Incidence of Descemet Membrane Detachment post Gonioscopy-Assisted Transluminal Trabeculotomy in patients with Open Angle Glaucoma

Incidence of Descemet Membrane Detachment post Gonioscopy-Assisted Transluminal Trabeculotomy in patients with Open Angle Glaucoma | 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 Incidence of Descemet Membrane Detachment post Gonioscopy-Assisted Transluminal Trabeculotomy in patients with Open Angle Glaucoma Marwa Elsayed Soliman, Ahmed Mohamed Sherif, Mohamed Ahmed Attya, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8090124/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 Background To determine the incidence of Descemet membrane detachment (DMD) following gonioscopy-assisted transluminal trabeculotomy (GATT) using anterior segment optical coherence tomography (AS-OCT) in patients with open-angle glaucoma. Methods This prospective clinical study included 30 eyes treated with GATT between June 2022 and January 2023. All patients were examined with spectral-domain AS-OCT (Optovue RTVue; Optovue Inc., Fremont, CA, USA) on the first postoperative day to assess for DMD. In cases where DMD was detected, AS-OCT imaging was repeated after one week to evaluate for spontaneous resolution. Results DMD occurred in 1 of the 30 eyes (3.3%), indicating a low incidence following GATT. Significant reductions were observed between pre- and postoperative intraocular pressure (IOP) and the number of glaucoma medications. Postoperative hyphema occurred in 20% of cases and resolved spontaneously within one week. Complete surgical success was achieved in 60% of eyes, while qualified success was noted in 30%, and 10% were classified as failures. IOP spikes were recorded in 3 eyes (10%). Conclusion The incidence of Descemet membrane detachment following GATT was low, supporting the procedure as a safe surgical option for patients with open-angle glaucoma. Trial Registration The study was approved by the Ethics Committee of Kasr AlAiny Medical School, Cairo University, and registered at ClinicalTrials.gov (NCT05932940) on 7th of May 2023 GATT Descemet membrane detachment open-angle glaucoma Figures Figure 1 Background Glaucoma is the leading cause of irreversible blindness worldwide.( 1 ) The most important risk factor for the development and progression of glaucoma is the elevated intraocular pressure. ( 2 ) The only treatment that can slow the progression of glaucoma is the reduction of IOP, either medically or surgically. ( 3 ) The inner wall of Schlemm’s canal and the juxtacanalicular trabecular meshwork are the primary sites of abnormal flow resistance in open angle glaucoma. ( 4 ) Among all, filtration surgery such as the trabeculectomy is the most successful approach to lower the IOP in different subtypes of primary and secondary glaucoma but it is associated with a significant complications including overfiltration, suprachoroidal hemorrhage, persistent hypotony, wipe out phenomenon, and bleb leak or failure. ( 5 ) The most recent approach to enhance the conventional outflow pathway is through addressing TM and Schlemm’s canal internally. ( 6 ) GATT was found to be an effective and safe intervention for open angle glaucoma, the advantages of GATT compared to filtration surgery are the low rate of long-term complications and that the intervention is feasible even when conjunctival scarring is encountered. ( 7 ) Gonioscopy-assisted transluminal trabeculotomy (GATT) procedure is a MIGS technique in which TM is circumferentially bypassed via suture or catheter. In this technique, aqueous humor passes through the collector canals and the episcleral veins through the cleaved open diseased TM. ( 7 ) It was first introduced by Grover et al. in 2014 ( 8 ) It has been shown to effectively lower IOP and NGMs (number of glaucoma medications) in primary, juvenile, and secondary open-angle glaucomas. ( 8 , 9 & 10 ). The most common complication post GATT surgery is transient hyphema, seen in 30% of patients at the 1-week visit. ( 7 ) Other reported complications such as persistent cornea oedema, Descemet membrane detachment, iridodialysis or cystoid macular oedema.