Department of Ophthalmology, Mt Sinai School of Medicine, New York, New York, USA.
Curr Opin Ophthalmol. 2023 Mar 1;34(2):138-145. doi: 10.1097/ICU.0000000000000927. Epub 2022 Nov 14.
To highlight progress in glaucoma therapy challenging the traditional medication-first approach and present evidence supporting early standalone surgery in the era of micro-invasive glaucoma surgery (MIGS).
Medical therapy is limited by well documented poor adherence that compromises the quality of intraocular pressure reduction. Results from modern clinical trials demonstrate advantages of selective laser trabeculoplasty and MIGS procedures in terms of both IOP control and progression risk.
The MIGS options for pseudophakic or precataractous patients are limited by regulatory rules that require the performance of some procedures only at the time of cataract surgery. These include the iStent/iStent Inject and the Hydrus implants. Nonbleb-forming procedures currently available for standalone use in eyes with mild-moderate primary open-angle glaucoma include gonioscopy-assisted transluminal trabeculotomy (which lowers IOP by 28-61% and medication use by 38-73% in various studies), trabecular ablation with the Trabectome (23-39% and 21-43%, respectively), excisional goniotomy with the Kahook Dual Blade (15-36% and 15-40%, respectively), ab interno canaloplasty (35% and 57%, respectively), and combined canaloplasty and trabeculotomy using the OMNI system (39-40% and 64-73%, respectively). For patients who would benefit from early standalone surgery, these procedures offer meaningful reductions in both IOP and medication burden.
综述目的：强调在青光眼治疗方面的进展，挑战传统的药物优先方法，并介绍支持在微创青光眼手术（MIGS）时代早期进行独立手术的证据。
最新发现：药物治疗受到众所周知的低依从性的限制，这会影响眼压降低的质量。现代临床试验的结果表明，选择性激光小梁成形术和 MIGS 手术在眼压控制和进展风险方面都具有优势。
总结：对于白内障或白内障前期的患者，MIGS 选择有限，因为监管规定要求某些手术只能在白内障手术时进行。这些包括 iStent/iStent Inject 和 Hydrus 植入物。目前可单独用于轻度至中度原发性开角型青光眼的非滤泡形成手术包括房角镜辅助经小梁切开术（在各种研究中降低眼压 28-61%和药物使用 38-73%）、Trabecular 消融术（Trabectome）（分别降低 23-39%和 21-43%）、带 Kahook Dual Blade 的内切开术（分别降低 15-36%和 15-40%）、内切开术（ab interno canaloplasty）（分别降低 35%和 57%）以及使用 OMNI 系统的联合内切开术和小梁切开术（分别降低 39-40%和 64-73%）。对于那些将从早期独立手术中受益的患者，这些手术可显著降低眼压和药物负担。
