Faculty Bibliography

Currently, IOP reduction is the only way we can help reduce or even stop glaucoma progression. Due to higher rates of blindness in vulnerable poorer groups with decreased access to expensive medications, safer, uncomplicated cataract extraction/refractive lensectomy and microinvasive trabecular bypass surgery should be considered earlier. We need more studies with randomized controlled clinical trials comparing earlier cataract surgery and trabecular bypass to medical, and laser therapies in order to reassess our algorithm for treating enlarged lens-related glaucoma in adults over the age of 50.

INTRODUCTION/BACKGROUND:To determine the efficacy and safety of Kahook Dual Blade (KDB) goniotomy alone or combined with phacoemulsification cataract surgery to lower intraocular pressure and medication burden in Black and Afro-Latinx patients with open angle glaucoma (OAG). MATERIALS AND METHOD/METHODS:A retrospective, single center case series of patients with OAG who were managed with medications and underwent phacoemulsification combined with goniotomy (PE + KDB) using Kahook Dual Blade or goniotomy alone (KDB alone) in pseudophakic patients. Indications for glaucoma surgery included reduction of intraocular pressure (IOP) and reduction of medication burden. Our study parameters included pre- and postoperative information on IOP, the use of IOP-lowering medications, visual field, and adverse events through 6 months of follow-up. RESULTS:Among all 63 eyes of 63 patients undergoing surgery, Kahook goniotomy with or without phacoemulsification, mean IOP was significantly reduced from 17.4 mmHg at baseline to 14.0 mmHg at month 6 (P = 0.0012), a 19.5% reduction (KDB alone -26.4%, PE + KDB -16.6%). The mean number of topical IOP-lowering medications was reduced from 2.6 at baseline to 1.6 ± 0.3 at month 6 (P = 0.0012), a 38.5% reduction (Kahook alone -10.7%, PE + Kahook -48.0%). Mean visual fields were stable in the PE + KDB group and progressed in the KDB alone group. Postoperative adverse events were mild and included transient hyphema, IOP spikes, posterior capsule opacification, tearing, glare and mild pain. CONCLUSION/CONCLUSIONS:Phacoemulsification combined with Kahook dual blade goniotomy significantly lowers both IOP and medication burden in Black and Afro-Latinx patients with open angle glaucoma. In pseudophakic patients with advanced glaucoma medication burden is not significantly reduced and visual field progression occurred. Adverse events were not sight-threatening and self limited.

The purpose of this study is to present the efficacy of combined goniotomy and intra-scleral ciliary sulcus suprachoroidal microtube insertion surgery in five patients with refractory and severe glaucoma. This Single-center, case series of five (5) Black and Afro-Latino patients with refractory and severe glaucoma who underwent combination microinvasive glaucoma surgery; 23-gauge goniotomy and intra-scleral ciliary sulcus suprachoroidal microtube insertion. Patients who underwent the above procedure with 6 months follow-up were included. Investigated parameters were intraocular pressure (IOP), number of medications, visual field findings, and visual acuity. Five patients with moderate to severe refractory glaucoma who had undergone 23-gauge cystotome goniotomy and ciliary sulcus suprachoroidal microtube had a reduction of IOP by 32% (mean pre-op and post-op 16.6 mmHg and 11 mmHg, respectively) and a reduction of ocular medications by 61.5% (mean pre-op and post-op of 5.2 and 2.4, respectively). All patients had either stabilization or improvement of their visual fields. Four of the five patients also showed an improvement in visual acuity. This novel approach of combined 23-gauge goniotomy and intra-scleral ciliary sulcus suprachoroidal microtube insertion surgery is safe and is an affordably effective means of managing patients with moderate to advanced refractory glaucoma, leading to a reduction in IOP and the number of medications with no serious adverse effects.

PURPOSE/OBJECTIVE:To report a case of a patient with mixed mechanism glaucoma and a clear lens who was successfully surgically treated with combination cataract extraction, goniosynechiolysis and the Hydrus stent. OBSERVATION/METHODS:A 59-year-old Afro-Latino woman with a history of mixed mechanism glaucoma. She was taking latanoprost OU QHS. Best corrected visual acuities were 20/25 OU. Her intraocular pressures were 18 mmHg OU. Anterior segment examination revealed pigment on the lens zonules, and intermittent peripheral anterior synechiae in the angle. Optic nerves revealed glaucomatous cupping OU. After discussion of the risks and benefits, she agreed to undergo combined lensectomy, goniosynechiolysis, and Hydrus stent to lower the intraocular pressure on less medical therapy. Her vision improved to 20/20 with a mean IOP in the right eye during the 6 months follow up period was 12 mmHg on no medication. CONCLUSION/CONCLUSIONS:and Importance: Patients mixed mechanism glaucoma may benefit from earlier cataract extraction, goniosynechiolysis and Hydrus stent placement to lower intraocular pressure and reduce medication burden.

Purpose/UNASSIGNED:To report a case of refractory open angle glaucoma (POAG) in an osteogenesis imperfecta patient who was successfully treated with combination microinvasive glaucoma surgery: combined kahook blade goniotomy and ciliary sulcus suprachoroidal microtube insertion. Observation/UNASSIGNED:A 57-year-old woman with a history of osteoporosis, breast cancer, osteogenesis imperfecta, with uncontrolled POAG in right more than left. Anterior segment examination revealed thin blue sclera, the optic nerve examination revealed glaucomatous cupping with cup to disc ration of 0.9 in right and 0.7 in left. Her IOP on six (6) medications was 26 mmHg in the right eye. After discussion of the risks and benefits, she agreed to undergo combined kahook blade goniotomy and ciliary sulcus suprachoroidal microtube insertion surgery to lower her intraocular pressure. Her IOP at 6 months follow up was 13 in the right eye and a decrease number of medications from six (6) to three. Conclusion and importance/UNASSIGNED:Patients with OI have homogenously thinner sclera and conjunctiva which pose a challenge to traditional subconjunctival surgical methods. Combined kahook blade goniotomy and ciliary sulcus suprachoroidal microtube insertion surgery are bleb sparing operations that enhances aqueous outflow to the aqueous veins and supraciliary space to lower intraocular pressure.

