Eyeworld

24 | EYEWORLD | AUGUST 2020 EYEWORLD JOURNAL CLUB ASCRS NEWS by Charles Medert, MD, Ann Quan, MD, Anne Kunkler, MD, Humberto Salazar, MD, Jesse Sengillo, MD, and Steven Gedde, MD excluded if they had occludable angles, a history of incisional glaucoma surgery, a history of corticosteroid-induced IOP elevation, recent glaucoma laser therapy, and/or oral IOP-lower- ing agents. Topical IOP-lowering therapies were discontinued on the day of surgery, but inves- tigators were allowed to restart them postoper- atively at their discretion. Follow-up visits were scheduled 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively. The primary outcome measure was the propor- tion of eyes with an IOP reduction ≥20% or reduction of IOP-lowering medications by ≥1 compared to baseline during the study period. Of the 166 eyes of 166 patients enrolled, 164 eyes were analyzed (82 in each group). Demographic characteristics were comparable between the groups with a Caucasian predom- inance and an average age of about 70 years. Most patients had a diagnosis of primary open angle glaucoma (152/164) and "mild" disease (127/164). The average baseline IOP was 18.5 mm Hg in both groups (p=0.97), and there was a similar baseline mean number of topical IOP-lowering medications in both groups (1.3 in KDB-phaco vs. 1.4 in iStent-phaco, p=0.69). Mean IOP was similar between treatment groups at all time points, except at 1 day and 1 month postoperatively in which the KDB-pha- co group had a lower IOP (p=0.019 and p=0.029, respectively). There were no signifi- cant differences in mean number of postoper- ative medications between the two groups. The KDB-phaco group had a significantly higher proportion of eyes that achieved the primary outcome compared to the iStent-phaco group (93.7% vs. 83.3%, p=0.04). The proportion of eyes that achieved both conditions specified in the primary outcome (i.e., IOP reduction and drop reduction), however, was similar in both groups (36.7% in the KDB-phaco group vs. 35.9% in the iStent-phaco group, p=0.92). Importantly, both groups had comparable VA throughout the study and experienced a similar number of adverse events, all of which resolved spontaneously or with medical management. Approximately one-third of patients in both C ataract and glaucoma frequently co- exist in the elderly population. It has been estimated that 20% of patients who undergo cataract surgery in the United States have comorbid glauco- ma or ocular hypertension. 1 Histor- ically, phacoemulsification (phaco) combined with trabeculectomy has been the preferred surgical approach for simultaneously managing cataract and glaucoma. 1 However, a growing concern about intraoperative and postoperative complications associated with trabeculectomy has encouraged many surgeons to explore alternative techniques. Recent studies have evaluated the safety and efficacy of micro- invasive glaucoma surgery (MIGS) combined with phaco. 2 MIGS procedures designed to bypass the diseased trabecular meshwork (TM) via an ab interno approach are becoming in- creasingly popular due to their shorter recovery period and better safety profile compared with traditional filtering procedures. 2,3 The iStent (Glaukos) was the first device approved by the Food and Drug Administra- tion to circumvent aqueous outflow resistance at the level of the TM. Similarly, the Kahook Dual Blade (KDB, New World Medical) is de- signed to bypass the TM by excising a segment of diseased TM and inner wall of Schlemm's canal. Few studies have compared the efficacy of these MIGS procedures head-to-head. 4–6 Falkenberry et al. report the first prospective randomized clinical trial comparing KDB-phaco with iStent-phaco in eyes with mild to moderate open angle glaucoma. Summary This was a multicenter randomized clinical trial involving nine centers across the United States that enrolled patients from June 2016 to January 2019. Patients eligible for the study were those scheduled for elective phaco of a visually signif- icant cataract and a concurrent history of mild to moderate open angle glaucoma treated with one to three topical therapies. Additional in- clusion criteria included an age range of 18–90 years and a preintervention intraocular pressure (IOP) between 14 and 28 mm Hg. Patients were Review of "Excisional goniotomy versus A prospective randomized clinical trial in eyes with Which of the many MIGS options works best as an adjunct to cataract surgery? This month, the Bascom Palmer residents reviewed this important randomized controlled trial that is pub- lished in the August issue of JCRS. —David F. Chang, MD EyeWorld Journal Club Editor Steven Gedde, MD Residency program director Bascom Palmer Eye Institute Miami, Florida

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