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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.]

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.An n=1 panel study.We collected cataract surgery video recordings performed by a single resident between 2021-2022. 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 labelled 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.The dataset comprised 100 videos spread across the resident's 6-760 cases. The median total time was 11.6min (interquartile range: 10.1min-14.4min), with overall speed increasing at a rate of 43.4s for every 10 videos (95% CI: 35.1s-52.7s). 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 were an average 26.9 distinct operative actions (excluding idle periods) in each video (range: 20 to 50).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, we found that a basic level of surgical competency is achieved after performing 80 cases. In addition, results from this study indicate that the next level in skill advancement towards surgical finesse occurs after 300 cases.

To present the 5-year results of the HORIZON trial comparing cataract surgery (CS) combined with an intracanalicular microstent with CS alone.Prospective, multicenter, controlled randomized clinical trial.Patients with cataract and primary open-angle glaucoma treated with 1 or more glaucoma medications, washed-out diurnal intraocular pressure (DIOP) of 22 to 34 mmHg, and no prior incisional glaucoma surgery.Eyes were randomized 2:1 to receive a Hydrus Microstent (HMS; Ivantis, Inc) or no stent after successful CS.Intraocular pressure (IOP), glaucoma medication use, repeat glaucoma surgery, visual acuity, visual field, procedure-related adverse events, and corneal endothelial cell counts.Three hundred sixty-nine eyes were randomized to HMS treatment, and 187 eyes were randomized to CS only. Study groups were well matched for preoperative IOP, medication use, washed-out DIOP, and glaucoma severity. Five-year follow-up was completed in 80% of patients. At 5 years, the HMS group included a higher proportion of eyes with IOP of 18 mmHg or less without medications than the CS group (49.5% vs. 33.8%; P = 0.003), as well as a greater likelihood of IOP reduction of 20% or more without medications than the CS group (54.2% vs. 32.8%; P0.001). The number of glaucoma medications was 0.5 ± 0.9 in the HMS group and 0.9 ± 0.9 in the CS group (P0.001), and 66% of eyes in the HMS group were medication free compared with 46% in the CS group (P0.001). The cumulative risk of incisional glaucoma surgery was lower in the HMS group (2.4% vs. 6.2%; P = 0.027, log-rank test). No clinical or statistically significant differences were found in the rate of endothelial cell loss from 3 to 60 months between the HMS and CS alone groups (P = 0.261).The addition of a Schlemm's canal microstent in conjunction with CS was safe, resulted in lowered IOP and medication use, and reduced the need for postoperative incisional glaucoma filtration surgery compared with CS after 5 years. Long-term presence of the implant did not affect the corneal endothelium adversely.

Sean Yonamine,1,* Lauren Ton,2,* 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*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

Purpose To evaluate the agreement between glaucomatous 24-2 visual field (VF) testing performed with the Toronto Portable Perimeter (TPP; VEM Medical Technologies) and the Humphrey Field Analyzer (HFA; Carl Zeiss Meditec). Design Multicenter prospective cohort analysis. Participants Patients with suspected or confirmed glaucoma treated at Prism Eye Institute (Oakville, Canada), York Finch Eye Associates (North York, Canada), or the Ontario Mobile Medical Eye Care Unit (Cochrane, Canada) between March 2019 and March 2020. Methods Patients underwent consecutive VF tests on the same eye using the HFA Swedish Interactive Threshold Algorithm Standard 24-2 test and TPP Standard 24-2 test in randomized order. Bland-Altman analysis and paired t tests were used to compare VF results obtained by the TPP and the HFA. Participants completed a 5-question validated questionnaire after completing both testing methods. Main Outcome Measures Mean difference and degree of agreement in mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), and test duration between VF modalities. Results One hundred fifty eyes from 91 patients were included in analysis. Average MD of the overall cohort using HFA and TPP VF testing was –4.32 ± 5.47 dB and –4.53 ± 5.22 dB, respectively (P = 0.74). Bland-Altman analysis showed good agreement between HFA and TPP tests. The mean differences (95% limits of agreement) between HFA and TPP for MD, PSD, VFI, and test duration were 0.21 dB (–4.25 to 4.67 dB), –0.13 dB (–3.72 to 3.47 dB), 0.66% (–10.94% to 12.26%), and 0.65 seconds (–97.51 to 98.81 seconds), respectively. No statistically significant mean difference was found between HFA and TPP tests for MD, PSD, VFI, or test duration. Mean deviation (R2 = 0.830) and VFI (R2 = 0.866) were correlated strongly with both modalities. Questionnaire results demonstrated that patients significantly preferred the TPP over the HFA for VF testing (P Conclusions Mean deviation, PSD, and VFI outcomes measured by the TPP were statistically similar to corresponding parameters obtained with the HFA. Test time duration did not differ significantly between the TPP and HFA, and patients significantly preferred the TPP to the HFA examination experience. These pilot results suggest that the TPP may offer an accessible alternative to HFA VF testing.

