Early outcomes of bent ab interno needle goniectomy and Espaillat goniotomy with phacoemulsification in open-angle glaucoma

Dear Editor, Minimally invasive glaucoma surgery(MIGS) has emerged as a revolutionary approach for effectively reducing intraocular pressure (IOP) with a good safety profile. It uses an ab interno approach with minimal tissue trauma and faster recovery. Among the array of MIGS procedures, the limited goniotomy procedures have the added advantage of balancing IOP reduction and limiting the damage to the trabecular meshwork (TM)–Schlemm’s canal (SC) complex. Bent ab interno needle goniectomy (BANG) uses a 25-gauge needle bent at the tip to excise TM.[1] A novel technique Espaillat juxtacanalicular goniotomy was recently described by Dr. Alejandro Espaillat, where TM is engaged and stretched bulldozed with the blunt tip of the Espaillat goniotome until it made an initial separation and opening into SC, without stripping TM[2] [Fig. 1]. There is limited literature on the outcomes of BANG and there are no previous studies on Espaillat goniotomy in India, to the best of our knowledge.Figure 1: (a and b) Bent ab interno needle goniectomy being performed with a bent 25-gauge needle. (c and d) Espaillat goniotome and Espaillat juxtacanalicular space goniotomy being performedIn a prospective, comparative case series we performed, 23 patients underwent BANG and 23 patients underwent Espaillat goniotomy with phacoemulsification. The mean (standard deviation) baseline IOP in BANG reduced from 15.65 (4.10) mmHg to 12.65 (3.05) mmHg (20% reduction), while for Espaillat, it reduced from 16.13 (5.22) mmHg to 12.78 (3.45) mmHg with 28.6% reduction at 6 months. Our results were consistent with Townsend et al.[3] (20.8%) and DeVience et al.[4] (28%). Studies by Eslami et al.[5] and Bukke et al.[6] showed IOP reduction of 32.1% and 31.8%, respectively. However, they included varying spectra of glaucoma. In the study by Espaillat,[2] the mean IOP was 22.1 ± 2.2 mmHg, which reduced to 15.22 ± 1.9 mmHg at 24 months. In our study, antiglaucoma medications (AGMs) reduced from 1.04 (1.07) to 0.17 (0.39) in the BANG group and from 0.61 (0.66) to 0 in the Espaillat group. Shute et al.[1] observed a 54.5% reduction at 6 months. In the Eslami et al.[5] study, AGM significantly declined from 1.2 ± 1.5 to 0.6 ± 1.1 at 6 months. Bukke et al.[6] and Shute et al.[1] showed a reduction of 24.3% and 54.5%, respectively. Espaillat[2] showed AGM usage reduced by 76% [Table 1].Table 1: Comparison of IOP and AGM between BANG and Espaillat groupsComplete success of 81% (IOP >6–≤15 mmHg/25% reduction without AGM) and qualified success of 33.3% (IOP >6–≤15 mmHg/25% reduction with AGM) were noted in the BANG group, and complete success of 85.7% and qualified success of 40% were observed in the Espaillat group. Shute et al.[1] study showed a ≥20% reduction in IOP in 73% of patients without AGM at 6 months, and Townsend et al.[3] reported success of 55.81%. Bukke et al.[6] showed a similar percentage of success for >20% IOP reduction (62.5%). Espaillat[2] showed that 31 out of 38 patients achieved >20% reduction in IOP. The postoperative complications noted were microhyphema and iritis, which were managed conservatively. Espaillat Juxtacanalicular space (JCS) goniotomy, a novel technique of MIGS, is safe and efficacious as BANG in mild to moderate open-angle glaucoma and has the added advantage of avoiding TM stripping. Both procedures had an equivocal reduction in IOP and postoperative need for AGMs. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.