What is the most effective And safest Glaucoma surgery: KDB goniotomy achieved higher rates of surgical success at six months compared to the iStent group.

The only place in the body where you can actually physically see a nerve die and malfunction is in the eye when we look at the optic nerve. It is an amazing site as you can see the front ending of the optic nerve as it's blood vessels pop out of its center Cup and determine everything you will see in your entire life. Understanding the Role of Micro-Invasive Glaucoma Surgery (MIGS) in Treating a Blinding Disease Glaucoma is a chronic, progressive optic nerve disease that, if left untreated, leads to irreversible blindness. It is often called the “silent thief of sight” because it causes gradual vision loss without obvious symptoms. Treating glaucoma requires reducing intraocular pressure (IOP) to prevent further optic nerve damage. Despite the advances in medical and surgical treatments, many patients hesitate when it comes to surgery and rightly so as the eye represents the most important sense organ. Glaucomaprocedures that leave a device or implant(s) in the eyes can also be concerning. This hesitation highlights the importance of patient education, particularly about the benefits of combining glaucoma treatment with cataract surgery. Combining Cataract Surgery with MIGS Glaucoma patients often require cataract surgery as they age, presenting an opportunity to address both conditions simultaneously. I, as many surgeons do, recommend performing micro-invasive glaucoma surgery (MIGS) during cataract surgery. MIGS procedures are designed to: • Lower IOP effectively • Prevent fluctuations in eye pressure • Reduce dependence on daily glaucoma medications These minimally invasive procedures aim to preserve vision and improve the patient’s quality of life. However, patients may express concerns about the use of stents or other devices left in their eyes after surgery. Addressing these concerns is crucial, as MIGS procedures represent a significant advancement in managing this blinding disease. Comparing MIGS Procedures: Insights from Research Recent studies comparing MIGS techniques have shed light on their effectiveness. The December 2024 meta-analysis by Guedes et al. evaluated the outcomes of Kahook Dual Blade (KDB) goniotomy versus trabecular micro-bypass stents (iStent and iStent inject) combined with cataract surgery (phacoemulsification). Key Findings: • KDB Goniotomy vs. iStent • KDB achieved higher rates of surgical success at six months compared to the iStent group. • KDB demonstrated a greater reduction in IOP (by 1.13 mmHg) at six months. • KDB Goniotomy vs. iStent Inject • Both groups showed similar IOP reduction by month 12, with no significant differences. • Safety and Medication Use • Both techniques had comparable rates of adverse events and medication reduction. This study highlights the efficacy of the KDB goniotomy, particularly for patients seeking a device-free option. Other MIGS Options There are numerous other MIGS procedures to consider, each with unique benefits and limitations: 1. XEN Gel Stent • A soft, gelatin-based implant that creates a permanent drainage pathway to reduce IOP. • Suitable for moderate to severe glaucoma but leaves a device in the eye. 2. GATT (Gonioscopy-Assisted Transluminal Trabeculotomy) • A suture is used to open the eye’s natural drainage pathway. • No foreign body is left behind, making it appealing to patients who prefer device-free options. 3. Hydrus Microstent • A crescent-shaped stent that improves aqueous outflow by scaffolding the trabecular meshwork. • Highly effective but involves implanting a device. Educating Patients For many patients, the idea of leaving a device in their eye may be unsettling. It’s essential to explain that: • MIGS devices, like the iStent or Hydrus, are biocompatible and designed to remain safely in the eye. • Device-free procedures like KDB or GATT are effective alternatives for those who prefer not to have an implant. Ultimately, the goal of all MIGS procedures is the same: to protect the optic nerve and prevent blindness. Conclusion Glaucoma is a serious, sight-threatening condition that requires proactive treatment. For patients undergoing cataract surgery, combining it with a MIGS procedure offers an effective way to control IOP, reduce medication burden, and preserve vision. Studies, like the one by Guedes et al., provide evidence-based insights to help patients and surgeons make informed decisions. As always, discussing individual needs, concerns, and expectations with a glaucoma specialist is the key to successful outcomes. References 1. Guedes, J., Amaral, D. C., de Oliveira Caneca, K., et al. Kahook Dual Blade Goniotomy versus iStent Implantation Combined with Phacoemulsification: A Systematic Review and Meta-analysis. Journal of Glaucoma, December 9, 2024. DOI: 10.1097/IJG.0000000000002522. 2. Ahmed, I. K., et al. Long-Term Outcomes of the Hydrus Microstent for Glaucoma Treatment. Ophthalmology, 2020. 3. Gillmann, K., Mansouri, K. XEN Gel Stent in Glaucoma Surgery: A Review. Journal of Glaucoma, 2021. 4. Grover, D. S., et al. Gonioscopy-Assisted Transluminal Trabeculotomy: Efficacy and Safety. Ophthalmology Glaucoma, 2022.