Purpose To compare the efficacy and safety of early versus later ab interno gelatin microstent placement with mitomycin C. Design Canada-wide, multicenter, retrospective propensity score-matched cohort study. Participants Two hundred seventy eyes (135 early cases and 135 later cases) with no prior incisional surgery. Methods Surgeons’ first 20 patients (early cases group), from 6 glaucoma surgeons across 4 Canadian sites, were matched 1:1 to patients with the closest propensity score from the later (21+) patients (later cases group). Main Outcome Measures Primary outcome was hazard ratio (HR) of failure of the early versus later cases groups, with failure defined as IOP of less than 6 mmHg with more than 2 lines of vision loss or more than 17 mmHg with no medications (complete success) on 2 consecutive visits despite in-clinic maneuvers (including needling) more than 1 month after surgery. Secondary outcomes were HRs for failure, defined as IOP outside the range of 6 to 14 mmHg and 6 to 21 mmHg with and without allowing for medications (qualified success), interventions, complications, and reoperations. Results Hazard ratio of failure for early versus later cases groups was 1.38 (95% confidence interval [CI], 0.97–1.96) for the IOP range of 6 to 17 mmHg, 1.29 (95% CI, 0.90–1.84) for 6 to 14 mmHg, and 1.48 (95% CI, 1.03–2.13) for 6 to 21 mmHg without medication and 0.95 (95% CI, 0.55–1.64), 0.95 (95% CI, 0.61–1.48), and 0.95 (95% CI, 0.52–1.75) for the same IOP ranges allowing for medications. Needling rates were 43.0% (early cases group) and 41.5% (later cases group). Complication rates after 1 month occurred in 9.6% (early cases group) and 11.1% (later cases group; P = 0.69). Reoperation rates were 14.8% (early cases group) and 8.1% (later cases group; P = 0.08). Conclusions There is some evidence for improved success in the later cases group. Similar needling rates, similar complication rates, and a slightly higher reoperation rate were found for the early cases group. The results suggest that this procedure can be adopted by existing surgeons with current training regimens, although they may see an improvement in their success outcomes over time.

BackgroundTo assess the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in uveitic glaucoma (UG).MethodsA 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.ResultsMean 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.ConclusionGATT is an effective surgical strategy in the management of UG. This microinvasive conjunctival-sparing procedure should be considered early in these patients.

Iris defects and distorted pupils are commonly managed with iris suturing techniques that aim to close the defect and/or reform the physiological pupil. The re-creation of an optimally sized and centered pupil is often challenging because of missing iris, asymmetrical iris damage, or variable tension around the pupil. Current options include removing or cutting iris tissue using microscissors or the vitreous cutter, instrument stretching, or postoperative laser photocoagulation. Iris microendodiathermy is a simple technique that is minimally traumatic, titratable, and controlled, avoids excessive tissue manipulation, and is able to create a round cosmetically pleasing pupil. A bipolar endodiathermy cautery is applied to the iris stroma to induce tissue contraction and to gently pull the pupil in the meridian to which probe is applied. Endothermal pupilloplasty (EDP) may be used to recenter or enlarge a small pupil, thereby avoiding additional trauma inflicted by a vitrector or microscissors that physically cuts the iris.