( 7 – 8 ) As this ab interno angle surgery is still novel, the goal of this study to assess its efficacy and safety and to detect the incidence of Descemet membrane detachment following gonioscopy-assisted transluminal trabeculotomy (GATT) by anterior segment optical coherence tomography in patients with open angle glaucoma. Methods Study design This was a prospective clinical study received approval from the ethics committee of Kasr Alainy medical school (Cairo University), and was registered at clinical trial.gov under the title of (incidence of descemet membrane detachment post GATT by AS OCT) with an ID NCT05932940). All procedures fulfilled declaration of Helsinki. Written informed consent was obtained from each subject at the time of the intervention. Patients: The study was conducted on 30 eyes with open angle glaucoma either primary or secondary aged 18–70 years. Aphakic patients, patients with neovascular glaucoma and patients with silicone induced glaucoma were excluded. Also patients undergoing combined phacoemulsification and GATT were excluded. Preoperative assessment: All selected patients received a thorough explanation of the study design, aims, and signed an informed consent. Pre-operative evaluation of all participants included: Best corrected visual acuity (BCVA) using decimal scale, slit lamp examination of the anterior segment, gonioscopy using Goldmann lens, intraocular pressure measurement using Goldman applanation tonometry and dilated fundus examination using slit- lamp bio microscopy using + 90 D Volk Condensing lens. Visual field testing was also performed whenever the vision permitted. Preoperative anterior segment OCT using SD-OCT: Optovue RTVue (Optovue Inc., Fremont, CA, USA) to exclude presence of Descemet membrane detachment for the cases that underwent previous anterior segment surgeries. Gonioscopy assisted transluminal trabeculotomy surgical steps: Surgery was conducted in all patients by the same surgeon (FA), with the following steps: Local Anesthesia or anterior subtenon anesthesia in advanced cases. After draping of the eye, the operating microscope is tilted 45 degrees. The surgeon sits on temporal side of the patient and elevate the head of the bed together with tilting the head of the patient to the opposite side. Temporal clear corneal incision was done by 20 Gauge MVR and small inferior or superior side port incision. The anterior chamber with formed using a cohesive viscoelastic. The angle is then examined by direct gonioscopy using Swan Jacob lens. Schlemm’s canal is the incised using 20-gauge MVR and cohesive OVD is injected to open the lips of the incision. A 5/0 prolene suture is then threaded inside Schlemm’s canal after making its tip blunt and creating a knob by cautery and pushing it inside the canal using 20 gauge anterior chamber forceps till it is retrieved from the other end of the incision. The knob of 5/0 prolene suture is then pulled until the Schlemm’s canal is incised 360°. The anterior chamber is washed by BSS and air is injected in the anterior chamber. Post-operative evaluation: Patients were put on NSAID eye drops 3 times per day for 2 weeks, topical broad spectrum antibiotic eye drops for 1 week together with oral tranexamic acid to control hyphema and were instructed to have semi setting position after surgery. On the first post-operative day the patients underwent: Slit lamp examination of the anterior segment, IOP measurement using GAT. And screening for Descemet membrane detachment by anterior segment optical coherence tomography using SD-OCT: Optovue RTVue (Optovue Inc., Fremont, CA, USA) for the angle day 1 post-operative for all patients and 1 week post-operative in cases with Descemet membrane detachment to check for spontaneous resolution. We also followed up these patients for one year to detect the success rate of the procedure. Statistical methods and analysis: Descriptive statistics were done and numerical variables were presented as mean and standard deviation or median (IQR). Categorical variables were presented as frequency and percentages. The incidence of Descemet membrane detachment was calculated. Comparison between the two groups was performed; those who developed Descemet membrane detachment versus those who did not. For the comparison of the numerical data, the Student’s t-test or the Mann-Whitney’s test was used as appropriate. The Chi-square test or the Fischer’s exact test was used for the categorical variables. P < 0.05 was considered significant. STATA 15.1 was used for the analysis. (Stata is a general-purpose statistical software package developed by StataCorp for data manipulation, visualization, statistics, and automated reporting). RESULTS Our study included 30 eyes of 28 patients with age range from 18 − 70 years underwent gonioscopy-assisted transluminal trabeculotomy 53.3% of them were males. Patient’s age, diagnosis, preoperative IOP, preoperative NGM, preoperative BCVA and preoperative cup to disc ratio values are shown in ( Table 1 ). Incidence of Descemet membrane detachment: We noticed that Descemet membrane detachment occurred in only one case and healed spontaneously after one week (3.3%) without the need for surgical intervention. (Fig. 1 ) The IOP reduction effect of GATT: The mean IOP decreased significantly from 2 4.73 (± 6.92) mmHg to 14.1 (± 3.57) mmHg at 12 months post-operative (p < 0.0001) with significant reduction at the number of glaucoma medications from 2.37 (± 1.30) preoperative to 0.87 (± 1.17) postoperative (p < 0.0001). ( Table 2 ) The success