We analysed all of the PubMed publications on ab-interno trabeculectomy (AIT) with the Trabectome (Neomedix, Irvine, California, USA) to determine the reduction in intraocular pressure (IOP) and medications following the procedure. For IOP outcomes, PubMed was searched for 'trabectome', 'ab interno trabeculotomy' and 'ab interno trabeculectomy' and all available papers retrieved. The meta-analysis used a random-effects model to achieve conservative estimates and assess statistical heterogeneity. To investigate complications, we included all abstracts from the American Glaucoma Society, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery and the Association for Research in Vision and Ophthalmology. The overall arithmetic mean baseline IOP for standalone Trabectome was 26.71±1.34 mm Hg and decreased by 10.5±1.9 mm Hg (39% decrease) on 0.99±0.54 fewer medications. Defining success as IOP ≤21 with a 20% decrease while avoiding reoperation, the overall average success rate after 2 years was 46±34%. For combined phacoemulsification-Trabectome, the baseline IOP of 21±1.31 mm Hg decreased by 6.24±1.98 mm Hg (27% decrease) on 0.76±0.35 fewer medications. The success rate using the same definition at 2 years was 85±7%. The weighted mean IOP difference from baseline to study endpoint was 9.77 mm Hg (95% CI 8.90 to 10.64) standalone and 6.04 mm Hg (95% CI 4.95 to 7.13) for combined cases. Despite heterogeneity, meta-analysis showed significant and consistent decrease in IOP and medications from baseline to end point in AIT and phaco-AIT. The rate of visually threatening complications was <1%. On average, trabectome lowers the IOP by approximately 31% to a final IOP near 15 mm Hg while decreasing the number of medications by less than one, with a low rate of serious complications. After 2 years, the overall average success rate is 66%.

AimTo evaluate outcomes of ab interno trabeculectomy (AIT) with the trabectome following failed trabeculectomy.MethodsProspective study of AITs and phaco-AITs after a failed trabeculectomy. The indication for AIT was intraocular pressure (IOP) above target on maximally tolerated therapy, and for phaco-AIT a visually significant cataract and need to lower IOP or glaucoma medications. Outcomes included IOP, medications, complications, secondary procedures and success, defined as IOP of less than 21 mm Hg and a greater than 20% reduction from baseline without further surgery. Exclusion criteria were trabeculectomy less than 3 months prior to AIT or follow-up under 1 year.ResultsSeventy-three eyes of 73 patients with 1 year follow-up were identified. At 1 year, mean IOP in AIT significantly decreased by 28% from 23.7±5.5 mm Hg, and medications from 2.8±1.2 to 2±1.3 (n=58). In phaco-AIT, the mean IOP decreased 19% from 20±5.9 mm Hg and medications from 2.5±1.5 to 1.6±1.4 (n=15). Transient hypotony occurred in 7%, and further surgery was necessary in 18%. For AIT and phaco-AIT, the 1-year cumulative probability of success was 81% and 87%, respectively.ConclusionsBoth AIT and phaco-AIT showed a reduction in IOP and medication use after 1 year, suggesting that AIT with or without cataract surgery is a safe and effective option following failed trabeculectomy.

AimTo analyse ab interno trabeculectomy (AIT) with the trabectome and combined phacoemulsification with AIT (phaco-AIT) by Shaffer angle grade (SG).MethodsProspective study of AIT and phaco-AIT with narrow angles of SG≤2 versus open angles ≥3. Outcomes included intraocular pressure (IOP), medications, complications, secondary surgery and success (IOP <21 mm Hg and >20% reduction without further surgery). Exclusion criteria were missing preoperative data and <1 year follow-up.ResultsOf 671 included cases, at 1 year AIT SG≤2 (n=43) had an IOP reduction of 42% from 27.3±7.4 to 15.7±3.0 mm Hg (p<0.01) versus AIT SG≥3 (n=271) with an IOP reduction of 37% from 26.1±7.8 to 16.4±3.9 mm Hg (p<0.01). In phaco-AIT with SG≤2 (n=48), IOP was reduced 24% from 20.7±7.0 to 15.7±3.6 mm Hg (p<0.01) versus phaco-AIT with SG≥3 (n=309) with an IOP reduction of 25% from 22.6±6.4 to 17.0±3.4 mm Hg (p<0.01). There was no difference between SG≤2 and SG≥3 in reduction of IOP or medications, complications, secondary surgery and success rates (p>0.05).ConclusionsSG≤2 is not associated with worse outcomes in AIT or phaco-AIT.

Minimally invasive glaucoma surgeries (MIGS) can improve the conventional, pressure dependent outflow by bypassing or ablating the trabecular meshwork or create alternative drainage routes into the suprachoroidal or subconjunctival space. They have a highly favorable risk profile compared to penetrating surgeries and lower intraocular pressure with variable efficacy that may depend on the extent of outflow segments accessed. Since they are highly standardized procedures that use clear corneal incisions, they can elegantly be combined with cataract and refractive procedures to improve vision in the same session. There is a growing need for surgeons to become proficient in MIGS to address the increasing prevalence of glaucoma and cataracts in a well-informed, aging population. Techniques of visualization and instrumentation in an anatomically highly confined space with semi-transparent tissues are fundamentally different from other anterior segment surgeries and present even experienced surgeons with a substantial learning curve. Here, we provide practical tips and review techniques and outcomes of TM bypass and ablation MIGS.

BackgroundTo analyze the results of repeat selective laser trabeculoplasty (SLT).MethodsInclusion criteria: participants with primary or secondary open-angle glaucoma (excluding uveitic) who had undergone SLT 360° (SLT 1) with diminution of response over time followed by repeat SLT 360° (SLT 2). Six months of follow-up were required and at least 6 months in between SLT 1 and 2. The main outcome measures were IOP reduction at 6 and 12 months and a comparison of the response between SLT 1 and 2.ResultsOne hundred thirty-seven patients met the inclusion criteria. If only one eye had repeat treatment, that eye was chosen; if both eyes qualified, one was chosen at random. The baseline intraocular pressure (IOP) for SLT 1 = 20.3+/− 5.2 mmHg and SLT 2 = 19.4 +/− 5.0 was reduced to 16.4 +/− 3.9 and 16.7 +/− 4.7 at 1 year, respectively (p < .001). Medication use was not significantly changed, and was 2.2 +/− 1.2 at baseline for SLT 1 and 2.1 +/− 1.3 for SLT 2, and at 1 year was 1.9 +/− 1.3 and 2.2 +/− 1.2, respectively. A subanalysis of 62 patients matched for equivalent baselines showed a baseline IOP = 18.7 +/− 3.8 for SLT 1 and 18.7 +/− 3.5 for SLT 2, reduced to 16.0 +/− 4.3 and 15.3 +/− 3.8 at 1 year (p < .001).ConclusionRepeat SLT laser (360-degree treatment, followed by a loss of effect over time, then a second 360-degree treatment) in this population resulted in IOP lowering similar to that of the initial treatment.