Resumen Objetivos Evaluar la eficacia y posibles complicaciones de la trabeculostomia laser excimer (excimer laser trabeculostomy, ELT) una tecnica de cirugia de glaucoma minimamente invasiva (minimally invasive glaucoma surgery, MIGS) emergente de tipo laser, realizada en combinacion con la cirugia de la catarata durante la practica clinica habitual. Pacientes y metodos Estudio intervencionista, retrospectivo, en un unico centro. Se recopilaron los datos clinicos preoperatorios y postoperatorios de pacientes con catarata y glaucoma de angulo abierto (GAA) que fueron sometidos a cirugia combinada de ELT y facoemulsificacion, en el dia preoperatorio, a una semana, y uno, dos, tres, seis, nueve y 12 meses despues de la cirugia. La variable principal del estudio fue la presion intraocular (PIO). El exito cualificado y completo se definio como una PIO menor de 21 mmHg con una reduccion del 20% o mas de la PIO preoperatoria, con o sin tratamiento medico adyuvante, respectivamente. Resultados Se incluyeron 34 ojos de 29 pacientes; 29 ojos completaron el seguimiento a un ano. La PIO preoperatoria media bajo medicacion hipotensora fue de 20,9 ± 2,6 mmHg (± desviacion estandar, DE) y disminuyo significativamente al ano (16,3 ± 1,9; p Conclusion La combinacion de ELT con facoemulsificacion en ojos diagnosticados de catarata y glaucoma de angulo abierto (GAA) leve a moderado redujo significativamente la PIO y el uso de medicamentos sin complicaciones significativas despues de un ano de seguimiento en un entorno de practica clinica habitual.

To evaluate the efficacy and complication profile of excimer laser trabeculostomy (ELT), an emerging laser-based trabecular minimally invasive glaucoma surgery (MIGS), combined with cataract surgery in routine clinical practice.Single-site, retrospective, interventional study. Preoperative and postoperative clinical data of patients with cataract and open-angle glaucoma (OAG) who underwent combined phacoemulsification and ELT were collected and analyzed at preoperative day, one week postoperatively, and after one, two, three, six, nine and 12 months. Main outcome measure was intraocular pressure (IOP). Qualified and complete success were defined as an IOP less than 21 mmHg and an IOP reduction ≥ 20% from preoperative medicated IOP with or without adjuvant medical treatment, respectively.Thirty-four eyes of 29 patients were included; 29 eyes completed 1-year follow-up. The mean preoperative IOP under medications was 20.9 ± 2.6 mmHg (± standard deviation, SD) and decreased significantly at one year (16.3 ± 1.9; p 0.0001). The mean number of IOP-lowering medications decreased from 1.7 ± 0.7 to 0.3 ± 0.8 (p 0.0001) at the 12-month follow-up. At one year, 81% of eyes were medication free. Qualified and complete success was obtained in 62% and 58% of eyes, respectively. Two eyes had postoperative hyphema, three eyes had transient IOP spikes and one patient underwent a subsequent filtering surgery at three months.Combining ELT with phacoemulsification in eyes with cataract and mild to moderate OAG significantly reduced IOP and medication use without meaningful complications after one-year follow-up in a real world clinical practice setting.

As cataract surgery has evolved, intraocular lens (IOL) complications are rare. The purpose of this review was to report the incidence, diagnosis, and management of IOL decentrations, uveitis-glaucoma-hyphema (UGH) syndrome, IOL opacifications, and refractive surprises. Literature review was performed by searching PubMed, MEDLINE, EMBASE, and the Cochrane Controlled Trial Database and the reference lists of original studies as well as reviews. Intraocular lens decentrations and dislocations can appear at any time, particularly in patients with predisposing factors such as pseudoexfoliation, prior vitreoretinal surgery, or trauma. Recognizing when they require surgical intervention for UGH or to improve visual function is critical in limiting long-term sequela. Intraocular lens opacifications such as glistenings rarely require intervention, but others, such as subsurface nanoglistenings, calcifications, or discolorations, may require IOL exchange. Finally, despite our best efforts to enhance measurements and IOL calculations, refractive surprises still occur. Intraocular lens complications are uncommon with modern cataract surgery. A number of these complications require proper identification and care to optimize patient outcomes.