rate of the procedure: The complete and qualified success rates were defined as an IOP ≤ 21 mmHg and a reduction of IOP by ≥ 20% from baseline with (qualified success) or without (complete success) glaucoma medications: complete success was achieved in 60% of the cases while qualified success was achieved in 30% of the cases and 10% of the cases failed to achieve these criteria. The best corrected visual acuity(BCVA): There was no statistically significant change in the mean preoperative BCVA was 0.33 (± 0.24) when compared to the postoperative BCVA after 12 months (p = 0.2) The incidence of complications: The Incidence of hyphema post-gonioscopy-assisted transluminal trabeculotomy was 23.3% and all cases resolved conservatively after 1 week. Post-operative IOP spikes was defined as IOP more than 30 mmHg that responded to systemic carbonic anhydrase inhibitors. (3 cases out of 30 cases): reached 30 mmHg at day 4 postoperative and resolved within 2 days using systemic carbonic anhydrase inhibitors, 2 cases were JOAG and one case was uveitic glaucoma. Statistical methods and analysis: Descriptive statistics were done and numerical variables were presented as mean and standard deviation or median (IQR). Categorical variables were presented as frequency and percentages. The incidence of Descemet membrane detachment was calculated. Comparison between the two groups was performed; those who developed Descemet membrane detachment versus those who did not. For the comparison of the numerical data, the Student’s t-test or the Mann-Whitney’s test was used as appropriate. The Chi-square test or the Fischer’s exact test was used for the categorical variables. P < 0.05 was considered significant. STATA 15.1 was used for the analysis. (Stata is a general-purpose statistical software package developed by StataCorp for data manipulation, visualization, statistics, and automated reporting). DISCUSSION During the past decade, conventional trabeculectomy has been the gold standard surgical treatment for glaucoma. However, this surgery has its own complications such as postoperative hypotony, shallow anterior chamber, choroidal effusion, persistent corneal edema, bleb leak, bleb-related infection and encapsulated bleb.( 5 ) Recently, MIGS has revolutionized glaucoma surgery with the goal of reducing failure rates and bleb-related complications hence improving the patient’s quality of life.( 7 ) GATT is one of the cost effective MIGS that was first described by Grover et al. in 2014. ( 11 ) In our study, which included 30 eyes of 28 patients with OAG who underwent 360° GATT, we found that the mean preoperative IOP was 24.73 mmHg which was reduced to 14.1 mmHg at 12 months post operatively and that was statistically significant difference with P value < 0.0001. The average IOP reduction rate was 44% in patients with open angle glaucoma primary and secondary types (uveitic, silicon oil induced glaucoma, PXG, and inflammatory glaucoma) which was similar to IOP reduction rate to that of Grover et al. in their 24-month follow-up outcome (37.3% in POAG and 49.8%. in SOAG). ( 11 ) In our study, the GATT procedure enabled a significant reduction in the number of drops taken daily while the mean preoperative NGM was 2.37, the mean postoperative NGM was 0.87 during one year of follow up which was statistically significant difference with P value < 0.0001. One of the major advantages of the GATT procedure is its safety. The most frequently described complications were hyphema, IOP spikes, transient hypotony, iridodialysis and descemet membrane detachment. ( 12 ) In our study we had 7 cases with microhyphema (23.33%) and all resolved after one week. Some authors described the hyphema in Schlemm’s-canal surgery as an inevitable event that happens after tearing the vascularized-angle structures and as a good predictive sign of surgical success because it demonstrates the functioning of the connection between the anterior chamber and the distal- outflow pathways for aqueous humor. ( 13 ) In our study, 3 cases of IOP spikes were observed, 2 cases were advanced JOAG and one case of uveitic glaucoma. IOP spike was defined as IOP more than 30 mmHg that responded to systemic carbonic anhydrase inhibitors. We can attribute this to the severity of glaucoma due to collector channels and intra-scleral plexus sclerosis and destruction in advanced disease. ( 14 ) Hemorrhagic Descemet membrane detachment is a reported complication after ab-interno canaloplasty. Lewis et al. reported a large inferonasal DMD developed from viscoelastic injection into the Schlemm canal done to break the obstruction. Subsequently, a saline wash and placement of an air bubble helped to resolve the DMD. ( 15 ) However descemet membrane detachment reported less frequently after GATT surgery. ( 11 ) This calls for safer methods to cut open the trabecular shelf with minimal shearing or ripping forces.