery. After 1 year, average IOP was 13.8 mm Hg on a median 1 medication, with 6% of patients being on oral CAIs. No sight threatening complications occurred during surgery or follow-up., Conclusion: GATT is an effective surgical strategy in the management of UG. This microinvasive conjunctival-sparing procedure should be considered early in these patients., Competing Interests: Competing interests: C: Consultant/Speaking Fees; S: Speakers Honoraria; R: Research Grant/Support. AB—Ioptima: C. IIKA—Aequus: C; Aerie Pharmaceuticals: C, R; Akorn: C; Alcon: C,S,R; Allergan: C,S,R; Aquea Health, Inc: C; ArcScan: C; Bausch Health: C; Beaver Visitec: C; Beyeonics: C; Carl Zeiss Meditec: C,S; Centricity Vision, Inc: C; CorNeat Vision: CELT Sight: C; ElutiMed: C; Equinox: C; Genentech: C; Glaukos: C, R’;Gore: C; Iantrek: C; InjectSense: C; Iridex: C; iStar: C; Ivantis: C, R; Johnson & Johnson Vision: C, S, R; LayerBio: C; Leica Microsystems: C; Long Bridge Medical, Inc: C; MicroOptx: C; MST Surgical: C, S; Mundipharma: S; New World Medical: C, R; Ocular Instruments: C; Ocular Therapeutix: C; Oculo: C; Omega Ophthalmics: C; PolyActiva: C; Radiance Therapeutics, Inc: C; Ripple Therapeutics: C; Sanoculis: C; Santen: C, R; Shifamed: C; Sight Sciences: C; Smartlens: C; Stroma: C; Thea Pharma: C; ViaLase: C; Vizzario: C. PG—C for Alcon, Allergan, Bausch andLomb, Glaukos, Santen. MBS—Aerie Pharmaceuticals: C; Alcon: C,S,R; Allergan: C,S,R; Bausch Health: C,R; Carl Zeiss Meditec: S; Ivantis: C; Johnson & Johnson Vision: C,S,R; Labtician: C; Santen: C,S,R., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To assess the outcomes of a novel toric trifocal intraocular lens (IOL) for refractive lens exchange (RLE) in a large series of eyes with corneal astigmatism., Methods: Consecutive eyes that underwent RLE with the PanOptix Toric IOL (Alcon Laboratories, Inc) were included. Outcomes measures included postoperative distance (UDVA), 60 cm intermediate (UIVA), and 40 cm near (UNVA) uncorrected visual acuity, manifest refraction, spherical and defocus equivalent, efficacy and safety indices, and vector analyses of refractive and toric IOL accuracy., Results: A total of 4,933 eyes had a median follow-up of 3 months. UDVA of 20/20 and 20/40 was obtained in 65% and 99% of eyes monocularly and 87% and 100% binocularly, respectively. UIVA at 60 cm of 20/25 and 20/40 was achieved in 70% and 99% of eyes monocularly and in 77% and 100% binocularly, respectively. UNVA at 40 cm of 20/25 and 20/40 was achieved in 85% and 96% of eyes monocularly and in 95% and 100% binocularly, respectively. A total of 67%, 89%, 97%, and 99% of eyes had a SEQ within 0.25, 0.50, 0.75, and 1.00 diopter (D) of intended target ( R 2 = 0.99). Postoperative refractive astigmatism of 0.50, 0.75, and 1.00 D or less was achieved in 86%, 95%, and 98% of eyes. The vector analysis correction index and index of success were 1.04 ± 0.35 and 0.41 ± 0.31 for toric IOL accuracy and 1.00 ± 0.46 and 0.36 ± 0.55 for refractive accuracy, respectively. The 3- and 12-month post-RLE excimer laser enhancement rates were 1.1% (95% CI: 0.8% to 1.4%) and 7.6% (95% CI: 6.9% to 8.3%), respectively., Conclusions: The PanOptix Toric IOL performed well for a wide range of axial lengths and corneal astigmatism in eyes that had RLE. Most patients achieved effective uncorrected binocular near, intermediate, and distance vision for daily functioning. [ J Refract Surg . 2023;39(5):302-310.] .

