Clinical Results of Ab Interno Trabeculotomy Using the Trabectome for Open-Angle Glaucoma: The Mayo Clinic Series in Rochester, Minnesota

doi:10.1016/j.ajo.2013.06.001

American Journal of Ophthalmology

Volume 156, Issue 5, November 2013, Pages 927-935.e2

https://doi.org/10.1016/j.ajo.2013.06.001 Get rights and content

Purpose

To determine outcomes of ab interno trabeculotomy for treatment of open-angle glaucoma (OAG).

Design

Retrospective interventional single-surgeon, single-center case series.

Methods

Data were collected from 246 patients undergoing ab interno trabeculotomy between September 1, 2006, and December 1, 2010, with 3 months' follow-up or longer. Kaplan-Meier analysis was performed using Criteria A (postoperative intraocular pressure [IOP] ≤21 mm Hg or ≥20% reduction from preoperative IOP) and Criteria B (IOP ≤18 mm Hg and ≥20% reduction in IOP). Failure included increased glaucoma medications or subsequent surgery. Failure risk factors were identified using Cox proportional hazards ratio (HR).

Results

Of 88 cases of ab interno trabeculotomy-only and 158 cases of ab interno trabeculotomy with cataract extraction, the retention rate was 70% for 1 year and 62% for 2 years. Preoperative mean IOP was 21.6 ± 8.6 mm Hg; the number of glaucoma medications was 3.1 ± 1.1. At 24 months postoperatively, mean IOP was reduced 29% to 15.3 ± 4.6 mm Hg (P < 0.001) and the number of glaucoma medications was reduced 38% to 1.9 ± 1.3 (P < 0.001) with a success rate of 62% (95% CI, 56%–68%) using Criteria A and 22% (95% CI, 16%–29%) using Criteria B. Failure risk factors using Criteria A included primary OAG (HR 3.14, P < 0.01, 95% CI, 1.91–5.17) and past argon laser trabeculoplasty (HR 1.81, P < 0.01, 95% CI, 1.18–2.77). Using Criteria B, the HR for pseudoexfoliative glaucoma was 0.43 (P < 0.01, 95% CI 0.27–0.67). Of the cases, 66 (26.8%) required subsequent surgery on an average of 10 months (2 days to 3.2 years) after ab interno trabeculotomy.

Conclusions

For criteria involving IOP ≤18 mm Hg, the 24-month survival of ab interno trabeculotomy is low. This surgery is appropriate for patients requiring a target IOP of 21 mm Hg or above.

Section snippets

Subjects

Patients who had undergone ab interno trabeculotomy by one surgeon (A.J.S.) at the Mayo Clinic in Rochester, Minnesota, between September 1, 2006, and December 1, 2010, were eligible for this study. Patients who underwent ab interno trabeculotomy at our center typically had OAG that was refractory to medical therapy, or they had visually significant cataracts in the setting of OAG on maximal medical therapy. In a small number of cases, patients with potentially occludable angles were included

Results

During the study period, there were 286 cases (246 patients) of ab interno trabeculotomy in total, of which 40 cases (38 patients) were excluded for the following reasons: lack of consent for medical records to be used for research purposes (9 cases); resident involvement in surgery (7 cases); fewer than 3 months of postoperative follow-up at our center (22 cases); and prior ab interno trabeculotomy (2 cases). A total of 246 cases (208 patients) of ab interno trabeculotomy were included,

Discussion

Ab interno trabeculotomy using the Trabectome is a relatively new option for reducing the IOP and the number of glaucoma medications in selected patients with OAG. However, our results show that when more stringent criteria for success are used, the overall success rate of ab interno trabeculotomy can drop within 24 months after surgery to levels that may be clinically unacceptable. Despite significant lowering of mean IOP and mean number of medications postoperatively, most patients do not

Yachna Ahuja, MD, is a glaucoma fellow at the Byers Eye Institute at Stanford in Palo Alto, California. She received her medical degree at Case Western Reserve University in Cleveland, Ohio as a four-year Amici Merit Scholar. She completed a clinical research training fellowship at the National Cancer Institute in Bethesda, Maryland, after which she did her residency in ophthalmology at the Mayo Clinic in Rochester, Minnesota.

