Goniotomy for adult refractory glaucoma after failed anti-glaucoma surgery: a 24-month prospective observation study

Goniotomy for adult refractory glaucoma after failed anti-glaucoma surgery: a 24-month prospective observation study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Goniotomy for adult refractory glaucoma after failed anti-glaucoma surgery: a 24-month prospective observation study Chunxin Lai, Di Wang, Yuqiao Zhang, Yuhan Feng, Yuxuan Li, Linjiang Chen, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8561228/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To evaluate the 24-month efficacy and safety of goniotomy for adult refractory glaucoma after failed incisional surgery. Methods: A prospective study was conducted involving patients with refractory glaucoma who underwent goniotomy. Study outcomes included changes in IOP, the number of anti-glaucoma medications (AGMs) , and postoperative complications over an 24-month period. Logistic regression analysis was performed to identify potential risk factors for surgical failure. Results: A total of 81 eyes from 72 patients were included. All participants had undergone at least one prior incision surgery. Following goniotomy, mean IOP significantly decreased from 23.27±5.12mmHg preoperatively to 15.70±2.78mmHg at 24 months ( P <0.001), accompanied by a reduction in AGMs use from 2.79±1.02 to 1.43±1.37 ( P <0.001). Fifteen eyes (18.52%) were classified as surgical failures, and three patients required reoperations. Higher preoperative IOP was identified as a risk factor for surgical failure ( P <0.05). Postoperative complications included hyphema in 18 eyes (22.22%) and transient IOP spike in 8 eyes (9.88%). Conclusion: Goniotomy effectively reduced IOP and the need for AGMs in refractory glaucoma after failed surgery over 24 months, suggesting it may serve as a safe and viable therapeutic option in this challenging population. goniotomy refractory glaucoma minimally invasive glaucoma surgery Figures Figure 1 Figure 2 Key Message Efficacy of Goniotomy in refractory glaucoma remains limited. The study demonstrates that goniotomy provides significant and sustained reduction in both intraocular pressure (IOP) and medication burden over a 24-month period in eyes with refractory glaucoma following failed incisional surgery. A higher preoperative IOP level was identified as a significant independent risk factor for surgical failure. Background Glaucoma is a leading cause of irreversible blindness worldwide, and intraocular pressure (IOP) remains the only modifiable risk factor[ 1 , 2 ]. Refractory glaucoma, defined as persistent uncontrolled IOP or disease progression despite maximum tolerated medical therapy and conventional surgery, encompasses not only cases that fail after initial filtration surgery but also conditions where filtration surgery is avoided due to a high predisposition to failure[ 3 ]. Sufficiently and Sustainably maintaining IOP for this form of glaucoma whose conditions have already been remodeled by previous interventions and prolonged used of anti-glaucoma medications (AGMs) is a big challenge. Conventional therapeutic options like repeating trabeculectomy and drainage procedures are associated with high risk of failure and complications. A randomized clinical trial reports a 5-year failure rate of 35% for trabeculectomy and 35% for tube shunt surgery, with complication rates of 21% and 37% respectively[ 4 , 5 ]. However, when the first filtering surgery fails early, the resultant conjunctival remodeling significantly limits the efficacy of a second surgery[ 6 , 7 ]. Hence, alternative therapeutic options should be considered to improve the success rate. Since 1999, minimally invasive glaucoma surgeries (MIGS) have been developed, whose design aims to achieve effective IOP control while prioritizing a high safety profile to mitigate the risks of traditional filtering surgery and enable rapid rehabilitation[ 8 , 9 ]. Many types of trabecular MIGS have been confirmed to be effective in managing glaucoma by randomized controlled trials[ 10 – 14 ]. However, few studies have evaluated the specific efficacy in refractory glaucoma. In two retrospective studies, gonioscopy-assisted transluminal trabeculotomy (GATT) appeared safe and successful in treating about 60% of open angle glaucoma (OAG) eyes with prior incisional glaucoma surgery at 1 year[ 15 , 16 ]. In a prospective multicentered study of 38 eyes following failed surgery, goniotomy (GT) achieved rates of 78.9% for qualified success and 42.1% for complete success at 12 months[ 17 ]. However, for eyes with refractory glaucoma, the evidence of the specific efficacy of GT is still limited. Therefore, we investigate the safety and efficacy of GT in refractory glaucoma. Methods Study Design and Participants This was a prospective observational study. All adult patients with refractory glaucoma who underwent GT in Nanfang hospital were recruited. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki and received approval from the Institutional Review Board (IRB) at Nanfang Hospital. All participants provided written informed consent before any surgical procedure was undertaken. The inclusion criteria for the patients in this study was: adult patients with prior diagnosed glaucoma, who failed to achieve or maintain target IOP with maximal tolerate medications or incision surgeries, underwent a subsequent GT surgery and completed a minimum of 24 months follow-up. Patients were excluded if they were contraindicated for GT, for those who had active neovascular glaucoma, active uveitis with secondary glaucoma, or were under active treatment for another ophthalmic condition. Surgical procedures and postoperative care GT was performed by the same experienced glaucoma surgeon at the inferior quadrant from the superior clear corneal incision under topical anesthesia. A superior 2.2 mm-clear corneal incision was made before the injection of viscoelastic (sodium hyaluronate) into the anterior chamber. For maximal and optimal visualization of the inferonasal angle, the patient’s head was rotated 35–40 degrees away from the surgeon, and the surgical microscope was tilted 30–40 degrees toward the surgeon. A surgical gonioscopy lens was placed on the cornea to observe the angle and the trabecular meshwork. A microhook (TMH; Tanito Microhook, Inami & Co, Ltd) was inserted into the anterior chamber through the corneal incision. The tip of the microhook was then inserted into the Schlemm’s canal and moved to incise the inner wall of Schlemm’s canal and trabecular meshwork over 120 degrees. After the viscoelastic was aspirated, the corneal incision was closed by corneal stromal hydration. In the presence of peripheral anterior synechiae, goniosynechialysis (GSL) was performed before the GT. A chopper was used to gently depress the synechiae at the iris root to enable the scleral spur and trabecular meshwork to be clearly observed. When combined with cataract extraction, GT with/without GSL was performed after phacoemulsification and intraocular lens implantation (PEI). Postoperatively, patients were prescribed topical steroids eye drop (prednisone acetate 1%) and ointment (tobramycin and dexamethasone) for 1 week, followed by non-steroidal anti-inflammatory (NSAID) eye drops for 3 weeks. Ocular hypotensive medications were discontinued, reduced, or continued on a case-by-case basis by the surgeon. Study outcomes Baseline demographic information, including gender, age, best corrected visual acuity (BCVA) documented as Logarithmic Minimum Angle of Resolution (logMAR), IOP (Goldmann applanation tonometry), number of glaucoma medications was collected from all participants. Follow-up data were collected at day 1, week 1 and months 1, 3, 6, 12, 18 and 24. At each visit, data were collected on IOP, the number of AGMs, and postoperative complications (including hyphema, IOP spike, and cornea edema). Hyphema was defined as the appearance of layered blood in the anterior chamber, and an IOP spike was defined as an IOP ≥ 30mmHg at any time point during the postoperative period. Surgical success was stratified by three distinct IOP thresholds: Criterion A (6 ≤ IOP ≤ 21mmHg), B (6 ≤ IOP ≤ 18mmHg), and C (6 ≤ IOP ≤ 15mmHg). Complete success was defined by achieving the target IOP with no loss of light perception, additional ocular hypotensive medication or re-operation. Qualified success: similar to that of complete success, except for the need of ocular hypotensive medications. Surgical failure was defined as postoperative IOP > 21mmHg at two consecutive follow-up visits or reduced < 20% from baseline, IOP < 6mmHg, re-operated for glaucoma, required more AGMs than baseline. Statistical analysis Statistical analysis was conducted using SPSS Sample Power Software (SPSS Inc., Chicago, IL, USA, 27.0). Continuous variables were presented as mean ± standard deviation, and categorical variables were presented as frequencies (percentage). Generalized Estimating Equations (GEE) was used to analyse tendency of IOP and AGMs during 24 months and Bonferroni for all pairwise comparisons. Univariate logistic regression and multivariate logistic regression were performed to analyze factors affected surgical failure. Statistical significance was defined when a p-value (P) was less than 0.05 (P < 0.05). Results Demographic and Characteristics of the Participants. This study included 81 eyes from 72 patients, with a mean age of 59.25 ± 14.20 years. About half of the participants were male and had undergone surgery in their right eyes. Night patients contributed both eyes, and no significant intra-patient clustering across any parameter was detected (all P > 0.05). 54 eyes (66.67%) accepted goniotomy with/without goniosynechialysis (GT ± GSL) and 27 eyes (33.33%) received combination with phacoemulsification and intraocular lens implantation (PEI + GT ± GSL). 35 eyes (43.21%) were diagnosed with primary open-angle glaucoma (POAG) and 32 eyes (39.51%) were primary angle-closure glaucoma (PACG). 