( 16 ) Risk factors for DMD includes preoperative patient-related factors such as age over 65 years, preexisting endothelial diseases like Fuchs dystrophy, and intrinsic descemet stromal interface abnormalities. ( 17 , 18 ) Intraoperative factors like clear corneal incision (small, oblique, ragged), blunt instrumentation and inadvertent damage by instruments.( 19 ) Post-operative factors like genetic causes of weak adhesion, abnormality in Descemet stromal interface and endothelial disorders like FECD. ( 18 ) To the best of our knowledge this is the first study conducted to document the descemet membrane detachment following GATT surgery by anterior segment OCT. Anterior segment OCT is done for the angle in the nasal, temporal, superior and inferior quadrants for all the patients on day one post-operative searching for possible Descemet membrane detachment from the incision or even during cannulation of the angle with 5 − 0 prolene suture. We found one case who was 70 years old male pseudophakic patient out of 30 cases (3.3%) had descemet membrane detachment in the nasal angle on day one post-operative which healed spontaneously after one week without the need for air or gas injection, which was comparable to the results of Grover et al. as they reported 2 cases out of 198 cases (0.5%). ( 11 ) This will add for the safety of GATT surgery. CONCLUSION Gonioscopy-assisted transluminal trabeculotomy is an effective conjunctival-sparing surgery in lowering the intraocular pressure and number of glaucoma medications for various forms of open angle glaucoma. It is a safe surgical procedure with low complications rate.Descemet membrane detachment is a rare complication post gonioscopy-assisted transluminal trabeculotomy and can heal spontaneously without surgical intervention. Abbreviations AS-OCT Anterior Segment Optical Coherence Tomography BCVA Best Corrected Visual Acuity BSS Balanced Salt Solution DMD Descemet Membrane Detachment FECD Fuchs Endothelial Corneal Dystrophy GAT Goldmann Applanation Tonometry GATT Gonioscopy-Assisted Transluminal Trabeculotomy IOP Intraocular Pressure JOAG Juvenile Open-Angle Glaucoma MIGS Minimally Invasive Glaucoma Surgery NGM Number of Glaucoma Medications NSAID Non-Steroidal Anti-Inflammatory Drug OAG Open-Angle Glaucoma OVD Ophthalmic Viscoelastic Device PXG Pseudoexfoliation Glaucoma SD-OCT Spectral-Domain Optical Coherence Tomography SOAG Secondary Open-Angle Glaucoma TM Trabecular Meshwork Declarations Ethics approval and consent to participate This prospective study received approval from the ethics committee of Kasr Alainy Medical School (Cairo University) with the number (MS-275-2022), and was and was registered at clinical trial.gov under the title of (incidence of descemet membrane detachment post GATT by AS OCT) with an ID NCT05932940. Informed consent was obtained from all individual participants included in the study. All procedures fulfilled the Declaration of Helsinki. Consent to publish The authors affirm that that human research participants provided informed consent for publication Competing Interests The authors have no relevant financial or non-financial interests to disclose. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All the authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Fayrouz Aboalazayem, Marwa Soliman, Ahmed Sherif and Mohammed Attya. The first draft of the manuscript was written by Marwa Soliman and all the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript.” Acknowledgement Not applicable Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Flaxman SR, Bourne RR, Resnikoff S, Ackland P, Braithwaite T, Cicinelli MV, Zheng Y. Global causes of blindness and distance vision impairment 1990–2020: a systematic review and meta-analysis. Lancet Global Health. 2017;5(12):e1221–34. Chauhan BC, Mikelberg FS, Balaszi AG, LeBlanc RP, Lesk MR, Trope GE. (2008)Canadian Glaucoma Study Group. Canadian Glaucoma Study: 2. risk factors for the progression of open-angle glaucoma. Arch Ophthalmol, 126(8):1030–6. Agis Investigators. The Advanced Glaucoma Intervention Study (AGIS) 7: the relationship between control of intraocular pressure and visual field deterioration. Am J Ophthalmol. 2000;130:429–40. Johnson M. What controls aqueous humour outflow resistance? Exp Eye Res. 2006;82(4):545–57. Olayanju JA, Hassan MB, Hodge DO, Khanna CL. Trabeculectomy- related complications in Olmsted County, Minnesota, 1985 through 2010. JAMA Ophthalmol. 2015;133(5):574–80. Conlon R, Saheb H, Ahmed II. Glaucoma treatment trends: a review. Can J Ophthalmol. 2017;52(1):114–24. Francis BA, Akil H, Bert BB. Ab interno Schlemm's canal surgery. Glaucoma Surge. 2017;59:127–416. Grover DS, Godfrey DG, Smith O, Feuer WJ, de Oca IM, Fellman RL. Gonioscopy-assisted transluminal trabeculotomy, ab interno trabeculotomy: technique report and preliminary results. Ophthalmology. 