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Effect of Preoperative Trabecular Meshwork Pigmentation and Other Eye Characteristics on Outcomes of Combined Phacoemulsification/Minimally Invasive Glaucoma Surgery
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To investigate associations between pigmentation of the trabecular meshwork (PTM) and other preoperative eye characteristics and outcomes of minimally invasive glaucoma surgery combined with phacoemulsification (Phaco/MIGS).
Retrospective interventional case series.
Academic glaucoma clinic patients with symptomatic cataract and glaucoma treated with combined Phaco/MIGS.
Analyzing preoperative PTM, intraocular pressure (IOP), IOP-lowering medications and visual acuity (VA) data in relation to Phaco/MIGS outcomes.
Pigmentation of the trabecular meshwork and other preoperative eye characteristics in relation to Phaco/MIGS success defined as postoperative IOP between 5 and 21 mmHg and IOP reduction of ≥ 20% and/or a reduction of ≥ 1 IOP-medications compared to baseline, and final IOP, IOP-lowering medications and VA.
A total of 265 eyes (172 patients, mean age, 73.5 [standard deviation, 10.0], range 35–95 years, male 40.0%) were identified and categorized with high PTM (108 eyes, 40.8%) or low PTM (157 eyes, 59.2%). The high PTM group, compared with the low PTM group, demonstrated higher preoperative IOP (16.7 [standard error 0.4] vs. 15.2 [0.4] mmHg, P = 0.009), included more eyes with primary open-angle glaucoma (POAG, P = 0.03), fewer eyes with normal-tension glaucoma (NTG, P = 0.01), and fewer eyes with mild stage glaucoma (P = 0.001). Compared to baseline, final IOP decreased by 6.5 [2.4]% and 13.4 [3.0]% (P = 0.075) to 13.5 [0.3] mmHg and 13.6 [0.4] mmHg (P = 0.77) in the low and high PTM groups, respectively, and IOP-lowering medications decreased by 34.6 [4.9]% (n = 116) and 18.1 [7.3]% (n = 85), respectively (P = 0.062). Surgical success was 59.9% and 58.3%, respectively (P = 0.87). It was positively associated with higher preoperative IOP (hazard ratio 1.08 [95% confidence interval 1.04–1.12] P < 0.0001) and higher number of preoperative IOP-medications (1.20 [1.05–1.37] P = 0.007), negatively associated with history of selective laser trabeculoplasty (SLT, 0.40 [0.23–0.68] P = 0.0009) and longer axial length (0.87 [0.80–0.94], P = 0.0006), but was not associated with PTM.
Higher PTM was associated with POAG rather than NTG, with more severe glaucoma and higher preoperative IOP, but not with Phaco/MIGS success. Surgical success was positively associated with higher preoperative IOP and number of IOP-medications and negatively associated with history of SLT and longer axial length. These findings may help guide glaucoma surgeons in surgical planning and patient counseling.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Comparison of Short-term Visual Acuity Changes After Trabeculotomy ab Interno Using Trabectome and Trabeculectomy ab Externo
2023, Ophthalmology Glaucoma
To compare short-term visual acuity (VA) changes after trabeculotomy ab interno (TAI) using trabectome and trabeculectomy ab externo (TAE) performed on pseudophakic eyes.
A single-center retrospective study.
Patients with pseudophakic eyes who had primary open-angle glaucoma or exfoliation glaucoma and underwent TAI or TAE alone.
Changes in intraocular pressure (IOP), medication score, Snellen VA, and the number of eyes with vision loss (loss of ≥ 2 Snellen lines) were evaluated at baseline, week 1, and months 1, 3, and 6. The risk factors for vision loss at 6 months postoperatively were analyzed in both groups.
Visual acuity changes.
A total of 112 eyes of 112 patients were examined: 46 in the TAI group and 66 in the TAE group. Intraocular pressure was significantly lower in both groups at each visit than at baseline. The TAI group had a significantly higher mean postoperative IOP than the TAE group. Medication scores in the TAI group were significantly different after 3 months compared with baseline; however, decreased significantly at all study visits in the TAE group. The mean VA in the TAI group did not decrease significantly at each visit. In the TAE group, it decreased significantly up to 3 months but was not significantly different at 6 months. At all study visits, the number of eyes with vision loss was significantly lower in the TAI group than in the TAE group. Only 2 eyes in the TAI group (4.3%) had vision loss at 6 months, which was caused by macular edema. In the TAE group, 13 eyes (19.7%) experienced vision loss at 6 months. In all cases, the presence of preoperative split fixation [odds ratio = 7.30, P < 0.05] and the occurrence of hypotony-related complications [odds ratio = 6.76, P < 0.05] within 6 months were risk factors for vision loss.
TAI lowered IOP less than TAE; however, there was less vision loss with TAI. For eyes with a target IOP in the mid-teens, TAI can be recommended as initial surgery.
Proprietary or commercial disclosuremay be found in the Footnotes and Disclosures at the end of this article.
Noninferiority of Microhook to Trabectome: Trabectome versus Ab Interno Microhook Trabeculotomy Comparative Study (Tram Trac Study)
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Citation Excerpt :
Besides, in facilities where Trabectome surgery was performed substantially, the 1-quadrant incision was a primary option for μTLO probably because of the familiarity of surgeons with the nasal incision of the trabecular meshwork.8 In addition, concomitant cataract surgery was reported to improve the surgical success rates of both ab externo and ab interno trabeculotomy.11,25–27,31–33 As such, various confounding factors affect the surgical outcomes in trabeculotomy.