8 eyes (9.88%) had secondary open-angle glaucoma (SOAG) and 6 eyes (7.41%) had secondary angle-closure glaucoma (SACG). All the participants had undergone at least one prior anti-glaucoma surgery, with trabeculectomy the most popular (43.21%), followed by PEI (28.40%). BCVA (logMAR) remained stable over 24 months (0.87 ± 0.96 vs. 0.84 ± 0.95, P > 0.05). Table 1 Baseline Demographics and Characteristics of participants. Parameters Descriptions No. eyes (patients) 81(72) Age, y (mean ± SD) 59.25 ± 14.20 Male, N(%) 48(59.26) Right eyes, N(%) 38(46.91) Surgical group, N(%) GT ± GSL 54(66.67) PEI + GT ± GSL 27(33.33) Types of glaucoma, N(%) POAG 35(43.21) PACG 32(39.51) SOAG* 8(9.88) SACG** 6(7.41) Stage of glaucoma, N(%) Mild 16(19.75) Moderate 8(9.88) Severe 57(70.37) No. prior anti-glaucoma surgeries, N(%) One prior surgery 66(81.48) Two prior surgeries 11(13.58) More than two prior surgeries 4(4.94) Eyes with prior surgery, N(%) Trabeculectomy 35(43.21) Peripheral iridectomy 10(12.35) PEI combined Ex-PRESS implant 7(8.64) Ahmed valve implant 6(7.41) Filtering blebs revision 5(6.17) Goniotomy 5(6.17) PEI combined Trabeculectomy 4(4.94) Ex-PRESS implant 2(2.47) Selective laser trabeculectomy 1(1.23) GT ± GSL: goniotomy combined with/without goniosynechialysis. PEI + GT ± GSL: phacoemulsification and intraocular lens implantation (PEI) combined with GT ± GSL. POAG: primary open angle glaucoma. PACG: primary angle closure glaucoma. SOAG: secondary open angle glaucoma. SACG: secondary angle closure glaucoma. * SOAG in this study included one case of steroid-induced glaucoma, one case of nonactive neovascular glaucoma, two cases of pigmentary glaucoma, two cases secondary to ocular trauma, and two cases secondary to Fuchs' heterochromic iridocyclitis. ** SACG included one case secondary to pars plana vitrectomy (PPV) and silicone oil implantation, one case following vitreous prolapse after posterior segment surgery, one case secondary to ocular trauma, one case of congenital microphthalmia, and two cases secondary to Fuchs' heterochromic iridocyclitis. Change of IOP, AGMs in 24 months. As shown in table 2, the mean IOP and AGMs significantly decreased at each time point ( P < 0.001), with IOP reduction of 7.57mmHg (32.53%) and AGMs reduction of 1.30 (46.59%) at 24 months. IOP on Day 7 was significant higher than that on Month 3 (17.30 ± 8.11mmHg vs. 14.77 ± 3.43mmHg, P = 0.032). AGMs significantly increased between each two follow-up time points ( P < 0.001). Table 2. Trends of IOP and AGMs during follow-ups. Outcomes Preoperative Day 1 Day 7 Month 1 Month 3 Month 6 Month 12 Month 18 Month 24 IOP/mmHg 23.27±5.12 15.09±6.82 17.30±8.11 15.62±3.92 14.77±3.43 15.15±2.94 15.88±4.05 15.71±2.70 15.70±2.78 Reduced IOP/mmHg - 8.18±12.28 5.97±12.38 7.65±11.30 8.49±10.55 8.12±11.00 7.39±11.11 7.55±11.11 7.57±11.45 Reduced percentage - 35.15% 25.66% 32.87% 36.48% 34.89% 31.76% 32.45% 32.53% Pa - <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 AGM/number 2.79±1.02 0.17±0.63 0.23±0.73 0.59±1.08 0.85±1.19 1.02±1.26 1.22±1.26 1.43±1.33 1.43±1.37 Reduced AGM/number - 2.62±1.19 2.56±1.28 2.20±1.36 1.94±1.33 1.77±1.31 1.57±1.30 1.36±1.31 1.30±1.36 Reduced percentage - 93.91% 91.76% 78.85% 69.53% 63.44% 56.27% 48.75% 46.59% Pb - <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 IOP: intraocular pressure; AGMs: anti-glaucoma medications. a IOP of postoperative versus preoperative, Generalized Estimating Equations (GEE), Bonferroni for all pairwise comparisons. b AGMs of postoperative versus preoperative, Generalized Estimating Equations (GEE), Bonferroni for all pairwise comparisons. Figure 1 . * Postoperative IOP did not differ significantly across time points, except at D7 compared to M3 (P = 0.032, Bonferroni correction). ** Pairwise comparisons revealed statistically significant differences in the number of AGMs between all follow-up time points (P < 0.001, Bonferroni correction). Both IOP and AGMs of each postoperative time point were significant different from the preopeartive one. IOP: intraocular pressure; AGMs: anti-glaucoma drugs; Pre: Preoperative; D1: postoperative 1 day ; D7: postoperative 7 day; M1: postoperative 1 month; M3: postoperative 3 month; M6: postoperative 6 month; M12: postoperative 12 month; M18: postoperative 18month; M24: postoperative 24 month. Surgical success rate and risk factors for failure. The surgical success rates of three criteria was shown in Table 3 . Tendency of criterion A and failure rate were shown in Fig. 2 . The increased qualified success rate was correspondent with increased used of AGMs in order to achieve more lower IOP for advanced cases. Complete success rate gradually declined over time. The first failure case occurred 3 months after surgery, and increased to 3 eyes (3.70%) on Month 6, 12 eyes (12.14%) on Month 12,14 eyes (17.28%) on Month 18, and 15 eyes (18.52%) on Month 24. Logistic regression analysis of risk factors for surgical failure was performed, which revealed that preoperative IOP was significantly associated with surgical failure (OR, 1.05; 95%Cl, 1.01–1.10; P = 0.040 in Univariate Logistic Regression Analysis; OR, 1.07; 95%Cl, 1.01–1.13; P = 0.014 in Multivariate Logistic Regression Analysis). However, age, sex, glaucoma type (OAG vs ACG), number of prior surgeries, and preoperative AGMs number were not significantly associated with surgical failure (P > 0.05). Figure 2 . Criterion A: Complete success was defined as a postoperative IOP ≤ 21mmHg without the need for additional AGMs. Qualified success was similar to that of complete success, except for the need of AGMs. Surgical failure was defined as postoperative IOP > 21mmHg at two consecutive follow-up visits or reduced < 20% from baseline, IOP < 6mmHg, re-operated for glaucoma, required more AGMs than baseline. Data were shown as number (percentage). Table 3. Success rates of three criteria during follow-up. Outcomes Total N = 81 eyes Day 1 Day 7 Month 1 Month 3 Month 6 Month 12 Month 18 Month 24 Criterion A (6 ≤ IOP ≤21 mmHg) Complete Success rate (N[%]) 67(82.7) 62(76.5) 58(71.6) 48(59.3) 40(49.4) 34(42.0) 28(34.6) 27(33.3) Qualified Success rate (N[%]) 70(86.4) 69(85.2) 75(92.6) 80(98.8) 78(96.3) 69(85.2) 67(82.7) 66(81.5) Criterion B (6 ≤ IOP ≤18 mmHg) Complete Success rate (N[%]) 57(70.4) 51(63.0) 55(67.9) 45(55.6) 38(46.9) 33(40.7) 27(33.3) 27(33.3) Qualified Success rate (N[%]) 59(72.8) 57(70.4) 69(85.2) 73(90.1) 67(82.7) 60(74.1) 64(79.0) 65(80.2) Criterion C (6 ≤ IOP ≤15 mmHg) Complete Success rate (N[%]) 50(61.7) 36(44.4) 30(37.0) 30(37.0) 30(37.0) 24(29.6) 19(23.5) 16(19.8) Qualified Success rate (N[%]) 52(64.2) 41(50.6) 38(46.9) 50(61.7) 44(54.3) 42(51.9) 39(48.1) 40(49.4) Complete success was defined by achieving the target IOP with no loss of light perception, additional ocular hypotensive medication or re-operation. Qualified success: similar to that of complete success, except for the need of ocular hypotensive medications. Table 4 Logistic Regression Analysis of risk factors for surgical failure at Month 24. Parameters Univariate Logistic Regression Multivariate Logistic Regression Odds ratio (95% CI) P Odds ratio (95% CI) P Age, per 1 year 0.99 (0.95 ~ 1.03) 0.617 Sex, male vs. female 0.96 (0.31 ~ 3.02) 0.948 Glaucoma type, OAG vs. ACG 0.99 (0.32 ~ 3.04) 0.983 Number of prior surgeries, single vs. mutiple 0.63 (0.13 ~ 3.13) 0.570 Complicated vs. not Complicated 1.69 (0.54 ~ 5.30) 0.365 1.50 (0.44 ~ 5.11) 0.514 Preoperative IOP, per 1 mmHg 1.05 (1.01 ~ 1.10) 0.040* 1.07 (1.01 ~ 1.13) 0.014* Preoperative ATG, number one vs. 1.00 (Reference) 1.00 (Reference) two 2.67 (0.26 ~ 27.48) 0.410 1.68 (0.15 ~ 19.52) 0.677 * statistically significant different. Surgical failure was defined as postoperative IOP > 21mmHg at two consecutive follow-up visits or reduced < 20% from baseline, IOP < 6mmHg, re-operated for glaucoma, required more AGMs than baseline. OAG: open angle glaucoma, including POAG and SOAG; ACG: angle closure glaucoma, including PACG and SACG; IOP: intraocular pressure; AGMs: anti-glaucoma medications. Postoperative complications. The most common postoperative complication was hyphema. Hyphema was observed in 18 eyes (22.22%), among which 16 eyes (88.89%) were resolved spontaneously within 1 week, while 2 of them required anterior chamber paracentesis and washing. The second most common complication was IOP spikes (8 eyes, 9.88%). 5 eyes (6.17%) developed corneal edema after PEI + GT ± GSL, and 1 eyes (1.23%) complicated with Descement membrane detachment which was reposition with anterior chamber air injection. 2 eyes (2.47%) failed to control IOP with maximal AGMs use and underwent Ahmed valve implantation after 3 months and 12 months respectively. 1 eyes (1.23%) developed malignant glaucoma at month 24 and underwent phacoemulsificaiton combined with irido-zonulo-hyaloido-vitrectomy. Discussions This prospective observational study demonstrates that GT significantly reduces IOP and AGMs use in adults with refractory glaucoma over a-24 month period. Postoperative IOP decreased significantly at all time points ( P < 0.001), with a mean reduction of 32.53% at 24 months (preoperative 23.27 ± 5.12 vs. 15.70 ± 2.78mmHg). Similarly, AGMs use decreased significantly after GT ( P < 0.001), with a 46.6% reduction at 24 months compared to baseline (2.79 ± 1.02 vs. 1.43 ± 1.37). These findings support the consideration of GT as an alternative before a second trabeculectomy or tube implantation in patients with prior surgical failure. The magnitude of IOP and AGMs reduction observed in our cohort is consistent with prior studies of ab interno trabeculotomy in adult refractory glaucoma[ 15 – 22 ]. For instance, a multicentered prospective study in 61 primary glaucoma eyes following failed incision surgery reported similar outcomes at 24 months (16.3 ± 4.8mmHg with 1.4 ± 1.4 medications)[ 17 ]. In a multicenter series of refractory OAG eyes, Kahook Dual Blade (KDB) goniotomy reduced IOP from 18.1 ± 5.0mmHg to 14.8 ± 3.7mmHg and medications from 2.5 ± 1.4 to 1.7 ± 1.2 at 12 months[ 19 ]. Gonioscopy-assisted transluminal trabeculotomy (GATT) has been reported to lower IOP from 27.4 ± 8.8 mmHg to 15.3 ± 2.7 mmHg at 24 months, accompanied by significant reductions in AGMs use[ 16 ]. For patients with prior failed trabeculectomy, traditional filtration surgery such as repeat trabeculectomy or Ahmed valve implantation achieved comparable outcomes to our study. Van Swol et al. reported that repeat trabeculectomy maintained an IOP of 15.3mmHg with 1.2 medications, while an Ahmed valve implantation achieved the same IOP with 2.4 medications in 24 months[ 23 ]. Other studies showed that repeat trabeculectomy for refractory POAG and pseudoexfoliation glaucoma resulted in a lower final IOP level of 12.9 ± 4.3mmHg with few AGMs of 0.2 ± 0.7, whereas a second Ahmed Valves implantation achieved 14.7 ± 5.5mmHg with 1.9 ± 1.3 AGMs, which was consistent with our findings[ 24 , 25 ]. It is important to note that our study cohort included 15 eyes (18.52%) of eyes with multiple (≥ 2) prior failed anti-glaucoma surgeries, whereas the aforementioned studies of filtration surgeries primarily enrolled eyes with only one prior surgical failure. A slight increase in IOP was observed at postoperative day 7 (17.3 ± 8.1mmHg), coinciding with the period of topical steroids eye drop use, and likely reflecting steroid-induced IOP elevation. Following the transition to non-steriod anti-inflammatory therapy, IOP decreased significantly by 3 months (14.77 ± 3.43mmHg vs. 17.3 ± 8.1mmHg, P = 0.032). Subgroup analysis showed comparable 24-month IOP outcomes between the GT ± GSL-only group and the combined PEI + GT ± GSL group (15.32 ± 2.73mmHg vs. 15.89 ± 2.81mmHg, P > 0.05), despite a slightly greater reduction in the GT ± GSL-only group, which may reflect its higher baseline IOP. Our study demonstrated that the complete success rates were 33.3% (Criterion A/B) and 19.8% (Criterion C), whereas qualified success rates were 81.5%, 80.2%, and 49.4% respectively. Compared with multicenter studies, our complete success rates were slightly lower, potentially due to the lower baseline IOP in our cohort[ 17 ]. Compared to repeat trabeculectomy, GT demonstrated lower complete success but higher qualified success, indicating that additional AGMs were required to achieve comparable pressure control[ 24 ]. Overall, 15 eyes (18.5%) met criteria for surgical failure at 24 months, among whom 2 eyes (2.47%) failed to control IOP with maximal AGMs use and underwent Ahmed valve implantation after 3 months and 12 months respectively, and 1 eyes (1.23%) developed malignant glaucoma at month 24 and underwent phacoemulsificaiton combined with irido-zonulo-hyaloido-vitrectomy. Logistic regression identified higher preoperative