Microinvasive glaucoma surgery (MIGS) is a potentially safer and more efficacious method studied in patients with mild-to-moderate open-angle glaucoma requiring less invasive treatment goals; however, the literature on MIGS must be thoroughly evaluated. We conducted a review of MIGS by searching MEDLINE, EMBASE, and Cochrane CENTRAL. Primary efficacy indicators were reductions in intraocular pressure and topical medication use postoperatively. While all comparative randomized controlled trials assessing MIGS in English peer-reviewed journals were included, only observational studies with a target follow-up of at least one year and a high priority score were analyzed, resulting in a total of 3476 eyes across 20 trials. The mean age was 69.5 ± 2.9 years, 53.7% were female, and 77.4% were Caucasian. One study had last follow-up at less than one year, fifteen studies had follow-up extending 1-2 years, and four had longer than two years of follow-up. A pattern of more significant intraocular pressure and medication reduction was observed in patients who underwent MIGS (n = 2170) relative to control (n = 1306) interventions. iStent had the most literature supporting its efficacy, followed by Hydrus. The most common adverse events after MIGS implantation included stent obstruction, inflammation, and subsequent surgical intervention. Surgical complication rates and efficacy are favorable after MIGS. This review helps to consolidate the high-quality evidence that exists for various MIGS procedures and to identify gaps where further research is needed.

Purpose To report 3-year outcomes of the HORIZON study comparing cataract surgery (CS) with Hydrus Microstent (Ivantis, Inc) implantation versus CS alone. Design Multicenter randomized clinical trial. Participants Five hundred fifty-six eyes from 556 patients with cataract and primary open-angle glaucoma (POAG) treated with 1 or more glaucoma medication, washed out diurnal intraocular pressure (IOP) of 22 to 34 mmHg, and no prior incisional glaucoma surgery. Methods After phacoemulsification, eyes were randomized 2:1 to receive a Hydrus Microstent or no stent. Follow-up included comprehensive eye examinations through 3 years. Main Outcome Measures Outcome measures included IOP, medical therapy, reoperation rates, visual acuity, adverse events, and changes in corneal endothelial cell counts. Results Three hundred sixty-nine eyes were randomized to microstent treatment and 187 to CS only. Preoperative IOP, medication use, washed-out diurnal IOP, and glaucoma severity did not differ between the two treatment groups. At 3 years, IOP was 16.7 ± 3.1 mmHg in the microstent group and 17.0 ± 3.4 mmHg in the CS group (P = 0.85). The number of glaucoma medications was 0.4 ± 0.8 in the microstent group and 0.8 ± 1.0 in the CS group (P Conclusions Combined CS and microstent placement for mild to moderate POAG is safe, more effective in lowering IOP with fewer medications, and less likely to result in further incisional glaucoma filtration surgery than CS alone at 3 years.

The Icare HOME (TA022, Icare Oy, Vanda, Finland) is rebound tonometer recently approved by the US Food and Drug Administration in March 2017 designed for self-measurement of intraocular pressure (IOP). IOP remains a major modifiable risk factor for glaucoma progression; however, IOP measurements typically occur through single office measurements on Goldmann applanation tonometry (GAT) and do not always reveal the complete picture of patient's IOP patterns and daily fluctuations, which are important for accurate diagnosis and evaluation. Numerous studies have now compared the efficacy of the Icare HOME to that of GAT. The objective of this article is to review the existing literature surrounding the Icare HOME tonometer and its efficacy as a self-tonometer in comparison to GAT. The available literature has shown promising results in its accuracy of measuring IOP but suggests cautious usage in patients with central corneal thicknesses or IOP ranges that are outside of a certain range. This article will also provide details and example cases for when the Icare HOME may be most clinically useful.