To elucidate the noninferiority of ab interno microhook trabeculotomy (μTLO) using a recently developed reusable stainless spatula-type microhook device to incise the trabecular meshwork to Trabectome (Neomeix, Inc) surgery in terms of the 1-year postoperative outcomes of Japanese patients with glaucoma by means of propensity score analyses.
Multicenter, retrospective cohort study.
We enrolled 553 and 392 patients who underwent Trabectome surgery and μTLO, respectively, between January 2014 and March 2020 at 10 facilities.
Logistic regression analysis was conducted to calculate the propensity score, which indicates the likelihood of treatment assignment (Trabectome or μTLO). We set the following factors as outcome-related covariates: age, sex, facility, glaucoma disease types, preoperative intraocular pressure (IOP), glaucoma drug score, mean deviation of Humphrey visual field test results, antithrombotic drug use, the presence or absence of combined cataract surgery, and incision range of the trabecular meshwork (1 or 2 quadrants). We analyzed 4 different methods (matching, inverse probability of treatment weighting [IPTW], stratification, and regression adjustment) using the propensity score. We set 15% as the noninferiority margin based on previous Trabectome meta-analysis results.
The primary outcome was surgical success at 1 year after surgery. We defined surgical success as satisfying all 3 criteria: (1) IOP within 5 to 21 mmHg, (2) IOP reduction of 20% or more from preoperative IOP, and (3) no additional glaucoma surgery.
The 95% confidence interval of risk difference of surgical failure in μTLO in reference to Trabectome surgery was −12.1% to +9.5% in matching, −12.7% to +11.1% in IPTW, −12.2 to +7.0 in stratification, and −9.7% to +8.1% in regression adjustment, all of which fell within the predetermined noninferiority margin of 15%.
Surgical success of μTLO at 1 year after was not inferior to that of Trabectome surgery.
A Prospective Study of Intraocular Pressure Spike and Failure After Gonioscopy-Assisted Transluminal Trabeculotomy in Juvenile Open-Angle Glaucoma: A Prospective Study of GATT in JOAG
2022, American Journal of Ophthalmology
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To our knowledge, this study is the first to prospectively evaluate the angle changes using anterior segment OCT after GATT and to analyze the rate of failure and its relationship with postoperative IOP spikes in JOAG. Currently, GATT is thought to be most successful in patients with mild to moderate glaucoma, similar to other minimally invasive glaucoma operations targeted at the same pathologic site.15,16 In this study, we found significant reductions in IOP and the number of medications in patients with JOAG, demonstrating a 1-year qualified success rate of 91.4% and complete success rate of 74.3%, with 55 (78.6%) of eyes demonstrating an IOP reduction >30% and 50 (71.4%) a reduction of >40%.
To identify risk factors for surgical failure after gonioscopy-assisted transluminal trabeculotomy (GATT) in juvenile open-angle glaucoma (JOAG).
Prospective, interventional case series.
GATT was the initial surgery in 70 eyes of 70 patients with JOAG. Surgical success was defined as a postoperative intraocular pressure (IOP) of ≤21 mm Hg with at least a 20% reduction from preoperative IOP, with or without the use of antiglaucoma medication (qualified and complete success, respectively) at each postoperative visit. IOP spike was defined as IOP >30 mm Hg and an increase of at least 10 mm Hg from IOP before the spike, and then reduced to ≤21 mm Hg.
The median age at the time of surgery was 19.3 years (range, 4.9-37.5 years) with a visual field mean deviation of −17.4 ± 10.6 dB. Mean IOP decreased from 31.3 ± 9.5 mm Hg preoperatively to 15.8 ± 2.7 at 12 months postoperatively. The complete and qualified success rates were 74.3% and 91.4%, respectively. An IOP spike occurred in 52 eyes (74%), with a median spike duration of 3.5 days (range, 1-21 days). Longer duration of IOP spike (P = .009) and older age at the time of surgery (P = .025) were both associated with worse surgical outcomes. Advanced disease was associated with prolonged IOP spike (P = .007).
GATT provided excellent outcomes in patients with severe JOAG. Older age and longer duration of postoperative IOP spike are risk factors for failure. Severe cases are more likely to have longer durations of IOP spike. Frequent IOP monitoring during the early postoperative period is needed to detect IOP spikes in these patients.
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Arthur J. Sit, SM, MD, is an Associate Professor of Ophthalmology at the Mayo Clinic in Rochester, Minnesota. He completed his Master's degree in Mechanical Engineering at the Massachusetts Institute of Technology, his MD and residency at the University of Toronto, and a glaucoma fellowship at the University of California San Diego. He currently serves as Chair of the American Glaucoma Society Research Committee. He is a Research to Prevent Blindness Special Scholar.

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Original articleClinical Results of Ab Interno Trabeculotomy Using the Trabectome for Open-Angle Glaucoma: The Mayo Clinic Series in Rochester, Minnesota

Purpose

Design

Methods

Results

Conclusions

Section snippets

Subjects

Results

Discussion

Exp Eye Res

J Cataract Refract Surg

Ophthalmology

J Biomed Inform

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

J Cataract Refract Surg

Ophthalmology

J Cataract Refract Surg

Prog Retin Eye Res

Original article
Clinical Results of Ab Interno Trabeculotomy Using the Trabectome for Open-Angle Glaucoma: The Mayo Clinic Series in Rochester, Minnesota