IOP as the only independent risk factor for surgical failure (OR, 1.07; 95% CI, 1.01–1.13; P = 0.014), whereas age, sex, glaucoma type, prior surgeries, and preoperative AGMs number were not significant predictors. This finding underscores the importance of baseline disease severity in determining GT outcomes. Postoperative complications were consistent with previous reports of ab interno trabeculotomy and were lower than those typically reported for traditional filtration surgeries[ 5 ]. Hyphema, was the the most common complication (18 eyes, 22.22%), resolving spontaneously 88.9% of cases within 1 week. IOP spikes ,defined as an IOP ≥ 30mmHg at early stage of postoperative period, occurred in 8 eyes (9.9%) and were generally manageable with short-term additional medication. No vision-threatening complications were observed over 24 months follow-up period. This study has several limitations. The sample size was relatively small, and the observational design limits generalizability. Additionally, there was no comparative control group, preventing direct assessment of GT relative to other surgical options. Future research should include larger, multicenter cohorts with comparative designs to evaluate the relative efficacy and safety of GT. Longer-term follow-up studies are also needed to assess the durability of GT outcomes and to explore additional patient-specific factors that may influence long-term success. In conclusion, GT is an effective and safe procedure for reducing IOP and decreasing AGMs dependence in adult refractory glaucoma over 24 months. Although complete success rates decline over time, the favorable safety profile and substantial reduction in IOP and medications support its use as a viable treatment alternative to repeat trabeculectomy or tube implantation. Declarations Clinical trial number: not applicable. Statements and Declarations: Competing Interests: no conflicting relationship exists for any author. Funding ： This work was supported by the National Natural Science Foundation of China [grant number 82171036, HYZ]; the Natural Science Foundation of Guangdong Province, China [grant number 2023A1515011735, HYZ] and the Science and Technology Project in Baiyun District, Guangzhou [grant numbers 2025-YL-005, CXL]. Competing interests ： The authors have no conflicts of interest to declare. Clinical trial number: not applicable. Ethics approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. It was approved by Ethics Committee of Nanfang Hospital (NFEC-2024-291). Consent to participate: All the written informed consent were obtained from the participants. Author Contributions: All authors met the criteria for authorship. Hongyang Zhang conceptualized and designed the study. Chunxin Lai enrolled the participants, processed the data, performed analysis, and drafted the manuscript. Di wang and Yuqiao Zhang processed the data, performed analysis and interpreted the results. Yuhan Feng and Yuxuan Li were responsible for enrolling the participants, collecting preoperative and postoperative data. Linjiang Chen and Minting Chen performed the statistical analysis. Yongjie Qin coordinated the study and revised the initial manuscript draft. Hongyang Zhang performed all surgeries, and reviewed and edited the final manuscript. All authors have read and approved the final version of the manuscript. Data availability ： The data that support the findings of this study are available from the corresponding author upon reasonable request. References Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY (2014) Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology 121:2081–2090. https://doi.org/10.1016/j.ophtha.2014.05.013 Weinreb RN, Aung T, Medeiros FA (2014) The pathophysiology and treatment of glaucoma: a review. JAMA 311:1901–1911. https://doi.org/10.1001/jama.2014.3192 Heintz V, Bastelica P, Baudouin C, Lachkar Y, Labbe A (2025) Management of Refractory Glaucoma, a New Surgical Paradigm: Review of the Literature. Curr Eye Res 50:771–784. https://doi.org/10.1080/02713683.2025.2494799 Gedde SJ, Feuer WJ, Lim KS, Barton K, Goyal S, Ahmed II, Brandt JD, Primary Tube Versus Trabeculectomy Study G (2022) Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 5 Years of Follow-up. Ophthalmology 129:1344–1356. https://doi.org/10.1016/j.ophtha.2022.07.003 Gedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC, Tube Versus Trabeculectomy Study G (2012) Postoperative complications in the Tube Versus Trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol 153:804–814e801. https://doi.org/10.1016/j.ajo.2011.10.024 Issa de Fendi L, Cena de Oliveira T, Bigheti Pereira C, Pereira Bigheti C, Viani GA (2016) Additive Effect of Risk Factors for Trabeculectomy Failure in Glaucoma Patients: A Risk-group From a Cohort Study. J Glaucoma 25:e879–e883. https://doi.org/10.1097/IJG.0000000000000490 Broadway DC, Grierson I, Hitchings RA (1998) Local effects of previous conjunctival incisional surgery and the subsequent outcome of filtration surgery. Am J Ophthalmol 125:805–818. https://doi.org/10.1016/s0002-9394(98)00045-2 Saheb H, Ahmed II (2012) Micro-invasive glaucoma surgery: current perspectives and future directions. Curr Opin Ophthalmol 23:96–104. https://doi.org/10.1097/ICU.0b013e32834ff1e7 Kerr NM, Wang J, Barton K (2017) Minimally invasive glaucoma surgery as primary stand-alone surgery for glaucoma. Clin Exp Ophthalmol 45:393–400. https://doi.org/10.1111/ceo.12888 Samuelson TW, Sarkisian SR Jr., Lubeck DM, Stiles MC, Duh YJ, Romo EA, Giamporcaro JE, Hornbeak DM, Katz LJ, iStent inject Study G (2019) Prospective, Randomized, Controlled Pivotal Trial of an Ab Interno Implanted Trabecular Micro-Bypass in Primary Open-Angle Glaucoma and Cataract: Two-Year Results. Ophthalmology 126:811–821. https://doi.org/10.1016/j.ophtha.2019.03.006 Samuelson TW, Chang DF, Marquis R, Flowers B, Lim KS, Ahmed IIK, Jampel HD, Aung T, Crandall AS, Singh K, Investigators H (2019) A Schlemm Canal Microstent for Intraocular Pressure Reduction in Primary Open-Angle Glaucoma and Cataract: The HORIZON Study. Ophthalmology 126:29–37. https://doi.org/10.1016/j.ophtha.2018.05.012 Hu K, Shah A, Virgili G, Bunce C, Gazzard G (2021) Ab interno trabecular bypass surgery with Trabectome for open-angle glaucoma. Cochrane Database Syst Rev 2:CD011693. https://doi.org/10.1002/14651858.CD011693.pub3 Otarola F, Virgili G, Shah A, Hu K, Bunce C, Gazzard G (2020) Ab interno trabecular bypass surgery with Schlemm s canal microstent (Hydrus) for open angle glaucoma. Cochrane Database Syst Rev 3:CD012740. https://doi.org/10.1002/14651858.CD012740.pub2 Song Y, Fan S, Tang L, Lin F, Li F, Lv A, Li X, Wen T, Lu L, Xiao M, Xie L, Zhu X, Tang G, Zhang H, Yan X, Yuan H, Song W, Yang Y, Xu J, Zhou F, Wang Z, Jin L, Liang X, Zhou M, Zhao X, Chen W, Park KH, Barton K, Aung T, Tham CC, Lam DSC, Weinreb RN, Wang N, Zhang X, Group PVPS (2025) Two-Year Outcomes of Phacogoniotomy vs Phacotrabeculectomy for Advanced Primary Angle-Closure Glaucoma With Cataract: A Noninferiority Randomized Clinical Trial. JAMA Ophthalmol 143:462–469. https://doi.org/10.1001/jamaophthalmol.2025.0685 Grover DS, Godfrey DG, Smith O, Shi W, Feuer WJ, Fellman RL (2017) Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Incisional Glaucoma Surgery. J Glaucoma 26:41–45. https://doi.org/10.1097/IJG.0000000000000564 Wang Y, Zhang W, Xin C, Sang J, Sun Y, Wang H (2023) Gonioscopy-assisted transluminal trabeculotomy for open-angle glaucoma with failed incisional glaucoma surgery: two-year results. BMC Ophthalmol 23:89. https://doi.org/10.1186/s12886-023-02830-7 Lin F, Li L, Xiaokaiti D, Fan S, Zhang Z, Yang Y, Tang G, Zhang H, Li Y, Song Y, Wang Z, Fang Z, Xu J, Zhang X (2026) Two-Year Outcomes of Goniotomy After Failed Surgery for Glaucoma: A Multicenter Study. Ophthalmol Sci 6:100922. https://doi.org/10.1016/j.xops.2025.100922 Siddhartha S, Krishnamurthy R, Dikshit S, Garudadri C, Ali MH, Senthil S (2024) Outcomes of Gonioscopy-Assisted Transluminal Trabeculotomy in Eyes With Prior Failed Glaucoma Surgery. J Glaucoma 33:612–617. https://doi.org/10.1097/IJG.0000000000002414 Bravetti GE, Gillmann K, Salinas L, Berdahl JP, Lazcano-Gomez GS, Williamson BK, Dorairaj SK, Seibold LK, Smith S, Aref AA, Darlington JK, Jimenez-Roman J, Mahootchi A, Mansouri K (2023) Surgical outcomes of excisional goniotomy using the kahook dual blade in severe and refractory glaucoma: 12-month results. Eye (Lond) 37:1608–1613. https://doi.org/10.1038/s41433-022-02196-y Coventon J, Cronin B (2021) The Hydrus Microstent in Pseudophakic Patients With Medically Refractory Open-angle Glaucoma. J Glaucoma 30:192–194. https://doi.org/10.1097/IJG.0000000000001694 Myers JS, Masood I, Hornbeak DM, Belda JI, Auffarth G, Junemann A, Giamporcaro JE, Martinez-de-la-Casa JM, Ahmed IIK, Voskanyan L, Katz LJ (2018) Prospective Evaluation of Two iStent((R)) Trabecular Stents, One iStent Supra((R)) Suprachoroidal Stent, and Postoperative Prostaglandin in Refractory Glaucoma: 4-year Outcomes. Adv Ther 35:395–407. https://doi.org/10.1007/s12325-018-0666-4 Lin F, Nie X, Shi J, Song Y, Lv A, Li X, Lu P, Zhang H, Jin L, Tang G, Fan S, Weinreb RN, Zhang X (2023) Safety and Efficacy of Goniotomy following Failed Surgery for Glaucoma. J Glaucoma 32:942–947. https://doi.org/10.1097/IJG.0000000000002301 Van Swol JM, Walden DN, Van Swol EG, Nguyen SA, Nutaitis MJ, Kassm TM (2023) Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery. J Glaucoma 32:744–749. https://doi.org/10.1097/IJG.0000000000002240 Meyer LM, Graf NE, Philipp S, Fischer MT, Haller K, Distelmaier P, Schonfeld CL (2015) Two-year outcome of repeat trabeculectomy with mitomycin C in primary open-angle and PEX glaucoma. Eur J Ophthalmol 25:185–191. https://doi.org/10.5301/ejo.5000542 Fatehi N, Morales E, Parivisutt N, Alizadeh R, Ang G, Caprioli J (2018) Long-term Outcome of Second Ahmed Valves in Adult Glaucoma. Am J Ophthalmol 186:96–103. https://doi.org/10.1016/j.ajo.2017.11.018 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8561228","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":577087290,"identity":"298e0b8d-2486-476e-b30a-092a7d449645","order_by":0,"name":"Chunxin Lai","email":"","orcid":"","institution":"The People's Hospital of Baiyun District","correspondingAuthor":false,"prefix":"","firstName":"Chunxin","middleName":"","lastName":"Lai","suffix":""},{"id":577087292,"identity":"0bf89ba3-18fd-418d-85bd-d20eafbfc066","order_by":1,"name":"Di Wang","email":"","orcid":"","institution":"Department of Ophthalmology, Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Di","middleName":"","lastName":"Wang","suffix":""},{"id":577087295,"identity":"5ccc8cb1-2007-4880-a7f7-e69af3e44946","order_by":2,"name":"Yuqiao Zhang","email":"","orcid":"","institution":"Department of Ophthalmology, Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuqiao","middleName":"","lastName":"Zhang","suffix":""},{"id":577087298,"identity":"dcdac67e-e29b-4769-b0b3-b0026b48dc02","order_by":3,"name":"Yuhan Feng","email":"","orcid":"","institution":"Department of Ophthalmology, Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuhan","middleName":"","lastName":"Feng","suffix":""},{"id":577087301,"identity":"4e56ac3f-c00d-4562-9012-55cbb3ae4570","order_by":4,"name":"Yuxuan Li","email":"","orcid":"","institution":"Department of