Purpose Reintervention rate is an important factor impacting on patients, surgeons, and society. To date, only a few studies have focused on this topic. For this reason, a systematic review and meta-analysis was undertaken to assess the reintervention rate after glaucoma filtering surgery. Materials and Methods Prospective studies reporting the reintervention rate after glaucoma filtering surgery and with at least 12 months of follow-up were systematically searched on PubMed, Medline and Embase databases. The primary outcome was the total reintervention rate following surgery. Secondary outcomes were: the rate of manipulation, in-clinic and in-operating room reintervention; the reintervention rate for intraocular pressure (IOP) control and for complications; demographic, clinical and surgical variables associated with reintervention rate. Results Ninety-three studies with a total of 8345 eyes were eligible. The total reintervention rate was 1.84 (95% CI 1.57–2.13), with a lower rate for Baerveldt (0.53, 95% CI 0.29–0.83) and Preserflo (0.60, 95% CI 0.15–1.29), and a higher rate for Xen (4.26, 95% CI 2.59–6.31). The manipulation rate was 0.99 (95% CI 0.77–1.23), the in-clinic reintervention rate was 0.08 (95% CI 0.05–0.12) and the in-operating room reintervention rate was 0.28 (95% CI 0.22–0.35). The reintervention rate for IOP control was 1.26 (95% CI 1.04–1.51) and the reintervention rate for complications was 0.27 (95% CI 0.21–0.35). Conclusions All types of surgery presented a total reintervention rate similar to the overall findings, except studies on Baerveldt and Preserflo Microshunt, with a lower rate, and Xen, with a higher rate. None of the variables evaluated were found to be directly associated with the explored outcomes.

Purpose To demonstrate canalogram patterns observed when trypan blue tracer is combined with oculoviscoelastic device during ab interno canaloplasty, and discuss surgical results and potential implications for diagnosis, prognosis, and treatment. Methods This is a retrospective small case series study. Results The authors performed this procedure on 5 patients with informed consent with 4 to 18 months of follow-up. All procedures have been complication free. The average preoperative intraocular pressure was 16.4 mm Hg with an average number of topical glaucoma medications being equal to 3.6. Postoperatively, the average intraocular pressure for the group was reduced to 13 mm Hg with a concurrent drop in the average number of topical medications used equaling 1.8. Conclusions Currently, there are limited practical options to evaluate the patency of the aqueous outflow system in our patients. The primary purpose of this paper is to describe canalogram patterns observed during ab interno canaloplasty with trypan blue. This technique may allow us to further our understanding of the aqueous outflow system and its role in the underlying pathophysiology of glaucoma. Further research is required to evaluate the prognostic and diagnostic significance of this technique.

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.

To assess 5-year effectiveness and safety of 2 iStent® trabecular micro-bypass stents in eyes with open-angle glaucoma (OAG) not controlled on 1 medication.This prospective, interventional, single-arm, multi-surgeon study (NCT #1252862, clinicaltrials.gov) enrolled eyes with OAG, preoperative intraocular pressure (IOP) of 18-30 mmHg on 1 ocular hypotensive medication, and 22-38 mmHg after medication washout. Eyes underwent standalone implantation of 2 iStent devices and were followed through 60 months postoperatively. Efficacy was quantified by mean diurnal IOP and medication usage. Efficacy endpoints included the proportion of eyes with ≥20% IOP reduction versus baseline unmedicated IOP (primary efficacy), and the proportion of eyes with IOP ≤18 mmHg (secondary efficacy) without medication or secondary glaucoma surgery. Safety parameters included visual acuity, cup-to-disc ratio, visual field, and complications and adverse events.Preoperative mean IOP on 1 medication was 20.6 ± 2.0 mmHg and post-washout unmedicated IOP was 24.1 ± 1.4 mmHg (n = 39). At 5 years postoperative, medication-free mean diurnal IOP reduced to 14.5 ± 2.2 mmHg, constituting a 40% decrease versus preoperative washed-out IOP (This prospective interventional study demonstrates persistent 5-year reductions in IOP and freedom from medications, together with favorable safety, following implantation of 2 first-generation trabecular micro-bypass stents in eyes with OAG on 1 preoperative medication.

Purpose 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.

