An Alternate Technique for Goniotomy: Description of Procedure and Preliminary Results
Purpose: Multiple glaucoma treatment modalities seek to lower IOP by bypassing or removing a portion of the juxtacanalicular trabecular meshwork. These procedures often require expensive implants or specialized surgical instruments. The authors developed a technique for ab interno goniectomy utilizing a standard disposable 25-gauge hypodermic needle. The surgical procedure—termed bent ab interno needle goniectomy (BANG)—and preliminary results are presented here.
Methods: A retrospective chart review was performed for all patients who underwent goniotomy using a modified hypodermic needle by one of the three authors between July 2017 and June 2018. The mean and standard deviation pre- and postoperative IOP and the number of glaucoma medications were calculated. The student paired t-test was used to compare pre- and postoperative data. A P-value of <0.05 was considered statistically significant.
Results: At postoperative month six, the mean IOP was 13.3 ± 2.5 mmHg (P = 3.6 × 10−7) on 0.5 ± 0.8 topical glaucoma medications (P = 0.01). A ≥20% reduction in IOP was achieved in 73% of patients. Seventy-three percent of patients required ≥1 fewer medication, while 73% of patients required no medications for IOP control. Forty-one percent of those treated achieved IOP ≤12 mmHg.
Conclusion: The BANG procedure is a low-cost MIGS technique available to surgeons around the world with preliminary outcomes similar to more expensive alternatives.
Glaucoma, Goniotomy, Microinvasive Glaucoma Surgery
1. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY, et al. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology 2014;121:2081–2090.
2. Grant WM. Clinical measurements of aqueous outflow. AMA Arch Ophthalmol 1951;46:113–131.
3. Grant WM. Experimental aqueous perfusion in enucleated human eyes. Arch Ophthalmol 1963;69:783–801.
4. Tamm ER. The trabecular meshwork outflow pathways: structural and functional aspects. Exp Eye Res 2009;88:648–655.
5. Herschler J, Davis EB. Modified goniotomy for inflammatory glaucoma. Histologic evidence for the mechanism of pressure reduction. Arch Ophthalmol 1980;98:684–687.
6. Luntz MH, Livingston DG. Trabeculotomy ab externo and trabeculectomy in congenital and adult-onset glaucoma. Am J Ophthalmol 1977;83:174–179.
7. Anderson DR. Trabeculotomy compared to goniotomy for glaucoma in children. Ophthalmology 1983;90:805–806.
8. Jacobi PC, Dietlein TS, Krieglstein GK. Technique of goniocurettage: a potential treatment for advanced chronic open angle glaucoma. Br J Ophthalmol 1997;81:302–307.
9. Minckler DS, Baerveldt G, Alfaro MR, Francis BA. Clinical results with the Trabectome for treatment of open-angle glaucoma. Ophthalmology 2005;112:962–967.
10. Seibold LK, Soohoo JR, Ammar DA, Kahook MY. Preclinical investigation of ab interno trabeculectomy using a novel dual-blade device. Am J Ophthalmol 2013;155:524–529.
11. Grover DS, Godfrey DG, Smith O, Feuer WJ, Montes de Oca I, Fellman RL. Gonioscopy-assisted transluminal trabeculotomy, ab interno trabeculotomy: technique report and preliminary results. Ophthalmology 2014;121:855–861.
12. Samuelson TW1, Katz LJ, Wells JM, Duh YJ, Giamporcaro JE. Randomized evaluation of the trabecular micro-bypass stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology 2011;118:459–467.
13. Manasses DT, Au L. The new era of glaucoma micro-stent surgery. Ophthalmol Ther 2016;5:135–146.
14. Jea SY, Francis BA, Vakili G, Filippopoulos T, Rhee DJ. Ab interno trabeculectomy versus trabeculectomy for openangle glaucoma. Ophthalmology 2012;119:36–42.
15. Ting JL, Damji KF, Stiles MC. Ab interno trabeculectomy: outcomes in exfoliation versus primary open-angle glaucoma. J Cataract Refract Surg 2012;38:315–323.
16. Francis BA, See RF, Rao NA, Minckler DS, Baerveldt G. Ab interno trabeculectomy: development of a novel device (Trabectome) and surgery for open-angle glaucoma. J Glaucoma 2006;15:68–73.
17. Grover DS, Godfrey DG, Smith O, Shi W, Feuer WJ, Fellman RL. Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in eyes with prior incisional glaucoma surgery. J Glaucoma 2017;26:41–45.
18. Wilmsmeyer S, Philippin H, Funk J. Excimerlaser trabeculotomy: a new, minimally invasive procedure for patients with glaucoma. Graefes Arch Clin Exp Ophthalmol 2006;244:670–676.
19. Neuhann TH, Scharrer A, Haefliger E. Excimer laser trabeculostomy (ELT) in the treatment of chronic open angle glaucoma. Ophthalmo-Chirurgies 2001;13:2–7.
20. Vogel M, Lauritzen K. Punktuelle excimerlaserablation des trabekelwerks. Ophthalmologe 1997;94:665–667.
21. Hodapp E, Heuer DK. A simple technique for goniotomy. Am J Ophthalmol 1986;102:537.
22. Laroche D, Okaka Y, Ng C. A novel low cost effective technique in using a 23 gauge straight cystotome to perform goniotomy: making Micro-invasive Glaucoma Surgery (MIGS) accessible to the Africans and the diaspora. J Natl Med Assoc 2019;111:193–197.
23. Dorairaj SK, Seibold LK, Radcliffe NM, Aref AA, Jimenez- Román J, Lazcano-Gomez GS, et al. 12-month outcomes of goniotomy performed using the Kahook Dual Blade combined with cataract surgery in eyes with medically treated glaucoma. Adv Ther 2018;35:1460–1469.