Ophthalmology, Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuxuan","middleName":"","lastName":"Li","suffix":""},{"id":577087310,"identity":"25b1a313-c18b-4cac-8500-ca857e153c59","order_by":5,"name":"Linjiang Chen","email":"","orcid":"","institution":"Department of Ophthalmology, Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Linjiang","middleName":"","lastName":"Chen","suffix":""},{"id":577087316,"identity":"354415fb-2756-4726-8a7f-73e271593142","order_by":6,"name":"Minting Chen","email":"","orcid":"","institution":"Department of Ophthalmology, Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Minting","middleName":"","lastName":"Chen","suffix":""},{"id":577087320,"identity":"7d16ae32-8c3c-4ae3-ba42-1526a7c07320","order_by":7,"name":"Yongjie Qin","email":"","orcid":"","institution":"Department of Ophthalmology, Guangdong Eye Institute, Guangdong Provincial People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yongjie","middleName":"","lastName":"Qin","suffix":""},{"id":577087327,"identity":"d3f9ef10-c367-486e-b447-8b3b55ed5e8a","order_by":8,"name":"Hongyang Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIie3QMQrCMBSA4ScFuzypY0qlNxAiBUtB6lUSBLs6OlaEuHgAxXuIY0SwSw9Qt2Z3qLugdXRKRsF8c/6XvABY1g+i4ErJny/03NVKNWYJ8vqROwN/e1lHxCyBaLTPnQndZaKPJklM2DzonbpIfSWAQBoOc02S7Pg16JWIccBFvYBZNJa6h1XtLdglmBz4hhKQ/GiQjNuEIr2dBUHDpF1fMKRVxzQp77xuSon+lrefTE12KTIp2VJOPbdQqlmmoTaBPvuaoDv+4WmHWpZl/b03cfRGJYLxZBoAAAAASUVORK5CYII=","orcid":"","institution":"Department of Ophthalmology, Nanfang Hospital, Southern Medical University","correspondingAuthor":true,"prefix":"","firstName":"Hongyang","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-01-09 12:53:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8561228/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8561228/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108388630,"identity":"7c9c6918-99c4-468a-86fd-7084fe7d870a","added_by":"auto","created_at":"2026-05-04 06:43:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87540,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends of IOP and AGMs changes.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8561228/v1/7c2bc2a84e0f3431f3f0d5e1.png"},{"id":108388631,"identity":"5bd13f25-bc22-44e2-b4d0-84dd05d19f6d","added_by":"auto","created_at":"2026-05-04 06:43:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":63304,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePlots of surgical outcomes for criterion A in 24 months follow-up.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8561228/v1/b775910e41c8dc29d49e3d60.png"},{"id":108493332,"identity":"8dd3d9ad-7cf7-4105-b387-b81f30538260","added_by":"auto","created_at":"2026-05-05 09:59:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":471766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8561228/v1/19d4ea50-971a-4b17-9ae8-f3e034a1dfbe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Goniotomy for adult refractory glaucoma after failed anti-glaucoma surgery: a 24-month prospective observation study","fulltext":[{"header":"Key Message","content":"\u003col\u003e\n \u003cli\u003eEfficacy of Goniotomy in refractory glaucoma remains limited.\u003c/li\u003e\n \u003cli\u003eThe study demonstrates that goniotomy provides significant and sustained reduction in both intraocular pressure (IOP) and medication burden over a 24-month period in eyes with refractory glaucoma following failed incisional surgery.\u003c/li\u003e\n \u003cli\u003eA higher preoperative IOP level was identified as a significant independent risk factor for surgical failure.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Background","content":"\u003cp\u003eGlaucoma is a leading cause of irreversible blindness worldwide, and intraocular pressure (IOP) remains the only modifiable risk factor[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Refractory glaucoma, defined as persistent uncontrolled IOP or disease progression despite maximum tolerated medical therapy and conventional surgery, encompasses not only cases that fail after initial filtration surgery but also conditions where filtration surgery is avoided due to a high predisposition to failure[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSufficiently and Sustainably maintaining IOP for this form of glaucoma whose conditions have already been remodeled by previous interventions and prolonged used of anti-glaucoma medications (AGMs) is a big challenge. Conventional therapeutic options like repeating trabeculectomy and drainage procedures are associated with high risk of failure and complications. A randomized clinical trial reports a 5-year failure rate of 35% for trabeculectomy and 35% for tube shunt surgery, with complication rates of 21% and 37% respectively[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, when the first filtering surgery fails early, the resultant conjunctival remodeling significantly limits the efficacy of a second surgery[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Hence, alternative therapeutic options should be considered to improve the success rate.\u003c/p\u003e \u003cp\u003eSince 1999, minimally invasive glaucoma surgeries (MIGS) have been developed, whose design aims to achieve effective IOP control while prioritizing a high safety profile to mitigate the risks of traditional filtering surgery and enable rapid rehabilitation[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Many types of trabecular MIGS have been confirmed to be effective in managing glaucoma by randomized controlled trials[\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, few studies have evaluated the specific efficacy in refractory glaucoma. In two retrospective studies, gonioscopy-assisted transluminal trabeculotomy (GATT) appeared safe and successful in treating about 60% of open angle glaucoma (OAG) eyes with prior incisional glaucoma surgery at 1 year[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In a prospective multicentered study of 38 eyes following failed surgery, goniotomy (GT) achieved rates of 78.9% for qualified success and 42.1% for complete success at 12 months[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, for eyes with refractory glaucoma, the evidence of the specific efficacy of GT is still limited. Therefore, we investigate the safety and efficacy of GT in refractory glaucoma.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThis was a prospective observational study. All adult patients with refractory glaucoma who underwent GT in Nanfang hospital were recruited. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki and received approval from the Institutional Review Board (IRB) at Nanfang Hospital. All participants provided written informed consent before any surgical procedure was undertaken.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for the patients in this study was: adult patients with prior diagnosed glaucoma, who failed to achieve or maintain target IOP with maximal tolerate medications or incision surgeries, underwent a subsequent GT surgery and completed a minimum of 24 months follow-up. Patients were excluded if they were contraindicated for GT, for those who had active neovascular glaucoma, active uveitis with secondary glaucoma, or were under active treatment for another ophthalmic condition.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical procedures and postoperative care\u003c/h3\u003e\n\u003cp\u003eGT was performed by the same experienced glaucoma surgeon at the inferior quadrant from the superior clear corneal incision under topical anesthesia. A superior 2.2 mm-clear corneal incision was made before the injection of viscoelastic (sodium hyaluronate) into the anterior chamber. For maximal and optimal visualization of the inferonasal angle, the patient\u0026rsquo;s head was rotated 35\u0026ndash;40 degrees away from the surgeon, and the surgical microscope was tilted 30\u0026ndash;40 degrees toward the surgeon. A surgical gonioscopy lens was placed on the cornea to observe the angle and the trabecular meshwork. A microhook (TMH; Tanito Microhook, Inami \u0026amp; Co, Ltd) was inserted into the anterior chamber through the corneal incision. The tip of the microhook was then inserted into the Schlemm\u0026rsquo;s canal and moved to incise the inner wall of Schlemm\u0026rsquo;s canal and trabecular meshwork over 120 degrees. After the viscoelastic was aspirated, the corneal incision was closed by corneal stromal hydration. In the presence of peripheral anterior synechiae, goniosynechialysis (GSL) was performed before the GT. A chopper was used to gently depress the synechiae at the iris root to enable the scleral spur and trabecular meshwork to be clearly observed. When combined with cataract extraction, GT with/without GSL was performed after phacoemulsification and intraocular lens implantation (PEI).\u003c/p\u003e \u003cp\u003ePostoperatively, patients were prescribed topical steroids eye drop (prednisone acetate 1%) and ointment (tobramycin and dexamethasone) for 1 week, followed by non-steroidal anti-inflammatory (NSAID) eye drops for 3 weeks. Ocular hypotensive medications were discontinued, reduced, or continued on a case-by-case basis by the surgeon.\u003c/p\u003e\n\u003ch3\u003eStudy outcomes\u003c/h3\u003e\n\u003cp\u003eBaseline demographic information, including gender, age, best corrected visual acuity (BCVA) documented as Logarithmic Minimum Angle of Resolution (logMAR), IOP (Goldmann applanation tonometry), number of glaucoma medications was collected from all participants. Follow-up data were collected at day 1, week 1 and months 1, 3, 6, 12, 18 and 24. At each visit, data were collected on IOP, the number of AGMs, and postoperative complications (including hyphema, IOP spike, and cornea edema). Hyphema was defined as the appearance of layered blood in the anterior chamber, and an IOP spike was defined as an IOP\u0026thinsp;\u0026ge;\u0026thinsp;30mmHg at any time point during the postoperative period. Surgical success was stratified by three distinct IOP thresholds: Criterion A (6\u0026thinsp;\u0026le;\u0026thinsp;IOP\u0026thinsp;\u0026le;\u0026thinsp;21mmHg), B (6\u0026thinsp;\u0026le;\u0026thinsp;IOP\u0026thinsp;\u0026le;\u0026thinsp;18mmHg), and C (6\u0026thinsp;\u0026le;\u0026thinsp;IOP\u0026thinsp;\u0026le;\u0026thinsp;15mmHg). Complete success was defined by achieving the target IOP with no loss of light perception, additional ocular hypotensive medication or re-operation. Qualified success: similar to that of complete success, except for the need of ocular hypotensive medications. Surgical failure was defined as postoperative IOP\u0026thinsp;\u0026gt;\u0026thinsp;21mmHg at two consecutive follow-up visits or reduced\u0026thinsp;\u0026lt;\u0026thinsp;20% from baseline, IOP\u0026thinsp;\u0026lt;\u0026thinsp;6mmHg, re-operated for glaucoma, required more AGMs than baseline.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using SPSS Sample Power Software (SPSS Inc., Chicago, IL, USA, 27.0). Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables were presented as frequencies (percentage). Generalized Estimating Equations (GEE) was used to analyse tendency of IOP and AGMs during 24 months and Bonferroni for all pairwise comparisons. Univariate logistic regression and multivariate logistic regression were performed to analyze factors affected surgical failure. Statistical significance was defined when a p-value (P) was less than 0.05 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic and Characteristics of the Participants.