2014;121(4):855–61. Aboalazayem F, Elhusseiny AM, El Sayed YM. Gonioscopy Assisted Transluminal Trabeculotomy: A Review. Curr Eye Res. 2022;48(4):329–38. Grover DS, Smith O, Fellman RL, Godfrey DG, Butler MR, de Oca IM, Feuer WJ. Gonioscopy assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy for the treatment of primary congenital glaucoma and juvenile open angle glaucoma. Br J Ophthalmol. 2015;99(8):1092–106. Grover DS, Smith O, Fellman RL, Godfrey DG, Gupta A, Montes de Oca I, Feuer WJ. Gonioscopy-assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy: 24 months follow-up. J Glaucoma. 2018;27(5):393–401. Guo CY, Qi XH, Qi JM. Systematic review and meta-analysis of treating open angle glaucoma with gonioscopy-assisted transluminalm trabeculotomy. Int J Ophthalmol. 2020;13(2):317. Sarkisian SR, Mathews B, Ding K, Patel A, Nicek Z. 360 ab-interno trabeculotomy in refractory primary open-angle glaucoma. Clin Ophthalmol (Auckland NZ). 2019;13:161. Shi Y, Wang H, Oatts JT, Xin C, Yin P, Zhang L, Tian J, Zhang Y, Cao K, Han Y, Wang N. A prospective study of intraocular pressure spike and failure after gonioscopy-assisted transluminal trabeculotomy in juvenile open-angle glaucoma: a prospective study of GATT in JOAG. Am J Ophthalmol. 2022;236:79–88. Lewis RA, von Wolff K, Tetz M, Koerber N, Kearney JR, Shingleton BJ, Samuelson TW. Canaloplasty: circumferential viscodilation and tensioning of Schlemm canal using a flexible microcatheter for the treatment of open- angle glaucoma in adults: two year interim clinical study results. J Cataract Refractive Surg. 2009;35(5):814–24. Rao A, Khan SM, Mukherjee S. Causes of Immediate and Early IOP Spikes After Circumferential Gonioscopy-Assisted Transluminal Trabeculotomy Using ASOCT. Clinical Ophthalmology; 2003. pp. 313–20. Benatti CA, Tsao JZ, Afshari NA. Descemet membrane detachment during cataract surgery: etiology and management. Curr Opin Ophthalmol. 2017;28(1):35–41. Chow VW, Agarwal T, Vajpayee RB, Jhanji V. (2013) Update on diagnosis and management of Descemet's membrane detachment. Curr Opin Ophthalmol, (4):356–61. Titiyal JS, Kaur M, Singh A, Arora T, Sharma N. Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in white cataract. Clin Ophthalmol. 2016;22:1357–64. Tables Table (1): Baseline characteristics of the study population. Patient’s age, diagnosis. values (n=30) Age (mean (SD)) 49.4 (19.34) Range: 18-75 Diagnosis POAG 17 (56.7%) JOAG 7 (23.33%) Uveitis OAG 1 (3.33%) Silicone induced glaucoma 2 (6.7%) PXG 2 (6.7%) Inflammatory glaucoma 1 (3.3%) Pre-operative IOP Mean (SD) 24.63 (7.26) mmHg Range: 14-40 Pre-operative medications number Mean (SD) 2.37 (1.33) Range: 0-4 Pre-operative BCVA Mean (SD) 0.28 (0.21) Pre-operative cup to disc ratio Mean (SD) 0.82 (0.19) Table (2): Comparison between preoperative and one year postoperative Intraocular pressure measurement by GAT and NGM (number of Glaucoma medications). Pre-operative Post-operative p IOP Mean (SD) 24.73 (6.92) 14.1 (3.57) <0.0001 Medications number Mean (SD) 2.37 (1.30) 0.87 (1.17) <0.0001 Additional Declarations No competing interests reported. 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16:32:35","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69046,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8090124/v1/6dc1e0dde47405405a450868.html"},{"id":99320124,"identity":"3233894f-0b76-4050-916f-6a3b7c5ccfc3","added_by":"auto","created_at":"2025-12-31 16:38:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":757246,"visible":true,"origin":"","legend":"\u003cp\u003eAnterior segment OCT of the nasal angle : (A) one day postoperative showing descemet membrane detachment. (B) one week postoperative showing spontaneous resolution of DMD.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8090124/v1/ec482c6d16c9bfde9e664369.png"},{"id":103904352,"identity":"701d8a3c-1638-48c6-bb3f-2e003d455661","added_by":"auto","created_at":"2026-03-04 10:28:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1841708,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8090124/v1/88e5b26e-c2c8-44e2-ac1a-68705507a377.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Incidence of Descemet Membrane Detachment post Gonioscopy-Assisted Transluminal Trabeculotomy in patients with Open Angle Glaucoma","fulltext":[{"header":"Background","content":"\u003cp\u003eGlaucoma is the leading cause of irreversible blindness worldwide.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) The most important risk factor for the development and progression of glaucoma is the elevated intraocular pressure. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) The only treatment that can slow the progression of glaucoma is the reduction of IOP, either medically or surgically. