Surgical technique for mitigating hyphema in minimally invasive glaucoma surgery – The “Mohi Wait” four-step technique

Background: The introduction of minimally invasive glaucoma surgery (MIGS) has caused a significant shift in the surgical management of glaucoma. [1] The safety profile of MIGS is better, but a dreaded complication is postoperative hyphema. [2,3] Currently, standardized guidelines for preventing MIGS-associated hyphema are lacking. Purpose: We intend to describe a surgical technique, which will reduce the rate of hyphema. Synopsis: This video demonstrates the step-by-step execution of the “MOHI Wait” four-step technique. Following completion of a standard 360-degree trabeculotomy (GATT), Step 1: The viscoelastic is removed and 0.1–0.2 cc of intracameral preservative-free adrenaline (0.1 ml to 0.2 ml of 1:1000 Epitrate [Sunways India Private Limited, Mumbai, India] mixed with 5 ml saline) is injected; Step 2: The anterior chamber is filled with air bubbles for a few minutes and exchanged with Aurogel plus (1.6% sodium hyaluronate) (Aurolab, India); Step 3: After a waiting period of 10–15 minutes, the viscoelastic is completely removed by irrigation–aspiration; Step 4: The anterior chamber is filled up to 1/3 rd with air and a 30% fill with Aurogel (1.4% sodium hyaluronate) (Aurolab, Madurai India) around the inferior border of the air bubble. Intracameral moxifloxacin 0.1 cc (Auromox, Aurolab, Madurai, India) is injected. In the end, the surgeon taps to ensure hard and watertight closure. Highlights: Technique: Demonstrates a structured four-step approach combining adrenaline use, air tamponade, viscoelastic tamponade, and a wait-and-watch strategy to control reflux bleeding after GATT. With the adoption of the Mohi-Wait four-step technique, we were able to substantially reduce the occurrence of postoperative hyphema from 21.22% to 5.22% following GATT and the need for an anterior chamber washout from 9.4% to 1.3%. Clinical Relevance: This technique may be particularly helpful in light of the rising trend of MIGS, in which the risk of hyphema tends to be higher. Addresses one of the most common complications of angle-based MIGS procedures. Outcomes: Significant reduction in postoperative hyphema and secondary interventions following adoption of the technique. Reproducibility: Simple, cost-effective method easily adaptable by MIGS surgeons in routine clinical practice. Video Link: https://youtu.be/TDh6QwKbNZk