Combination technique lowers IOP in angle-closure glaucoma

An innovative technique combining goniosynechialysis and goniotomy achieved clinically meaningful IOP-lowering effects in patients with angle-closure glaucoma, according to a study.

Goniosynechialysis has been reported with different devices but not in combination with goniotomy performed with a Kahook Dual Blade (New World Medical), lead study author Syril Dorairaj, MD, FACS, of the Mayo Clinic, told Ocular Surgery News.

“Angle closure glaucoma is a preventable disease that, if detected early and treated promptly, can be reversed and would stop the progression of blindness. The KDB excisional goniotomy and goniosynechialysis combined with phacoemulsification for angle-closure glaucoma removes the anatomical causes for dysfunctional aqueous humor outflow, thereby altering the course of the disease and modifying its progression,” Dorairaj said.

Technique and results

The retrospective, interventional case series included 42 eyes of 24 patients with angle-closure glaucoma and cataract. Preoperatively, mean IOP was 25.5 mm Hg, and mean number of IOP-lowering medications was 2.3. After phacoemulsification and IOL implantation, the eye was prepped for insertion of the Kahook Dual Blade through the surgical incision under direct gonioscopy. The pointed tip of the blade was used to engage the peripheral iris, disrupt peripheral adhesions and expose the trabecular meshwork before proceeding to goniotomy.

“Through disruption of the peripheral anterior synechiae and removal of part of the dysfunctional trabecular meshwork associated with cataract removal, this technique allows for the aqueous humor drainage pathway to be reestablished, assuming that the collector channels are working, thereby successfully dropping the IOP and medication burden,” Dorairaj said.

In all eyes at 6 months postoperatively, IOP was reduced at least 20%, and medication burden was reduced by at least one. Mean IOP dropped to 12.8 mm Hg from baseline, a statistically significant decrease (P < .0001).

IOP in 39 eyes (92.9%) was 18 mm Hg or less, and 36 eyes (85.7%) needed no medication.

Advantages

The primary benefit of using a Kahook Dual Blade is its precision, according to Dorairaj.

“The basic design of the device allows precise excision of the diseased trabecular meshwork while minimizing damage to the surrounding tissues, thereby reducing complications and ensuring a faster recovery. KDB accomplishes both goniotomy and goniosynechialysis at the same time,” Dorairaj said.

Surgeons should be open to the concept of minimally invasive glaucoma surgery, which leads to faster recovery times and allows comprehensive ophthalmologists to treat severe glaucoma surgically, Dorairaj said. However, most MIGS techniques depend on a patient having open-angle glaucoma, while angle-closure glaucoma has limited treatment options.

The combined technique “is basically a MIGS procedure for angle-closure glaucoma,” Dorairaj said.

“It also important to be aware that MIGS surgeries are entirely dependent on the precision of the surgery. To ensure success, it is important to understand the anatomy of the angle and to perform a thorough postoperative exam by gonioscopy and imaging in cases of bad outcomes and to monitor for any development of peripheral anterior synechiae,” he said.

Surgeons must follow up with patients after the procedure to monitor disease progression, but most patients experience a “drastic drop in intraocular pressure” and avoid the need for incisional surgery or trabeculectomy for severe angle-closure glaucoma, Dorairaj said.

“Compared to trabeculectomy and other much more invasive options that we have to treat glaucoma in angle-closure patients, this is a much more minimally invasive, safe and effective procedure for angle closure,” he said. – by Robert Linnehan

Disclosure: Dorairaj reports no relevant financial disclosures.

An innovative technique combining goniosynechialysis and goniotomy achieved clinically meaningful IOP-lowering effects in patients with angle-closure glaucoma, according to a study.

Goniosynechialysis has been reported with different devices but not in combination with goniotomy performed with a Kahook Dual Blade (New World Medical), lead study author Syril Dorairaj, MD, FACS, of the Mayo Clinic, told Ocular Surgery News.

“Angle closure glaucoma is a preventable disease that, if detected early and treated promptly, can be reversed and would stop the progression of blindness. The KDB excisional goniotomy and goniosynechialysis combined with phacoemulsification for angle-closure glaucoma removes the anatomical causes for dysfunctional aqueous humor outflow, thereby altering the course of the disease and modifying its progression,” Dorairaj said.

Technique and results

The retrospective, interventional case series included 42 eyes of 24 patients with angle-closure glaucoma and cataract. Preoperatively, mean IOP was 25.5 mm Hg, and mean number of IOP-lowering medications was 2.3. After phacoemulsification and IOL implantation, the eye was prepped for insertion of the Kahook Dual Blade through the surgical incision under direct gonioscopy. The pointed tip of the blade was used to engage the peripheral iris, disrupt peripheral adhesions and expose the trabecular meshwork before proceeding to goniotomy.

“Through disruption of the peripheral anterior synechiae and removal of part of the dysfunctional trabecular meshwork associated with cataract removal, this technique allows for the aqueous humor drainage pathway to be reestablished, assuming that the collector channels are working, thereby successfully dropping the IOP and medication burden,” Dorairaj said.

In all eyes at 6 months postoperatively, IOP was reduced at least 20%, and medication burden was reduced by at least one. Mean IOP dropped to 12.8 mm Hg from baseline, a statistically significant decrease (P < .0001).

IOP in 39 eyes (92.9%) was 18 mm Hg or less, and 36 eyes (85.7%) needed no medication.

Advantages

The primary benefit of using a Kahook Dual Blade is its precision, according to Dorairaj.

“The basic design of the device allows precise excision of the diseased trabecular meshwork while minimizing damage to the surrounding tissues, thereby reducing complications and ensuring a faster recovery. KDB accomplishes both goniotomy and goniosynechialysis at the same time,” Dorairaj said.

Surgeons should be open to the concept of minimally invasive glaucoma surgery, which leads to faster recovery times and allows comprehensive ophthalmologists to treat severe glaucoma surgically, Dorairaj said. However, most MIGS techniques depend on a patient having open-angle glaucoma, while angle-closure glaucoma has limited treatment options.

The combined technique “is basically a MIGS procedure for angle-closure glaucoma,” Dorairaj said.

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“It also important to be aware that MIGS surgeries are entirely dependent on the precision of the surgery. To ensure success, it is important to understand the anatomy of the angle and to perform a thorough postoperative exam by gonioscopy and imaging in cases of bad outcomes and to monitor for any development of peripheral anterior synechiae,” he said.

Surgeons must follow up with patients after the procedure to monitor disease progression, but most patients experience a “drastic drop in intraocular pressure” and avoid the need for incisional surgery or trabeculectomy for severe angle-closure glaucoma, Dorairaj said.

“Compared to trabeculectomy and other much more invasive options that we have to treat glaucoma in angle-closure patients, this is a much more minimally invasive, safe and effective procedure for angle closure,” he said. – by Robert Linnehan

Disclosure: Dorairaj reports no relevant financial disclosures.