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included 81 eyes from 72 patients, with a mean age of 59.25\u0026thinsp;\u0026plusmn;\u0026thinsp;14.20 years. About half of the participants were male and had undergone surgery in their right eyes. Night patients contributed both eyes, and no significant intra-patient clustering across any parameter was detected (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). 54 eyes (66.67%) accepted goniotomy with/without goniosynechialysis (GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL) and 27 eyes (33.33%) received combination with phacoemulsification and intraocular lens implantation (PEI\u0026thinsp;+\u0026thinsp;GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL). 35 eyes (43.21%) were diagnosed with primary open-angle glaucoma (POAG) and 32 eyes (39.51%) were primary angle-closure glaucoma (PACG). 8 eyes (9.88%) had secondary open-angle glaucoma (SOAG) and 6 eyes (7.41%) had secondary angle-closure glaucoma (SACG). All the participants had undergone at least one prior anti-glaucoma surgery, with trabeculectomy the most popular (43.21%), followed by PEI (28.40%). BCVA (logMAR) remained stable over 24 months (0.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96 vs. 0.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline Demographics and Characteristics of participants.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDescriptions\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNo.\u0026nbsp;eyes\u0026nbsp;(patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e81(72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge,\u0026nbsp;y\u0026nbsp;(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e59.25\u0026thinsp;\u0026plusmn;\u0026thinsp;14.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMale,\u0026nbsp;N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e48(59.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRight\u0026nbsp;eyes,\u0026nbsp;N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e38(46.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSurgical\u0026nbsp;group,\u0026nbsp;N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e54(66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePEI\u0026thinsp;+\u0026thinsp;GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e27(33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTypes\u0026nbsp;of\u0026nbsp;glaucoma,\u0026nbsp;N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePOAG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e35(43.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePACG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e32(39.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSOAG*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e8(9.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSACG**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e6(7.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eStage\u0026nbsp;of\u0026nbsp;glaucoma,\u0026nbsp;N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e16(19.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e8(9.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e57(70.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNo.\u0026nbsp;prior\u0026nbsp;anti-glaucoma\u0026nbsp;surgeries,\u0026nbsp;N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOne\u0026nbsp;prior\u0026nbsp;surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e66(81.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTwo\u0026nbsp;prior\u0026nbsp;surgeries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11(13.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMore\u0026nbsp;than\u0026nbsp;two\u0026nbsp;prior\u0026nbsp;surgeries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e4(4.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eEyes\u0026nbsp;with\u0026nbsp;prior\u0026nbsp;surgery,\u0026nbsp;N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTrabeculectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e35(43.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePeripheral\u0026nbsp;iridectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e10(12.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePEI\u0026nbsp;combined\u0026nbsp;Ex-PRESS\u0026nbsp;implant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e7(8.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAhmed\u0026nbsp;valve\u0026nbsp;implant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e6(7.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFiltering\u0026nbsp;blebs\u0026nbsp;revision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5(6.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGoniotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5(6.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePEI\u0026nbsp;combined\u0026nbsp;Trabeculectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e4(4.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eEx-PRESS\u0026nbsp;implant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2(2.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSelective\u0026nbsp;laser\u0026nbsp;trabeculectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1(1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eGT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL: goniotomy combined with/without goniosynechialysis. PEI\u0026thinsp;+\u0026thinsp;GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL: phacoemulsification and intraocular lens implantation (PEI) combined with GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL. POAG: primary open angle glaucoma. PACG: primary angle closure glaucoma. SOAG: secondary open angle glaucoma. SACG: secondary angle closure glaucoma. * SOAG in this study included one case of steroid-induced glaucoma, one case of nonactive neovascular glaucoma, two cases of pigmentary glaucoma, two cases secondary to ocular trauma, and two cases secondary to Fuchs\u0026apos; heterochromic iridocyclitis. ** SACG included one case secondary to pars plana vitrectomy (PPV) and silicone oil implantation, one case following vitreous prolapse after posterior segment surgery, one case secondary to ocular trauma, one case of congenital microphthalmia, and two cases secondary to Fuchs\u0026apos; heterochromic iridocyclitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChange of IOP, AGMs in 24 months.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in table 2, the mean IOP and AGMs significantly decreased at each time point (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with IOP reduction of 7.57mmHg (32.53%) and AGMs reduction of 1.30 (46.59%) at 24 months. IOP on Day 7 was significant higher than that on Month 3 (17.30\u0026thinsp;\u0026plusmn;\u0026thinsp;8.11mmHg vs. 14.77\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43mmHg, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032). AGMs significantly increased between each two follow-up time points (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Trends of IOP and AGMs during follow-ups.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDay\u0026nbsp;1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDay\u0026nbsp;7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003eIOP/mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e23.27\u0026plusmn;5.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e15.09\u0026plusmn;6.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e17.30\u0026plusmn;8.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e15.62\u0026plusmn;3.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e14.77\u0026plusmn;3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e15.15\u0026plusmn;2.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e15.88\u0026plusmn;4.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e15.71\u0026plusmn;2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e15.70\u0026plusmn;2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003eReduced\u0026nbsp;IOP/mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e8.18\u0026plusmn;12.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e5.97\u0026plusmn;12.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e7.65\u0026plusmn;11.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e8.49\u0026plusmn;10.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e8.12\u0026plusmn;11.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e7.39\u0026plusmn;11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e7.55\u0026plusmn;11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e7.57\u0026plusmn;11.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003eReduced\u0026nbsp;percentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e35.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e25.66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e32.87%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e36.48%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e34.89%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e31.76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e32.45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e32.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cem\u003ePa\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003eAGM/number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e2.79\u0026plusmn;1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.17\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.23\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.59\u0026plusmn;1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.85\u0026plusmn;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.02\u0026plusmn;1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e1.22\u0026plusmn;1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e1.43\u0026plusmn;1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e1.43\u0026plusmn;1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003eReduced\u0026nbsp;AGM/number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2.62\u0026plusmn;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2.56\u0026plusmn;1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e2.20\u0026plusmn;1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.94\u0026plusmn;1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.77\u0026plusmn;1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e1.57\u0026plusmn;1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e1.36\u0026plusmn;1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e1.30\u0026plusmn;1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003eReduced\u0026nbsp;percentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e93.91%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e91.76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e78.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e69.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e63.44%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e56.27%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e48.75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e46.59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cem\u003ePb\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIOP: intraocular pressure; AGMs: anti-glaucoma medications. \u003csup\u003ea\u003c/sup\u003e IOP of postoperative versus preoperative, Generalized Estimating Equations (GEE), Bonferroni for all pairwise comparisons. \u003csup\u003eb\u003c/sup\u003e AGMs of postoperative versus preoperative, Generalized Estimating Equations (GEE), Bonferroni for all pairwise comparisons.