Purpose/UNASSIGNED:The purpose was to determine the real-world efficacy of phacoemulsification cataract surgery and Hydrus microstent in Black and Afro-Latinx patients with glaucoma. Methods/UNASSIGNED:A retrospective noncomparative single-center study of 76 Black and Afro-Latinx patients with glaucoma who underwent phacoemulsification cataract surgery and Hydrus microstent placement for treatment of glaucoma at single practice. Investigated parameters were intraocular pressure (IOP), number of medications, mean deviation on visual field test, and visual acuity. Patients were also subgrouped into mild, moderate, and advance glaucoma for further analysis. Results/UNASSIGNED: = 6, 7.9%, respectively) with spontaneous resolution in all cases. No sight-threatening complications were reported at 6 months. Conclusion/clinical relevance/UNASSIGNED:This 6-month retrospective study demonstrated the efficacy of phacoemulsification cataract surgery and Hydrus microstent in reducing the medication burden while maintaining lower IOP in Black and Afro-Latinx patients with glaucoma.

The coronavirus 19 (COVID-19) pandemic has overwhelmed our healthcare systems and caused the deaths of tens of thousands of Americans. Black and Hispanic individuals comprise a disproportionate number of those deaths, primarily because of pre-existing health conditions such as hypertension, obesity, and asthma. Health inequities that underlie these disparities also exist within ophthalmology around the world, and more ophthalmologists should advocate for healthcare reform that advances health equity. Immediate actions to reduce health disparities in ophthalmology during the pandemic include taking time to ensure all ophthalmology leadership and industry is diversified with people reflecting the fabric of their countries, embracing telemedicine to increase access to medical care, and advocating for legislation that will increase health insurance coverage during this unprecedented time. Longitudinal actions include recognizing structural racism as a root cause of health inequity and actively rejecting it through addressing modifiable risk factors, increasing cultural competency training, promoting diversity in the workforce, and global leadership.

PURPOSE/OBJECTIVE:The aim of this study was to determine the postoperative course after the ab interno XEN45 Gel Stent implantation in Black and Afro-Latino, patients with glaucoma. METHODS:This was a single-center, retrospective study. All patients with glaucoma who underwent ab interno XEN implantation were included in the study. All of the patients were Black and Afro-Latino making up the demographics of the local community. Investigated parameters were intraocular pressure (IOP), the number of medications, visual acuity, IOP-follow-up, intraoperative and postoperative complications, and additionally performed surgeries. RESULTS:Of 20 eyes that had undergone the procedure with 1-year follow-up, eight failed before 12 months requiring additional glaucoma surgery. Of the 12 that were successful at 1 year, 9 (75%) eyes underwent XEN + cataract surgery and 3 (25%) had XEN surgery alone. Of the eyes that completed 12-month follow-up, the mean medicated IOP was 15.3 ± 6.2 mmHg at baseline, and 12.9 ± 4.5 mmHg at 12 months, a 16% IOP reduction. Mean medications dropped from 3.58 ± 0.7 preoperatively to 1.75 ± 1.5 at 12 months. CONCLUSIONS:The ab interno XEN gel implant as a standalone procedure or combined with cataract surgery demonstrated a safe and sustained IOP reduction for only 60% of patients after 12 months. In Black and Afro-Latino patients receiving the ab interno XEN implant, 40% of patients needed additional surgery within 12 months.

PURPOSE/OBJECTIVE:The suprachoroidal space (SCS) has been a successful target to lower intraocular pressure (IOP) in glaucoma patients. We present the results of 4 patients who underwent a novel glaucoma surgical procedure to lower IOP: Intrascleral Ciliary Sulcus-Suprachoroidal Microtube. METHODS:A sterile medical grade silicone microtube (Tube extender, New World Medical) was surgically placed to drain aqueous from the posterior chamber ciliary sulcus of the eye to the SCS. The internal diameter of the tube was 300 um and the length varied from 8-10mm. After informed consent was obtained and witnessed, this procedure was performed in glaucoma patients with pseudophakia. The tube was placed intrasclerally beneath an inferotemporal sclera flap (50% thickness approximately 4mm x 4mm). The anterior end of the tube was inserted into the ciliary sulcus approximately 2mm from the limbus and the posterior end was placed into the SCS approximately 4mm from the limbus. The microtube was sutured to the sclera with a 10-0 nylon suture. 8-0 vicryl sutures were used to close the sclera flap and the conjunctiva inferotemporally. RESULTS:All 4 patients had lower IOP. The average reduction of IOP was 36% at 3 months. The amount of glaucoma medications per patient at 3 months dropped from an average of 3 to 0.25. The risks are similar to traditional glaucoma incisional surgery. CONCLUSION/CONCLUSIONS:This new technique of Intrascleral Ciliary Sulcus-Suprachoroidal Microtube in all four patients with mild, moderate, and advanced glaucoma demonstrated a significant lowering of IOP and a decrease in the number of medications. Further research is required to assess long term efficacy and safety.