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) The inner wall of Schlemm\u0026rsquo;s canal and the juxtacanalicular trabecular meshwork are the primary sites of abnormal flow resistance in open angle glaucoma. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Among all, filtration surgery such as the trabeculectomy is the most successful approach to lower the IOP in different subtypes of primary and secondary glaucoma but it is associated with a significant complications including overfiltration, suprachoroidal hemorrhage, persistent hypotony, wipe out phenomenon, and bleb leak or failure. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) The most recent approach to enhance the conventional outflow pathway is through addressing TM and Schlemm\u0026rsquo;s canal internally. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eGATT was found to be an effective and safe intervention for open angle glaucoma, the advantages of GATT compared to filtration surgery are the low rate of long-term complications and that the intervention is feasible even when conjunctival scarring is encountered. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Gonioscopy-assisted transluminal trabeculotomy (GATT) procedure is a MIGS technique in which TM is circumferentially bypassed via suture or catheter. In this technique, aqueous humor passes through the collector canals and the episcleral veins through the cleaved open diseased TM. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) It was first introduced by Grover et al. in 2014 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) It has been shown to effectively lower IOP and NGMs (number of glaucoma medications) in primary, juvenile, and secondary open-angle glaucomas. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e \u0026amp; \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The most common complication post GATT surgery is transient hyphema, seen in 30% of patients at the 1-week visit. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Other reported complications such as persistent cornea oedema, Descemet membrane detachment, iridodialysis or cystoid macular oedema.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAs this ab interno angle surgery is still novel, the goal of this study to assess its efficacy and safety and to detect the incidence of Descemet membrane detachment following gonioscopy-assisted transluminal trabeculotomy (GATT) by anterior segment optical coherence tomography in patients with open angle glaucoma.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e This was a prospective clinical study received approval from the ethics committee of Kasr Alainy medical school (Cairo University), and was registered at clinical trial.gov under the title of (incidence of descemet membrane detachment post GATT by AS OCT) with an ID NCT05932940). All procedures fulfilled declaration of Helsinki. Written informed consent was obtained from each subject at the time of the intervention.\u003c/p\u003e \u003cp\u003ePatients:\u003c/p\u003e \u003cp\u003eThe study was conducted on 30 eyes with open angle glaucoma either primary or secondary aged 18\u0026ndash;70 years. Aphakic patients, patients with neovascular glaucoma and patients with silicone induced glaucoma were excluded. Also patients undergoing combined phacoemulsification and GATT were excluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePreoperative assessment:\u003c/h3\u003e\n\u003cp\u003e All selected patients received a thorough explanation of the study design, aims, and signed an informed consent.\u003c/p\u003e\n\u003ch3\u003ePre-operative evaluation of all participants included:\u003c/h3\u003e\n\u003cp\u003eBest corrected visual acuity (BCVA) using decimal scale, slit lamp examination of the anterior segment, gonioscopy using Goldmann lens, intraocular pressure measurement using Goldman applanation tonometry and dilated fundus examination using slit- lamp bio microscopy using\u0026thinsp;+\u0026thinsp;90 D Volk Condensing lens. Visual field testing was also performed whenever the vision permitted.\u003c/p\u003e \u003cp\u003ePreoperative anterior segment OCT using SD-OCT: Optovue RTVue (Optovue Inc., Fremont, CA, USA) to exclude presence of Descemet membrane detachment for the cases that underwent previous anterior segment surgeries.\u003c/p\u003e\n\u003ch3\u003eGonioscopy assisted transluminal trabeculotomy surgical steps:\u003c/h3\u003e\n\u003cp\u003eSurgery was conducted in all patients by the same surgeon (FA), with the following steps: Local Anesthesia or anterior subtenon anesthesia in advanced cases.