\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. * Postoperative IOP did not differ significantly across time points, except at D7 compared to M3 (P\u0026thinsp;=\u0026thinsp;0.032, Bonferroni correction). ** Pairwise comparisons revealed statistically significant differences in the number of AGMs between all follow-up time points (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Bonferroni correction). Both IOP and AGMs of each postoperative time point were significant different from the preopeartive one. IOP: intraocular pressure; AGMs: anti-glaucoma drugs; Pre: Preoperative; D1: postoperative 1 day ; D7: postoperative 7 day; M1: postoperative 1 month; M3: postoperative 3 month; M6: postoperative 6 month; M12: postoperative 12 month; M18: postoperative 18month; M24: postoperative 24 month.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical success rate and risk factors for failure.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgical success rates of three criteria was shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Tendency of criterion A and failure rate were shown in Fig. \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The increased qualified success rate was correspondent with increased used of AGMs in order to achieve more lower IOP for advanced cases. Complete success rate gradually declined over time. The first failure case occurred 3 months after surgery, and increased to 3 eyes (3.70%) on Month 6, 12 eyes (12.14%) on Month 12,14 eyes (17.28%) on Month 18, and 15 eyes (18.52%) on Month 24. Logistic regression analysis of risk factors for surgical failure was performed, which revealed that preoperative IOP was significantly associated with surgical failure (OR, 1.05; 95%Cl, 1.01\u0026ndash;1.10; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.040 in Univariate Logistic Regression Analysis; OR, 1.07; 95%Cl, 1.01\u0026ndash;1.13; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014 in Multivariate Logistic Regression Analysis). However, age, sex, glaucoma type (OAG vs ACG), number of prior surgeries, and preoperative AGMs number were not significantly associated with surgical failure (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Criterion A: Complete success was defined as a postoperative IOP\u0026thinsp;\u0026le;\u0026thinsp;21mmHg without the need for additional AGMs. Qualified success was similar to that of complete success, except for the need of AGMs. Surgical failure was defined as postoperative IOP\u0026thinsp;\u0026gt;\u0026thinsp;21mmHg at two consecutive follow-up visits or reduced\u0026thinsp;\u0026lt;\u0026thinsp;20% from baseline, IOP\u0026thinsp;\u0026lt;\u0026thinsp;6mmHg, re-operated for glaucoma, required more AGMs than baseline. Data were shown as number (percentage).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Success rates of three criteria during follow-up.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"741\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;N\u0026nbsp;=\u0026nbsp;81\u0026nbsp;eyes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDay\u0026nbsp;1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDay\u0026nbsp;7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u0026nbsp;24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 98px;\"\u003e\n \u003cp\u003eCriterion\u0026nbsp;A\u0026nbsp;(6\u0026nbsp;\u0026le;\u0026nbsp;IOP\u0026nbsp;\u0026le;21\u0026nbsp;mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eComplete\u0026nbsp;Success\u0026nbsp;rate\u0026nbsp;(N[%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e67(82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e62(76.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e58(71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e48(59.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e40(49.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e34(42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e28(34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e27(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eQualified\u0026nbsp;Success\u0026nbsp;rate\u0026nbsp;(N[%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e70(86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e69(85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e75(92.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e80(98.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e78(96.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e69(85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e67(82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e66(81.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 98px;\"\u003e\n \u003cp\u003eCriterion\u0026nbsp;B\u0026nbsp;(6\u0026nbsp;\u0026le;\u0026nbsp;IOP\u0026nbsp;\u0026le;18\u0026nbsp;mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eComplete\u0026nbsp;Success\u0026nbsp;rate\u0026nbsp;(N[%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e57(70.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e51(63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e55(67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e45(55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e38(46.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e33(40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e27(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e27(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eQualified\u0026nbsp;Success\u0026nbsp;rate\u0026nbsp;(N[%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e59(72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e57(70.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e69(85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e73(90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e67(82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e60(74.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e64(79.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e65(80.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 98px;\"\u003e\n \u003cp\u003eCriterion\u0026nbsp;C\u0026nbsp;(6\u0026nbsp;\u0026le;\u0026nbsp;IOP\u0026nbsp;\u0026le;15\u0026nbsp;mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eComplete\u0026nbsp;Success\u0026nbsp;rate\u0026nbsp;(N[%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e50(61.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e36(44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e30(37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e30(37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e30(37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e24(29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e19(23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e16(19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eQualified\u0026nbsp;Success\u0026nbsp;rate\u0026nbsp;(N[%])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e52(64.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e41(50.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e38(46.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e50(61.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e44(54.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e42(51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e39(48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e40(49.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eComplete success was defined by achieving the target IOP with no loss of light perception, additional ocular hypotensive medication or re-operation. Qualified success: similar to that of complete success, except for the need of ocular hypotensive medications.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLogistic Regression Analysis of risk factors for surgical failure at Month 24.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\" style=\"width: 31.5725%;\"\u003e\n \u003cp\u003eUnivariate\u0026nbsp;Logistic\u0026nbsp;Regression\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\" style=\"width: 0.9828%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\" style=\"width: 31.4883%;\"\u003e\n \u003cp\u003eMultivariate\u0026nbsp;Logistic\u0026nbsp;Regression\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eOdds\u0026nbsp;ratio\u0026nbsp;(95%\u0026nbsp;CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eOdds\u0026nbsp;ratio\u0026nbsp;(95%\u0026nbsp;CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge,\u0026nbsp;per\u0026nbsp;1\u0026nbsp;year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.99\u0026nbsp;(0.95\u0026nbsp;~\u0026nbsp;1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSex,\u0026nbsp;male\u0026nbsp;vs.\u0026nbsp;female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.96\u0026nbsp;(0.31\u0026nbsp;~\u0026nbsp;3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e0.948\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGlaucoma\u0026nbsp;type,\u0026nbsp;OAG\u0026nbsp;vs.\u0026nbsp;ACG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.99\u0026nbsp;(0.32\u0026nbsp;~\u0026nbsp;3.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNumber\u0026nbsp;of\u0026nbsp;prior\u0026nbsp;surgeries,\u0026nbsp;single\u0026nbsp;vs.\u0026nbsp;mutiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.63\u0026nbsp;(0.13\u0026nbsp;~\u0026nbsp;3.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e0.570\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eComplicated\u0026nbsp;vs.\u0026nbsp;not\u0026nbsp;Complicated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1.69\u0026nbsp;(0.54\u0026nbsp;~\u0026nbsp;5.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e0.365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e1.50\u0026nbsp;(0.44\u0026nbsp;~\u0026nbsp;5.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.514\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePreoperative\u0026nbsp;IOP,\u0026nbsp;per\u0026nbsp;1\u0026nbsp;mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1.05\u0026nbsp;(1.01\u0026nbsp;~\u0026nbsp;1.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.040*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e1.07\u0026nbsp;(1.01\u0026nbsp;~\u0026nbsp;1.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePreoperative\u0026nbsp;ATG,\u0026nbsp;number\u0026nbsp;one\u0026nbsp;vs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e1.00\u0026nbsp;(Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e1.00\u0026nbsp;(Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003etwo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2.67 (0.26\u0026nbsp;~\u0026nbsp;27.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e0.410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\" style=\"width: 1.1056%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e1.68\u0026nbsp;(0.15\u0026nbsp;~\u0026nbsp;19.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.677\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e* statistically significant different. Surgical failure was defined as postoperative IOP\u0026thinsp;\u0026gt;\u0026thinsp;21mmHg at two consecutive follow-up visits or reduced\u0026thinsp;\u0026lt;\u0026thinsp;20% from baseline, IOP\u0026thinsp;\u0026lt;\u0026thinsp;6mmHg, re-operated for glaucoma, required more AGMs than baseline. OAG: open angle glaucoma, including POAG and SOAG; ACG: angle closure glaucoma, including PACG and SACG; IOP: intraocular pressure; AGMs: anti-glaucoma medications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative complications.