Purpose: To track operative phases of cataract surgery over a resident's training to measure action times and frequencies as a surrogate for competency and skill progression., Design: An n = 1 panel study., Methods: Cataract surgery video recordings performed by a single resident between 2021-2022 were collected. Only full-length videos of adequate quality without supervisor intervention were included. The start and end times of 19 distinct operative phases of cataract surgery were manually labeled by a trained annotator. Timeseries analysis was employed to measure the direction and magnitude of trends in the resident's surgical timing for each action across their first year of training., Results: The dataset comprised 100 videos spread across the resident's sixth to 760 th cases. The median total time was 11.6 minutes (IQR 10.1-14.4 minutes), with overall speed increasing at a rate of 43.4 seconds for every 10 videos (95% CI 35.1, 52.7 seconds). Nine operative phases significantly decreased in time throughout training. The main incision, phacoemulsification, and hydrodissection had the greatest improvements in speed relative to their average procedural time. There was an average of 26.9 distinct operative actions (excluding idle periods) in each video (range 20-50)., Conclusions: This is the first study to quantitatively track operative times and frequencies across all relevant actions in cataract surgery and derive learning curves for each. Consistent with previous works, it was found that a basic level of surgical competency was achieved after performing 80 cases. In addition, results from this study indicated that the next level in skill advancement towards surgical finesse occurs after 300 cases., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Prcis: Analysis of efficacy, safety, and risk factors for failure of superior versus inferior 180-degree segmental gonioscopy-assisted transluminal trabeculectomy showed no significant difference between approaches, with novel risk factors for failure identified., Purpose: Compare the efficacy, safety, and risk factors for failure of superior versus inferior 180-degree segmental suture gonioscopy-assisted transluminal trabeculotomy (GATT)., Design: Multicenter, retrospective interventional cohort study of 297 eyes of 243 glaucomatous patients, which underwent superior or inferior 180-degree suture hemi-GATT surgery combined with phacoemulsification at one of 3 Canadian ophthalmological surgical centres in Calgary, Alberta or Toronto, Ontario., Main Outcome Measures: The primary outcome measure was the hazard ratio (HR) of failure for the "primary success" criteria. "Primary success" was defined as an intraocular pressure (IOP) <18 mm Hg and either 1) IOP reduced by ≥20% from baseline on the same number of IOP-lowering medications or 2) IOP ≤ baseline on fewer medications. Secondary outcome measures included HRs of failure for alternative criteria ("complete success", "qualified success" and "20% IOP reduction"), cross-sectional analysis, and Cox proportional hazard analysis for risk factors associated with increased failure for the complete cohort., Results: Baseline characteristics were similar between groups. The crude and adjusted HR of failure for the "primary success" criteria for superior surgeries relative to inferior surgeries were 1.27 (95% CI = 0.86-1.88) and 1.50 (95% CI = 0.91-2.46), with no statistically significant difference between approaches. Of the secondary criteria, there was statistical significance in favor of inferior surgeries only for crude analysis of the "20% reduction" criteria (1.40/1.27 (95% CI = 1.01-1.92). Increased risk of failure by the "primary success" measure for either intervention was seen with primary open angle glaucoma, advanced disease, and age below 70 years. There were no significant differences in the frequency of postoperative complications between cohorts, which were present in 72 superior (44.4%) and 67 inferior (49.6%; P value = 0.41) eyes; mostly early postoperative hyphema, iritis, and corneal edema., Conclusions: This retrospective study showed no difference in inferior versus superior 180 degrees of hemi-GATT/phacoemulsification cataract surgeries through the majority of analyses. Nonmodifiable factors including glaucoma type, advanced disease, and younger age were associated with a significantly higher risk of failure in this cohort. Further study is warranted., Competing Interests: Disclosure: A.B.: IOPtima. I.I.K.A.: Aequus, Aerie Pharmaceuticals, Akorn, Alcon, Allergan, ArcScan, Bausch Health, Beaver Visitec, Beyeonics, Camras Vision, Carl Zeiss Meditec, CorNeat Vision, Ellex, ELT Sight, ElutiMed, Equinox, Genentech, Glaukos, Gore, InjectSense, Iridex, iStar, Ivantis, Johnson and Johnson Vision, KeLoTec, LayerBio, Leica Microsystems, MicroOptx, MST Surgical, Mundipharma, Mynosys, New World Medical, Ocular Instruments, Ocular Therapeutix, Omega Ophthalmics, PolyActiva, Sanoculis, Santen, Science Based Health, Sight Sciences, Stroma, Thea Pharma, ViaLase, Vizzario. M.B.S.: Abbvie, Alcon, Bausch Health, Johnson and Johnson, Thea-Labtician, Santen, Zeiss. P.G.: Alcon, Allergan, Bausch and Lomb, Glaukos, Santen. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Current methods used to estimate surgical wait times in Ontario may be subject to inconsistencies and inaccuracies. In this population-level study, we aimed to estimate cataract surgery wait times in Ontario using a novel, objective and data-driven method., Methods: We identified adults who underwent cataract surgery between 2005 and 2019 in Ontario, using administrative records. Wait time 1 represented the number of days from referral to initial visit with the surgeon, and wait time 2 represented the number of days from the decision for surgery until the first eye surgery date. In the primary analysis, a ranking method prioritized referrals from optometrists, followed by ophthalmologists and family physicians., Results: The cohort consisted of 1 138 532 people with mostly female patients (57.4%) and those aged 65 years and older (79.0%). In the primary analysis, the median was 67 days for wait time 1 (interquartile range [IQR] 29-147). There was a median of 77 days for wait time 2 (IQR 37-155). Overall, the following proportions of patients waited less than 3, 6 and 12 months: 54.1%, 78.5% and 91.7%, respectively. For wait time 2, the proportions of patients who waited less than 3, 6 and 12 months were 49.5%, 77.1% and 93.3%, respectively. In total, 19.3% of patients did not meet the provincial target for wait time 1, 20.5% did not meet the target for wait time 2 and 35.0% did not meet the target for wait times 1 or 2., Interpretation: Administrative health services data can be used to estimate cataract surgery wait times. With this method, 35.0% of patients in 2005-2019 did not receive initial consultation or surgery within the provincial wait time target., Competing Interests: Competing interests: Marko Popovic has received research grant support from PSI Foundation and Fighting Blindness Canada. Matthew Schlenker has received consulting fees and speaker honoraria from Alcon and Allergan. He has also received speaker honoraria from Bausch Health, Johnson & Johnson Vision and Théa-Labtician. He has received consulting fees from Light Matter Interaction and Santen. Iqbal Ahmed has received consulting fees from Aequus, Aerie Pharmaceuticals, Akorn, Alcon, Allergan, Aquea Health, Inc, ArcScan, Bausch Health, Beaver Visitec, Beyeonics, Carl Zeiss Meditec, Centricity Vision, Inc., CorNeat Vision, Costum Surgical, ELT Sight, ElutiMed, Equinox, Genentech, Glaukos, Gore, Iantrek, InjectSense, Iridex, iStar, Ivantis, Johnson & Johnson Vision, LayerBio, Leica Microsystems, Long Bridge Medical, Inc., MicroOptx, MST Surgical, New World Medical, Ocular Instruments, Ocular Therapeutix, Oculo, Omega Ophthalmics, PolyActiva, Radiance Therapeutics, Inc., Ripple Therapeutics, Sanoculis, Santen, Shifamed, LLC, Sight Sciences, Smartlens, Inc., Stroma, Thea Pharma, ViaLase and Vizzario. He has also received speaker honoraria from Alcon, Allergan, Carl Zeiss Meditec, Johnson & Johnson Vision and MST Surgical. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Purpose: Pilot study to evaluate adverse events and intraocular pressure (IOP)-lowering of a novel, noninvasive glaucoma procedure, femtosecond laser, image-guided, high-precision trabeculotomy (FLIGHT)., Design: Prospective, nonrandomized, single-center, interventional, single-arm clinical trial., Participants: Eighteen eyes from 12 patients with open-angle glaucoma., Methods: Eighteen eyes from 12 patients underwent FLIGHT, creating a single channel measuring 500-μm wide by 200-μm high through the trabecular meshwork and into Schlemm's canal. Adverse events, IOP, and other parameters were evaluated out to 24 months., Main Outcome Measures: Outcomes were the rates and types of adverse events and the rate of postprocedure best-corrected visual acuity loss (≥ 2 lines) compared with baseline. Efficacy outcomes were reduction in mean intraocular pressure (IOP) with respect to baseline and the percentage of eyes with a ≥ 20% reduction in IOP., Results: Eighteen eyes from 12 patients were enrolled in the study; 11 patients (17 eyes) returned at 24 months. There were no serious adverse events related to the laser treatment. Well-defined channels were clearly visible at 24 months by gonioscopy and anterior segment OCT, with no evidence of closure. At 24 months, the mean IOP was reduced by 34.6% from 22.3 ± 5.5 to 14.5 ± 2.6 mmHg ( P < 5e-5), with an average of 2.0 ± 1.2 hypotensive medications compared with 2.2 ± 1.1 at baseline ( P  = 0.22). Fourteen out of the 17 study eyes (82.3%) achieved a ≥ 20% reduction in IOP at 24 months when compared with baseline., Conclusion: The FLIGHT system demonstrated a favorable safety profile in this initial pilot study, with no device-related serious adverse events. The channels appeared patent at 24 months, indicating medium-term durability., Financial Disclosures: Proprietary or commercial disclosure may be found after the references., (© 2023 by the American Academy of Ophthalmology.)