\u003c/p\u003e \u003cp\u003eAfter draping of the eye, the operating microscope is tilted 45 degrees. The surgeon sits on temporal side of the patient and elevate the head of the bed together with tilting the head of the patient to the opposite side. Temporal clear corneal incision was done by 20 Gauge MVR and small inferior or superior side port incision. The anterior chamber with formed using a cohesive viscoelastic. The angle is then examined by direct gonioscopy using Swan Jacob lens. Schlemm\u0026rsquo;s canal is the incised using 20-gauge MVR and cohesive OVD is injected to open the lips of the incision. A 5/0 prolene suture is then threaded inside Schlemm\u0026rsquo;s canal after making its tip blunt and creating a knob by cautery and pushing it inside the canal using 20 gauge anterior chamber forceps till it is retrieved from the other end of the incision. The knob of 5/0 prolene suture is then pulled until the Schlemm\u0026rsquo;s canal is incised 360\u0026deg;. The anterior chamber is washed by BSS and air is injected in the anterior chamber.\u003c/p\u003e\n\u003ch3\u003ePost-operative evaluation:\u003c/h3\u003e\n\u003cp\u003ePatients were put on NSAID eye drops 3 times per day for 2 weeks, topical broad spectrum antibiotic eye drops for 1 week together with oral tranexamic acid to control hyphema and were instructed to have semi setting position after surgery.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOn the first post-operative day the patients underwent:\u003c/h2\u003e \u003cp\u003eSlit lamp examination of the anterior segment, IOP measurement using GAT. And screening for Descemet membrane detachment by anterior segment optical coherence tomography using SD-OCT: Optovue RTVue (Optovue Inc., Fremont, CA, USA) for the angle day 1 post-operative for all patients and 1 week post-operative in cases with Descemet membrane detachment to check for spontaneous resolution.\u003c/p\u003e \u003cp\u003e We also followed up these patients for one year to detect the success rate of the procedure.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical methods and analysis:\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics were done and numerical variables were presented as mean and standard deviation or median (IQR). Categorical variables were presented as frequency and percentages. The incidence of Descemet membrane detachment was calculated. Comparison between the two groups was performed; those who developed Descemet membrane detachment versus those who did not. For the comparison of the numerical data, the Student\u0026rsquo;s t-test or the Mann-Whitney\u0026rsquo;s test was used as appropriate. The Chi-square test or the Fischer\u0026rsquo;s exact test was used for the categorical variables. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. STATA 15.1 was used for the analysis. (Stata is a general-purpose statistical software package developed by StataCorp for data manipulation, visualization, statistics, and automated reporting).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOur study included 30 eyes of 28 patients with age range from 18 \u0026minus;\u0026thinsp;70 years underwent gonioscopy-assisted transluminal trabeculotomy 53.3% of them were males. Patient\u0026rsquo;s age, diagnosis, preoperative IOP, preoperative NGM, preoperative BCVA and preoperative cup to disc ratio values are shown in (\u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIncidence of Descemet membrane detachment:\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eWe noticed that Descemet membrane detachment occurred in only one case and healed spontaneously after one week (3.3%) without the need for surgical intervention. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe IOP reduction effect of GATT:\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe mean IOP decreased significantly from 2 4.73 (\u0026plusmn;\u0026thinsp;6.92) mmHg to 14.1 (\u0026plusmn;\u0026thinsp;3.57) mmHg at 12 months post-operative (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) with significant reduction at the number of glaucoma medications from 2.37 (\u0026plusmn;\u0026thinsp;1.30) preoperative to 0.87 (\u0026plusmn;\u0026thinsp;1.17) postoperative (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). (\u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe success rate of the procedure:\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe complete and qualified success rates were defined as an IOP\u0026thinsp;\u0026le;\u0026thinsp;21 mmHg and a reduction of IOP by \u0026ge;\u0026thinsp;20% from baseline with (qualified success) or without (complete success) glaucoma medications: complete success was achieved in 60% of the cases while qualified success was achieved in 30% of the cases and 10% of the cases failed to achieve these criteria.