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most common postoperative complication was hyphema. Hyphema was observed in 18 eyes (22.22%), among which 16 eyes (88.89%) were resolved spontaneously within 1 week, while 2 of them required anterior chamber paracentesis and washing. The second most common complication was IOP spikes (8 eyes, 9.88%). 5 eyes (6.17%) developed corneal edema after PEI\u0026thinsp;+\u0026thinsp;GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL, and 1 eyes (1.23%) complicated with Descement membrane detachment which was reposition with anterior chamber air injection. 2 eyes (2.47%) failed to control IOP with maximal AGMs use and underwent Ahmed valve implantation after 3 months and 12 months respectively. 1 eyes (1.23%) developed malignant glaucoma at month 24 and underwent phacoemulsificaiton combined with irido-zonulo-hyaloido-vitrectomy.\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eThis prospective observational study demonstrates that GT significantly reduces IOP and AGMs use in adults with refractory glaucoma over a-24 month period. Postoperative IOP decreased significantly at all time points (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with a mean reduction of 32.53% at 24 months (preoperative 23.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12 vs. 15.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78mmHg). Similarly, AGMs use decreased significantly after GT (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with a 46.6% reduction at 24 months compared to baseline (2.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02 vs. 1.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37). These findings support the consideration of GT as an alternative before a second trabeculectomy or tube implantation in patients with prior surgical failure.\u003c/p\u003e \u003cp\u003eThe magnitude of IOP and AGMs reduction observed in our cohort is consistent with prior studies of ab interno trabeculotomy in adult refractory glaucoma[\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For instance, a multicentered prospective study in 61 primary glaucoma eyes following failed incision surgery reported similar outcomes at 24 months (16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8mmHg with 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 medications)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a multicenter series of refractory OAG eyes, Kahook Dual Blade (KDB) goniotomy reduced IOP from 18.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0mmHg to 14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7mmHg and medications from 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 to 1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 at 12 months[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Gonioscopy-assisted transluminal trabeculotomy (GATT) has been reported to lower IOP from 27.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 mmHg to 15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 mmHg at 24 months, accompanied by significant reductions in AGMs use[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. For patients with prior failed trabeculectomy, traditional filtration surgery such as repeat trabeculectomy or Ahmed valve implantation achieved comparable outcomes to our study. Van Swol et al. reported that repeat trabeculectomy maintained an IOP of 15.3mmHg with 1.2 medications, while an Ahmed valve implantation achieved the same IOP with 2.4 medications in 24 months[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Other studies showed that repeat trabeculectomy for refractory POAG and pseudoexfoliation glaucoma resulted in a lower final IOP level of 12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3mmHg with few AGMs of 0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7, whereas a second Ahmed Valves implantation achieved 14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5mmHg with 1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 AGMs, which was consistent with our findings[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It is important to note that our study cohort included 15 eyes (18.52%) of eyes with multiple (\u0026ge;\u0026thinsp;2) prior failed anti-glaucoma surgeries, whereas the aforementioned studies of filtration surgeries primarily enrolled eyes with only one prior surgical failure.\u003c/p\u003e \u003cp\u003eA slight increase in IOP was observed at postoperative day 7 (17.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1mmHg), coinciding with the period of topical steroids eye drop use, and likely reflecting steroid-induced IOP elevation. Following the transition to non-steriod anti-inflammatory therapy, IOP decreased significantly by 3 months (14.77\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43mmHg vs. 17.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1mmHg, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032). Subgroup analysis showed comparable 24-month IOP outcomes between the GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL-only group and the combined PEI\u0026thinsp;+\u0026thinsp;GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL group (15.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.73mmHg vs. 15.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.81mmHg, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), despite a slightly greater reduction in the GT\u0026thinsp;\u0026plusmn;\u0026thinsp;GSL-only group, which may reflect its higher baseline IOP.\u003c/p\u003e \u003cp\u003eOur study demonstrated that the complete success rates were 33.3% (Criterion A/B) and 19.8% (Criterion C), whereas qualified success rates were 81.5%, 80.2%, and 49.4% respectively. Compared with multicenter studies, our complete success rates were slightly lower, potentially due to the lower baseline IOP in our cohort[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Compared to repeat trabeculectomy, GT demonstrated lower complete success but higher qualified success, indicating that additional AGMs were required to achieve comparable pressure control[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Overall, 15 eyes (18.5%) met criteria for surgical failure at 24 months, among whom 2 eyes (2.47%) failed to control IOP with maximal AGMs use and underwent Ahmed valve implantation after 3 months and 12 months respectively, and 1 eyes (1.23%) developed malignant glaucoma at month 24 and underwent phacoemulsificaiton combined with irido-zonulo-hyaloido-vitrectomy. Logistic regression identified higher preoperative IOP as the only independent risk factor for surgical failure (OR, 1.07; 95% CI, 1.01\u0026ndash;1.13; P\u0026thinsp;=\u0026thinsp;0.014), whereas age, sex, glaucoma type, prior surgeries, and preoperative AGMs number were not significant predictors. This finding underscores the importance of baseline disease severity in determining GT outcomes.\u003c/p\u003e \u003cp\u003ePostoperative complications were consistent with previous reports of ab interno trabeculotomy and were lower than those typically reported for traditional filtration surgeries[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Hyphema, was the the most common complication (18 eyes, 22.22%), resolving spontaneously 88.9% of cases within 1 week. IOP spikes ,defined as an IOP\u0026thinsp;\u0026ge;\u0026thinsp;30mmHg at early stage of postoperative period, occurred in 8 eyes (9.9%) and were generally manageable with short-term additional medication. No vision-threatening complications were observed over 24 months follow-up period.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The sample size was relatively small, and the observational design limits generalizability. Additionally, there was no comparative control group, preventing direct assessment of GT relative to other surgical options. Future research should include larger, multicenter cohorts with comparative designs to evaluate the relative efficacy and safety of GT. Longer-term follow-up studies are also needed to assess the durability of GT outcomes and to explore additional patient-specific factors that may influence long-term success.\u003c/p\u003e \u003cp\u003eIn conclusion, GT is an effective and safe procedure for reducing IOP and decreasing AGMs dependence in adult refractory glaucoma over 24 months. Although complete success rates decline over time, the favorable safety profile and substantial reduction in IOP and medications support its use as a viable treatment alternative to repeat trabeculectomy or tube implantation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatements and Declarations: Competing Interests:\u0026nbsp;\u003c/strong\u003eno conflicting relationship exists for any author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThis work was supported by the National Natural Science Foundation of China [grant number 82171036, HYZ]; the Natural Science Foundation of Guangdong Province, China [grant number 2023A1515011735, HYZ] and the Science and Technology Project in Baiyun District, Guangzhou [grant numbers 2025-YL-005, CXL].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. It was approved by Ethics Committee of Nanfang Hospital (NFEC-2024-291).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eAll the written informed consent were obtained from the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eAll authors met the criteria for authorship. Hongyang Zhang conceptualized and designed the study. Chunxin Lai enrolled the participants, processed the data, performed analysis, and drafted the manuscript. Di wang and Yuqiao Zhang processed the data, performed analysis and interpreted the results. Yuhan Feng and Yuxuan Li were responsible for enrolling the participants, collecting preoperative and postoperative data. Linjiang Chen and Minting Chen performed the statistical analysis. Yongjie Qin coordinated the study and revised the initial manuscript draft. Hongyang Zhang performed all surgeries, and reviewed and edited the final manuscript. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY (2014) Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology 121:2081\u0026ndash;2090. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ophtha.2014.05.013\u003c/span\u003e\u003cspan address=\"10.1016/j.ophtha.2014.05.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinreb RN, Aung T, Medeiros FA (2014) The pathophysiology and treatment of glaucoma: a review. JAMA 311:1901\u0026ndash;1911. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.2014.3192\u003c/span\u003e\u003cspan address=\"10.1001/jama.2014.3192\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeintz V, Bastelica P, Baudouin C, Lachkar Y, Labbe A (2025) Management of Refractory Glaucoma, a New Surgical Paradigm: Review of the Literature. Curr Eye Res 50:771\u0026ndash;784. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/02713683.2025.2494799\u003c/span\u003e\u003cspan address=\"10.1080/02713683.2025.2494799\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGedde SJ, Feuer WJ, Lim KS, Barton K, Goyal S, Ahmed II, Brandt JD, Primary Tube Versus Trabeculectomy Study G (2022) Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 5 Years of Follow-up. Ophthalmology 129:1344\u0026ndash;1356. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ophtha.2022.07.003\u003c/span\u003e\u003cspan address=\"10.1016/j.ophtha.2022.07.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC, Tube Versus Trabeculectomy Study G (2012) Postoperative complications in the Tube Versus Trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol 153:804\u0026ndash;814e801. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajo.2011.10.024\u003c/span\u003e\u003cspan address=\"10.1016/j.ajo.2011.10.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIssa de Fendi L, Cena de Oliveira T, Bigheti Pereira C, Pereira Bigheti C, Viani GA (2016) Additive Effect of Risk Factors for Trabeculectomy Failure in Glaucoma Patients: A Risk-group From a Cohort Study. J Glaucoma 25:e879\u0026ndash;e883. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IJG.0000000000000490\u003c/span\u003e\u003cspan address=\"10.1097/IJG.0000000000000490\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBroadway DC, Grierson I, Hitchings RA (1998) Local effects of previous conjunctival incisional surgery and the subsequent outcome of filtration surgery. Am J Ophthalmol 125:805\u0026ndash;818. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0002-9394(98)00045-2\u003c/span\u003e\u003cspan address=\"10.1016/s0002-9394(98)00045-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaheb H, Ahmed II (2012) Micro-invasive glaucoma surgery: current perspectives and future directions. Curr Opin Ophthalmol 23:96\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/ICU.0b013e32834ff1e7\u003c/span\u003e\u003cspan address=\"10.1097/ICU.0b013e32834ff1e7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKerr NM, Wang J, Barton K (2017) Minimally invasive glaucoma surgery as primary stand-alone surgery for glaucoma. Clin Exp Ophthalmol 45:393\u0026ndash;400. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ceo.12888\u003c/span\u003e\u003cspan address=\"10.1111/ceo.12888\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamuelson TW, Sarkisian SR Jr., Lubeck DM, Stiles MC, Duh YJ, Romo EA, Giamporcaro JE, Hornbeak DM, Katz LJ, iStent inject Study G (2019) Prospective, Randomized, Controlled Pivotal Trial of an Ab Interno Implanted Trabecular Micro-Bypass in Primary Open-Angle Glaucoma and Cataract: Two-Year Results. Ophthalmology 126:811\u0026ndash;821. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ophtha.2019.03.006\u003c/span\u003e\u003cspan address=\"10.1016/j.ophtha.2019.03.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamuelson TW, Chang DF, Marquis R, Flowers B, Lim KS, Ahmed IIK, Jampel HD, Aung T, Crandall AS, Singh K, Investigators H (2019) A Schlemm Canal Microstent for Intraocular Pressure Reduction in Primary Open-Angle Glaucoma and Cataract: The HORIZON Study. Ophthalmology 126:29\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ophtha.2018.05.012\u003c/span\u003e\u003cspan address=\"10.1016/j.ophtha.2018.05.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu K, Shah A, Virgili G, Bunce C, Gazzard G (2021) Ab interno trabecular bypass surgery with Trabectome for open-angle glaucoma. Cochrane Database Syst Rev 2:CD011693. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD011693.pub3\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD011693.pub3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOtarola F, Virgili G, Shah A, Hu K, Bunce C, Gazzard G (2020) Ab interno trabecular bypass surgery with Schlemm s canal microstent (Hydrus) for open angle glaucoma. Cochrane Database Syst Rev 3:CD012740. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD012740.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD012740.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong Y, Fan S, Tang L, Lin F, Li F, Lv A, Li X, Wen T, Lu L, Xiao M, Xie L, Zhu X, Tang G, Zhang H, Yan X, Yuan H, Song W, Yang Y, Xu J, Zhou F, Wang Z, Jin L, Liang X, Zhou M, Zhao X, Chen W, Park KH, Barton K, Aung T, Tham CC, Lam DSC, Weinreb RN, Wang N, Zhang X, Group PVPS (2025) Two-Year Outcomes of Phacogoniotomy vs Phacotrabeculectomy for Advanced Primary Angle-Closure Glaucoma With Cataract: A Noninferiority Randomized Clinical Trial. JAMA Ophthalmol 143:462\u0026ndash;469. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamaophthalmol.2025.0685\u003c/span\u003e\u003cspan address=\"10.1001/jamaophthalmol.2025.0685\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrover DS, Godfrey DG, Smith O, Shi W, Feuer WJ, Fellman RL (2017) Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Incisional Glaucoma Surgery. J Glaucoma 26:41\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IJG.0000000000000564\u003c/span\u003e\u003cspan address=\"10.1097/IJG.0000000000000564\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Zhang W, Xin C, Sang J, Sun Y, Wang H (2023) Gonioscopy-assisted transluminal trabeculotomy for open-angle glaucoma with failed incisional glaucoma surgery: two-year results. BMC Ophthalmol 23:89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12886-023-02830-7\u003c/span\u003e\u003cspan address=\"10.1186/s12886-023-02830-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin F, Li L, Xiaokaiti D, Fan S, Zhang Z, Yang Y, Tang G, Zhang H, Li Y, Song Y, Wang Z, Fang Z, Xu J, Zhang X (2026) Two-Year Outcomes of Goniotomy After Failed Surgery for Glaucoma: A Multicenter Study. Ophthalmol Sci 6:100922. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.xops.2025.100922\u003c/span\u003e\u003cspan address=\"10.1016/j.xops.2025.100922\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiddhartha S, Krishnamurthy R, Dikshit S, Garudadri C, Ali MH, Senthil S (2024) Outcomes of Gonioscopy-Assisted Transluminal Trabeculotomy in Eyes With Prior Failed Glaucoma Surgery. J Glaucoma 33:612\u0026ndash;617. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IJG.0000000000002414\u003c/span\u003e\u003cspan address=\"10.1097/IJG.0000000000002414\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBravetti GE, Gillmann K, Salinas L, Berdahl JP, Lazcano-Gomez GS, Williamson BK, Dorairaj SK, Seibold LK, Smith S, Aref AA, Darlington JK, Jimenez-Roman J, Mahootchi A, Mansouri K (2023) Surgical outcomes of excisional goniotomy using the kahook dual blade in severe and refractory glaucoma: 12-month results. Eye (Lond) 37:1608\u0026ndash;1613. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41433-022-02196-y\u003c/span\u003e\u003cspan address=\"10.1038/s41433-022-02196-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoventon J, Cronin B (2021) The Hydrus Microstent in Pseudophakic Patients With Medically Refractory Open-angle Glaucoma. J Glaucoma 30:192\u0026ndash;194. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IJG.0000000000001694\u003c/span\u003e\u003cspan address=\"10.1097/IJG.0000000000001694\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyers JS, Masood I, Hornbeak DM, Belda JI, Auffarth G, Junemann A, Giamporcaro JE, Martinez-de-la-Casa JM, Ahmed IIK, Voskanyan L, Katz LJ (2018) Prospective Evaluation of Two iStent((R)) Trabecular Stents, One iStent Supra((R)) Suprachoroidal Stent, and Postoperative Prostaglandin in Refractory Glaucoma: 4-year Outcomes. Adv Ther 35:395\u0026ndash;407. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12325-018-0666-4\u003c/span\u003e\u003cspan address=\"10.1007/s12325-018-0666-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin F, Nie X, Shi J, Song Y, Lv A, Li X, Lu P, Zhang H, Jin L, Tang G, Fan S, Weinreb RN, Zhang X (2023) Safety and Efficacy of Goniotomy following Failed Surgery for Glaucoma. J Glaucoma 32:942\u0026ndash;947. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IJG.0000000000002301\u003c/span\u003e\u003cspan address=\"10.1097/IJG.0000000000002301\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Swol JM, Walden DN, Van Swol EG, Nguyen SA, Nutaitis MJ, Kassm TM (2023) Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery. J Glaucoma 32:744\u0026ndash;749. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IJG.0000000000002240\u003c/span\u003e\u003cspan address=\"10.1097/IJG.0000000000002240\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer LM, Graf NE, Philipp S, Fischer MT, Haller K, Distelmaier P, Schonfeld CL (2015) Two-year outcome of repeat trabeculectomy with mitomycin C in primary open-angle and PEX glaucoma. Eur J Ophthalmol 25:185\u0026ndash;191. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5301/ejo.5000542\u003c/span\u003e\u003cspan address=\"10.5301/ejo.5000542\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFatehi N, Morales E, Parivisutt N, Alizadeh R, Ang G, Caprioli J (2018) Long-term Outcome of Second Ahmed Valves in Adult Glaucoma. Am J Ophthalmol 186:96\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajo.2017.11.018\u003c/span\u003e\u003cspan address=\"10.1016/j.ajo.2017.11.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"goniotomy, refractory glaucoma, minimally invasive glaucoma surgery","lastPublishedDoi":"10.21203/rs.3.rs-8561228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8561228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo evaluate the 24-month efficacy and safety of goniotomy for adult refractory glaucoma after failed incisional surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eA prospective study was conducted involving patients with refractory glaucoma who underwent goniotomy. Study outcomes included changes in IOP, the number of anti-glaucoma medications (AGMs) , and postoperative complications over an 24-month period. Logistic regression analysis was performed to identify potential risk factors for surgical failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 81 eyes from 72 patients were included. All participants had undergone at least one prior incision surgery. Following goniotomy, mean IOP significantly decreased from 23.27±5.12mmHg preoperatively to 15.70±2.78mmHg at 24 months (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), accompanied by a reduction in AGMs use from 2.79±1.02 to 1.43±1.37 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Fifteen eyes (18.52%) were classified as surgical failures, and three patients required reoperations. Higher preoperative IOP was identified as a risk factor for surgical failure (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). Postoperative complications included hyphema in 18 eyes (22.22%) and transient IOP spike in 8 eyes (9.88%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eGoniotomy effectively reduced IOP and the need for AGMs in refractory glaucoma after failed surgery over 24 months, suggesting it may serve as a safe and viable therapeutic option in this challenging population.\u003c/p\u003e","manuscriptTitle":"Goniotomy for adult refractory glaucoma after failed anti-glaucoma surgery: a 24-month prospective observation study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 06:43:08","doi":"10.21203/rs.3.rs-8561228/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d6d71cb5-9f12-4689-b412-d2757f3d1b7a","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T06:43:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 06:43:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8561228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8561228","identity":"rs-8561228","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}