Purpose To determine the efficacy, risk factors for failure, and adverse events of a standalone novel ab externo SIBS microshunt with mitomycin C (MMC) during 1-year follow-up. Design Retrospective, interventional case series. Subjects Glaucomatous eyes with an intraocular pressure (IOP) above target and/or progressing on maximally tolerated medical therapy. Methods Consecutive patients with open-angle glaucoma (OAG) and no previous filtering surgery received an ab externo SIBS microshunt with MMC from July 2015 to November 2017. Main outcome measures were proportion of eyes at 1-year with (1) no 2 consecutive IOP readings >17 mm Hg or clinical hypotony without (complete) or with glaucoma medications (qualified); and (2) at least a 20% reduction from decision IOP. Secondary outcomes included upper IOP thresholds of 14 mm Hg and 21 mm Hg with and without a 20% IOP reduction from baseline, median IOP, medications, risk factors for failure, interventions, complications, and reoperations. Results A total of 164 eyes in 132 patients were included. Complete success was achieved in 76.9% of eyes, qualified success in 92.5%. Complete success was 75.6% for an upper IOP cut-off of 14 mm Hg and 76.9% for 21 mm Hg, and qualified success was 91.9% and 92.5%. MMC dose of 0.2 vs 0.4-0.5 mg/mL (hazard ratio [HR] 2.51; 95% CI 1.12-5.65) and primary open-angle glaucoma vs secondary open-angle glaucoma (SOAG) (HR 2.51; 95% CI 1.01-6.23) represented the only risk factors for failure in multivariable analysis. Needling was performed in 8.5% of eyes. Two eyes received surgical revision, and 1 a reoperation. Conclusions One-year results of the ab externo SIBS microshunt demonstrated promising rates of qualified and complete success, decreased drop use, few complications, and infrequent postoperative interventions.

Cataract is a common cause of reversible blindness. Visual acuity alone is not enough to assess appropriateness for surgery, prioritization, and outcomes. Catquest-9SF questionnaire evaluates patients' self-assessed visual function as related to daily tasks. We summarize and assess the validity of Catquest-9SF as a patient-reported outcome questionnaire to determine its suitability for clinical use. Thirteen studies with sample sizes ranging 102-10,886 (total n = 15,289) undertaken from 2009 to 2018 were included. Catquest-9SF showed unidimensionality, ordered response thresholds, and acceptable precision in all studies. Nine studies had significant mistargeting (range 0.66 to -2.04); the tasks being easy relative to the respondent ability in most studies. Two studies had misfitting items. We conclude Catquest-9SF is a valid and reliable tool to measure visual function in patients with cataract in various populations. Because results can be population specific, it is recommended that Catquest-9SF be validated in a new population before it is incorporated in routine practice.

Objective To evaluate binocular visual outcomes and presence of photic phenomena in patients with bilateral extended depth of focus (EDF) intraocular lens (IOL) implants. Design Retrospective consecutive case series. Participants Patients above the age of 18 years without prior ocular pathology or surgery with bilateral EDF IOL implants (ZXR00; Johnson & Johnson Vision) between January 2015 and December 2017 in Canadian ophthalmology centres. Methods Patient charts were retrospectively evaluated for binocular uncorrected distance visual acuity (UCDVA), binocular corrected distance visual acuity (CDVA), binocular uncorrected near visual acuity (UCNVA), photic phenomena (glare, halos, or dysphotopsia), complications, or reoperations. Subgroup analysis investigated the effect of monovision on the above outcomes. Results In total, 87 individuals with bilateral EDF IOL implants were included in the analysis. Median logMAR pre-operative CDVA was 0.18 (0.1–0.3). The median logMAR postoperative bilateral UCDVA was 0.14 (0.00–0.18), median CDVA was 0.00 (0.00–0.10), and median UCNVA was 0.10 (0.10–0.20). Overall, 16 (18.4%) cases self-reported the presence of photic phenomena, the most common of which were halos (13.8%). Subgroup analysis determined that there was no significant difference in visual outcomes or presence of photic phenomena when stratifying patients based on the degree of postoperative monovision (p = 0.31–0.57). Conclusions Overall, the Tecnis Symfony EDF IOL provided a reasonable range of binocular distance and near vision. Approximately 12.6% of patients self-reported any postoperative photic phenomena; however, all cases were subjectively considered mild and tolerable. Monovision had no effect on visual outcomes or the presence of photic phenomena.