Background: Although traditional surgical procedures for glaucoma (such as trabeculectomy and tube-shunt implantation) can significantly reduce intraocular pressure (IOP), they are associated with numerous complications, some of which are vision-threatening, or involve prolonged recovery or a highly intensive postoperative course. Micro-invasive glaucoma surgery (MIGS) procedures have shown better safety but reduced efficacy in achieving target IOP. Combinations of these methods have led to the development of subconjunctival micro-invasive procedures with safety comparable to traditional surgery and greater efficacy than minimally invasive methods. This review describes the use of one of these devices, the poly(styrene-block-isobutylene-block-styrene) (SIBS)-based PreserFlo MicroShunt (Santen, Emeryville, CA), in the surgical treatment of patients with glaucoma., Main Text: The MicroShunt is an 8.5-mm tube made of an inert polymer with no endplate, an internal diameter of 70 μm, and fins intended to prevent peritubular flow and anchor the device within the sclera to prevent proximal migration into the eye. Following ab externo implantation, the tube provides a conduit for flow of aqueous humor from the anterior chamber into the subconjunctival/sub-Tenon space. Clinical trials to date have shown that, when paired with mitomycin C (MMC) treatment, MicroShunt implantation significantly reduced both IOP and the number of glaucoma medications. These IOP-lowering results were found both when surgery was performed alone and with phacoemulsification. The MicroShunt also showed a safety profile comparable to that of traditional filtering surgery., Conclusions: The MicroShunt and other novel subconjunctival procedures have shown substantial IOP reductions while mitigating hypotony-related complications. MMC, which modulates fibrosis and scarring postoperatively, is essential to surgical success. Randomized, long-term clinical trials will further clarify the role of controlled micro-incisional device-assisted ab externo glaucoma filtering surgery in long-term glaucoma management., (© 2023. The Author(s).)

Purpose: To validate the Iris Glare, Appearance, and Photophobia (Iris GAP) questionnaire, a new symptom-based and appearance-based quality-of-life measure for patients with iris defects., Setting: Single tertiary glaucoma clinic in Toronto, Ontario, Canada., Design: Prospective cohort study., Methods: Patients with varying degrees of iris defects were enrolled. Patients completed the Iris GAP questionnaire and the glare and driving subscales of the Refractive Status and Vision Profile (RSVP) questionnaire. Test-retest reliability, defined by Cronbach α and intraclass correlation coefficients (ICCs), was evaluated with repeat testing 2 weeks later., Results: The study included 73 patients with iris defects, 68 controls with no iris defects, 77 patients with peripheral iridotomies (PIs) or transillumination defects (TIDs), and 22 patientswith surgically repaired irides (n = 22). Iris GAP scores ranged from 0 to 32 with a 97% completion rate. Iris GAP had high test-retest reliability (Cronbach α = 0.866, ICC = 0.953, P < .0005). Iris GAP scores were reliably distinguishable between patients with iris defects, repaired iris defects, and PIs and TIDs and controls (1-way analysis of variance, P < .0005). In pairwise comparisons, the major defect group had statistically significant higher scores than any of the other groups ( P < .005 for each). The control and repaired groups had the lowest scores, whereas the PI/TID group had intermediate scores. 9 patients underwent iris repair between tests and had a mean difference of 8.2 ± 6.2 points between their preoperative and postoperative scores ( P = .004). Iris GAP scores positively correlated with RSVP scores ( R2 = 0.73)., Conclusions: Iris GAP can reliably evaluate symptomatology and patient-reported appearance in patients with iris defects., (Copyright © 2022 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)