EyeWorld India December 2021 Issue

NEWS & OPINION EWAP DECEMBER 2021 49 by Jessica Chow, MD, Wendy Linderman, MD, and Hetal Ray, MD Contact information Chow: jessica.chow@yale.edu Ray: hetal.ray@yale.edu Review of ‘Reoperation for complications within 90 days of minimally invasive glaucoma surgery’ G laucoma is a leading cause of blindness worldwide. 1 Adequate lowering of IOP remains the mainstay of glaucoma treatment. Prior to 2012, surgical management of glaucoma consisted primarily of trabeculectomy and glaucoma drainage implants. Since 2012, minimally invasive glaucoma surgeries (MIGS) have been developed to lower IOP by bypassing the trabecular meshwork for mild to moderate glaucoma. MIGS boasts faster recovery, lower impact on leisure activities, and a greater safety profile compared to traditional glaucoma filtering surgeries. However, reported complications of MIGS include decreased vision, IOP elevation, hyphema, corneal edema, device movement, and need for reoperation. This paper is the first of its kind to describe short-term postoperative complications in eyes after minimally invasive glaucoma surgery. Design This was a retrospective case series studying postoperative complications in the 90 days following MIGS procedures. Data was collected at a single tertiary care center over a 6-month period. The procedures included in the study were iStent (Glaukos), iStent inject (Glaukos), Hydrus (Ivantis), OMNI (Sight Sciences), gonioscopy-assisted transluminal trabeculotomy (GATT), and XEN (Allergan). The primary outcomes of the study were reoperation rates and indications within a 90-day period following MIGS procedure. Additional data included details of intraoperative and postoperative complications, time to reoperation, and outcomes at 1 month following reoperation. Results There were 448 MIGS procedures included in the study. Twenty-three eyes underwent reoperation. Patients who underwent reoperation had a mean age of 70, were predominantly female, and most often had moderate to severe glaucoma. Sixteen of the 23 eyes that underwent reoperation had the XEN, 4 iStent/iStent inject, and 3 goniotomy/GATT/OMNI. Therefore, all types of MIGS except Hydrus were represented in the group of eyes that required reoperation, though the sample size of patients undergoing Hydrus was small (8 patients). There was a statistically significant higher rate of reoperation in the XEN group. Eleven of the 16 eyes that required reoperation after XEN were implanted in an ab interno fashion. The most common indication for reoperation was elevated IOP. The XEN group also had bleb-related indications for reoperation including exposure, wound leak, and early encapsulation. The most common reoperation performed in the XEN group was needling with an antifibrotic agent. A few eyes required major procedures such as a second XEN, trabeculectomy, or glaucoma drainage device. In the iStent group, 2 eyes required IOL repositioning or secondary IOL implantation related to cataract surgery complications and 2 eyes required XEN. In the angle-based group, 3 eyes required trabeculectomy. In all groups, average time to reoperation was 39 days, with a range of 4 to 82 days. Postoperative results following reoperation were encouraging. Following reoperation, there was a statistically significant reduction in IOP, improvement in visual acuity, and decrease in number of IOP-lowering drops at postoperative month 1. Across groups, there were no visually devastating complications in the 90-day postoperative period. Summary The 90-day reoperation rate for MIGS in this study was 5.3 %. The most common indication for reoperation was elevated IOP. If elevated IOP is excluded as an indication for reoperation as in prior studies, the reoperation rate for MIGS in this study was 1.6 %. This rate is lower than the 90-day reoperation rate of 2.5–3.1 % for traditional glaucoma surgeries reported by Chu et al. 2 The XEN group had a statistically significant higher rate of reoperation rate of 10.5 %. Reoperation was more common with the ab interno approach. The most common indication for reoperation with XEN was high IOP, which is similar to other MIGS, but this group also had bleb-related indications for reoperation. Of these, 2.6 % required reoperation for implant exposure or wound leak. This can be compared to a rate of tube exposure of 1.6 % and rate of wound leak of 1.8 % in the immediate postoperative period. 2 Discussion The American Society of Cataract and Refractive Surgery (ASCRS) Journal Club panelists highlighted the large number of MIGS procedures performed by a diverse group of surgeons as This article originally appeared in the September 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.