Comment on “Outcomes of bent ab interno needle goniectomy with phacoemulsification in moderate to severe primary open angle glaucoma”

Dear Editor, In the original article by Bukke et al,[1] the method described is as follows: Under topical anesthesia, the eye was cleaned and draped in an aseptic manner. With the surgeon seated on the temporal side, a 1 mm side port entry and a 2.2 mm temporal keratome entry were made. The anterior chamber was filled with a visco-cohesive agent. Thirty degrees was marked at the nasal limbus with a toric marker at the desired location. The microscope was titled toward the surgeon, and the patient’s head was titled away from the surgeon for better visualization of the nasal angle. A disposable 26-gauge hypodermic needle was bent to a 90° angle at the tip, with the bevel facing upward, and was attached to a Healon GV Pro (1.8% Sodium hyaluronate (HA)) (Johnson-Johnson Surgical Vision, Inc, Santa Ana, CA, USA) syringe. The bent 26-gauge needle was used to excise 30° of the nasal TM under visualization with a Swan-Jacob gonioprism (University of Oregon, Portland, OR, USA) before performing capsulorrhexis for cataract surgery. Following the goniectomy, the microscope and patient’s head were rotated to the primary position, and standard phacoemulsification (phaco) steps were conducted to complete the surgical procedure. In this procedure, it was not clearly explained whether the pupil was constricted at the start. After the goniectomy, the pupil was dilated for phacoemulsification. If the goniectomy was performed before phacoemulsification, there is a chance of hyphema, making cataract surgery more difficult in cases of intraoperative hyphema. This study does not mention how many cases of intraoperative hyphema were observed and how it was managed. Hyphema is a common complication observed after incisional or excisional goniotomy. In this study, hyphema was seen in 10 eyes out of 32 eyes, which resolved spontaneously over 1 week with conservative management. According to the study by Eslami Y et al.[2], phacoemulsification was performed using either a temporal or superior approach. After completing continuous curvilinear capsulorhexis and hydrodissection, phacoemulsification was conducted using the stop-and-chop technique. A foldable intraocular lens (IOL) was injected into the capsular bag at the end of the procedure. In the case of the superior approach for phacoemulsification, the position was changed to the temporal side to perform a nasal goniotomy. All goniotomies were conducted with a 25-gauge needle using a Swan-Jacob goniolens. By applying a dispersive ophthalmic viscosurgical device on the cornea, an enface image of the nasal angle was obtained. The needle was advanced at least 45° in the superior and inferior directions. The goal was to incise the pigmented part of the trabecular meshwork and expose Schlemm’s canal in the anterior chamber for 90°. In cases of hyphema, irrigation was continued until the blood cleared from the anterior chamber. At the end of the procedure, a drop of topical pilocarpine 1% was instilled on the ocular surface. Although bent ab interno needle goniectomy is a cost-effective MIGS technique and a boon for developing countries in managing open-angle glaucoma, the author could have provided a detailed surgical procedure, including the management of intraoperative hyphema before phacoemulsification. This information would help readers apply these techniques in glaucoma management. A response from the authors regarding these comments would enhance readers’ understanding of the study. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.