Purpose To review evidence and provide guidelines on intracameral (ICM) injection techniques and monitoring. Materials and methods A review of published literature on ICM injection and intravitreal injections formed the basis for roundtable deliberations by an expert panel of ophthalmologists. Results ICM injection as a way to deliver medications is growing in popularity. However, there is limited published literature and no standard approach to best practices for ICM injections, particularly when not accompanying another surgical procedure. Fortunately, there is long clinical experience with ICM manipulation and a large body of evidence surrounding intravitreal injections that has provided important guidance. The expert panel formulates several concrete guidelines and many suggested techniques to help physicians safely and effectively employ ICM injections. Conclusions This committee addressed the many considerations surrounding ICM injection of drugs or implants and agree that it is a safe and effective surgical procedure when performed with appropriate training and according to established safe practices.

Purpose To assess, from the Canadian public payer perspective, the cost-utility of implanting iStent Inject trabecular bypass stent (TBS) devices in conjunction with cataract surgery versus cataract surgery alone in patients with open-angle glaucoma (OAG) and visually significant cataract. Design Cost-utility analysis using efficacy and safety results of pivotal randomized clinical trial. Participants Modeled cohort of patients with OAG (83.1% with mild disease, 16.9% with moderate disease) and visually significant cataract. Methods Open-angle glaucoma treatment costs and effects were projected over a 15-year time horizon using a Markov model with Hodapp-Parrish-Anderson glaucoma stages (mild, moderate, advanced, severe or blind) and death as health states. Patients in the mild or moderate OAG health states received implantation of iStent Inject during cataract surgery versus cataract surgery alone. On worsening of visual field defect and optic disc damage, patients could receive selective laser trabeculoplasty and trabeculectomy. We measured treatment effect as reduction in intraocular pressure (IOP) and mean medication use and estimated transition probabilities based on efficacy-adjusted visual field mean deviation decline per month. Healthcare resource utilization and utility scores were obtained from the literature. Cost inputs (2017 Canadian dollars [C$]) were derived using the Ontario Health Insurance Plan, expert opinion, medication claims datasets, and Ontario Drug Benefit Formulary medication consumption costs. We conducted deterministic and probabilistic sensitivity analyses to examine the impact of alternative model input values on results. Main Outcome Measures Incremental cost per quality-adjusted life year (QALY) gained. Results Compared with cataract surgery alone, TBS plus cataract surgery showed a 99% probability of being more effective (+0.023 QALYs; 95% confidence interval [CI], 0.004 to 0.044) and a 73.7% probability of being cost-saving (net cost, –C$389.00; 95% CI, –C$1712.00 to C$850.70). In 95% of all simulations, TBS plus cataract surgery showed a cost per QALY of C$62 366 or less. Results were robust in additional sensitivity and scenario analyses. Conclusions iStent Inject TBS implantation during cataract surgery seems to be cost effective for reducing IOP in patients with mild to moderate OAG versus cataract surgery alone.

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.Single tertiary glaucoma clinic in Toronto, Ontario, Canada.Prospective cohort study.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.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).Iris GAP can reliably evaluate symptomatology and patient-reported appearance in patients with iris defects.

Glaucoma is a chronic, debilitating disease and a leading cause of global blindness. Despite treatment efforts, 10% of patients demonstrate loss of vision. In the US, > 80% of glaucoma cases are classified as open-angle glaucoma (OAG), with primary open-angle (POAG) being the most common. Although there has been tremendous innovation in the surgical treatment of glaucoma as of late, two clinical variants of OAG, normal-tension glaucoma (NTG) and severe POAG, are especially challenging for providers because patients with access to care and excellent treatment options may progress despite achieving a “target” intraocular pressure value. Additionally, recent research has highlighted the importance of nocturnal IOP control in avoiding glaucomatous disease progression. There remains an unmet need for new treatment options that can effectively treat NTG and severe POAG patients, irrespective of baseline IOP, while overcoming adherence limitations of current pharmacotherapies, demonstrating a robust safety profile, and more effectively controlling nocturnal IOP. Funding The Rapid Service Fees were funded by the corresponding author, Tanner J. Ferguson, MD.

To describe the safety and efficacy of a novel, supraciliary, microinvasive glaucoma surgery drainage system, MINIject (iSTAR Medical, Wavre, Belgium), in the study.Prospective, multicenter, interventional, single-arm trial.Twenty-six patients with primary open-angle glaucoma uncontrolled with 1 or more intraocular pressure (IOP)-lowering medications.Using an ab interno approach, 25 eyes were implanted successfully in a stand-alone procedure with a 5-mm long device made of biocompatible STAR material, which is soft and flexible silicone in a microporous, network design. Intraocular pressure, medication use, and other ocular parameters were evaluated before surgery, 1 day, 1 and 2 weeks, and 1, 3, and 6 months after surgery.Intraocular pressure reduction at 6 months compared with baseline analyzed using a paired t test. Safety evaluation entailed tabulation of the nature and frequency of adverse events.Mean baseline diurnal IOP was 23.2 mmHg (standard error, 0.6 mmHg) using a mean ± standard deviation of 2.0±1.1 IOP-lowering medication classes. During the 6-month follow-up period, mean IOP ranged from 10.0-16.3 mmHg (mean reductions, 6.9-13.2 mmHg or 31.0%-56.8%). Six months after surgery, mean diurnal IOP was 14.2 mmHg (standard error, 0.9 mmHg), equivalent to a reduction of 9.0 mmHg or 39.1% (P0.0001). The mean ± standard deviation number of IOP-lowering medications was 0.3±0.7. Of 24 patients seen at 6-month follow-up, 21 (87.5%) were medication-free and 23 (95.8%) achieved a minimum 20% IOP reduction from baseline. There were no serious adverse events related to the device or procedure, and no additional glaucoma surgery was required. Frequently reported events included anterior chamber inflammation (n = 8), IOP elevation (n = 6), of which 1 event was an IOP spike per protocol, visual acuity reduction (n = 3), and hyphema (n = 3), all of which resolved. There was no change to mean central or peripheral corneal endothelial cell density. No device-related adverse events were reported.The MINIject glaucoma drainage system significantly lowered IOP and eliminated the need for medication in most patients 6 months after surgery when implanted in a standalone procedure. There were no serious ocular adverse events.

To evaluate 5-year safety and efficacy of 2 trabecular micro-bypass stents versus prostaglandin as initial stand-alone treatment for newly diagnosed, treatment-naive primary open-angle glaucoma (POAG).Prospective, randomized, controlled, multi-surgeon clinical trial.Enrolled eyes (n = 101) were phakic and had a confirmed POAG diagnosis, normal angle anatomy, mean diurnal intraocular pressure (IOP) 21 to 40 mmHg, and vertical cup-to-disc (C:D) ratio ≤0.9.Eyes were randomized (1:1) to receive either 2 stents (iStent trabecular micro-bypass; Glaukos Corporation, San Clemente, CA) or once-daily topical travoprost.The primary and secondary efficacy end points were the change from screening in mean diurnal IOP at months 12 and 24, respectively, without glaucoma surgery or add-on medication (any medication in stent eyes or a second medication in travoprost eyes). Two additional secondary end points were the proportion of eyes achieving treatment success at months 12 and 24, defined as IOP 6 to 18 mmHg without additional medication or glaucoma surgery. This report shows these efficacy measures through 60 months. Safety measures included best-corrected visual acuity, C:D ratio, visual field, pachymetry, complications, and adverse events.Of 101 enrolled eyes (54 stent eyes, 47 travoprost eyes), 90 eyes (49 stent eyes, 41 travoprost eyes) completed 5-year follow-up. Five-year mean diurnal IOP was 16.5±1.2 mmHg in stent eyes (35.3% reduced vs. 25.5±2.5 mmHg preoperatively; P0.0001) and 16.3±1.9 mmHg in travoprost eyes (35.1% reduced vs. 25.1±4.6 mmHg preoperatively; P0.0001). During follow-up, add-on medication was initiated in 12 stent eyes (22.2% of the initial 54-eyes) and 18 travoprost eyes (38.3% of the initial 47-eyes). By 5 years, 17% (6/35) of stent eyes and 44% (14/32) of travoprost eyes needed add-on medication to control IOP (P = 0.017). Treatment success was achieved in 77% (27/35) of stent eyes and 53% (17/32) of travoprost eyes (P = 0.04). Both groups exhibited excellent safety.This prospective randomized trial demonstrates 5-year effectiveness and safety of 2 trabecular bypass stents in patients with newly diagnosed, treatment-naive POAG, with comparably favorable outcomes as topical prostaglandin.