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe best corrected visual acuity(BCVA):\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThere was no statistically significant change in the mean preoperative BCVA was 0.33 (\u0026plusmn;\u0026thinsp;0.24) when compared to the postoperative BCVA after 12 months (p\u0026thinsp;=\u0026thinsp;0.2)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe incidence of complications:\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe Incidence of hyphema post-gonioscopy-assisted transluminal trabeculotomy was 23.3% and all cases resolved conservatively after 1 week.\u003c/p\u003e \u003cp\u003ePost-operative IOP spikes was defined as IOP more than 30 mmHg that responded to systemic carbonic anhydrase inhibitors. (3 cases out of 30 cases): reached 30 mmHg at day 4 postoperative and resolved within 2 days using systemic carbonic anhydrase inhibitors, 2 cases were JOAG and one case was uveitic glaucoma.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods and analysis:\u003c/h2\u003e \u003cp\u003eDescriptive statistics were done and numerical variables were presented as mean and standard deviation or median (IQR). Categorical variables were presented as frequency and percentages. The incidence of Descemet membrane detachment was calculated. Comparison between the two groups was performed; those who developed Descemet membrane detachment versus those who did not. For the comparison of the numerical data, the Student\u0026rsquo;s t-test or the Mann-Whitney\u0026rsquo;s test was used as appropriate. The Chi-square test or the Fischer\u0026rsquo;s exact test was used for the categorical variables. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. STATA 15.1 was used for the analysis. (Stata is a general-purpose statistical software package developed by StataCorp for data manipulation, visualization, statistics, and automated reporting).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eDuring the past decade, conventional trabeculectomy has been the gold standard surgical treatment for glaucoma. However, this surgery has its own complications such as postoperative hypotony, shallow anterior chamber, choroidal effusion, persistent corneal edema, bleb leak, bleb-related infection and encapsulated bleb.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Recently, MIGS has revolutionized glaucoma surgery with the goal of reducing failure rates and bleb-related complications hence improving the patient\u0026rsquo;s quality of life.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) GATT is one of the cost effective MIGS that was first described by Grover et al. in 2014. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn our study, which included 30 eyes of 28 patients with OAG who underwent 360\u0026deg; GATT, we found that the mean preoperative IOP was 24.73 mmHg which was reduced to 14.1 mmHg at 12 months post operatively and that was statistically significant difference with P value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001. The average IOP reduction rate was 44% in patients with open angle glaucoma primary and secondary types (uveitic, silicon oil induced glaucoma, PXG, and inflammatory glaucoma) which was similar to IOP reduction rate to that of Grover et al. in their 24-month follow-up outcome (37.3% in POAG and 49.8%. in SOAG). (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) In our study, the GATT procedure enabled a significant reduction in the number of drops taken daily while the mean preoperative NGM was 2.37, the mean postoperative NGM was 0.87 during one year of follow up which was statistically significant difference with P value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001.\u003c/p\u003e \u003cp\u003eOne of the major advantages of the GATT procedure is its safety. The most frequently described complications were hyphema, IOP spikes, transient hypotony, iridodialysis and descemet membrane detachment. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) In our study we had 7 cases with microhyphema (23.33%) and all resolved after one week. Some authors described the hyphema in Schlemm\u0026rsquo;s-canal surgery as an inevitable event that happens after tearing the vascularized-angle structures and as a good predictive sign of surgical success because it demonstrates the functioning of the connection between the anterior chamber and the distal- outflow pathways for aqueous humor. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) In our study, 3 cases of IOP spikes were observed, 2 cases were advanced JOAG and one case of uveitic glaucoma. IOP spike was defined as IOP more than 30 mmHg that responded to systemic carbonic anhydrase inhibitors. We can attribute this to the severity of glaucoma due to collector channels and intra-scleral plexus sclerosis and destruction in advanced disease. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHemorrhagic Descemet membrane detachment is a reported complication after ab-interno canaloplasty. Lewis et al. reported a large inferonasal DMD developed from viscoelastic injection into the Schlemm canal done to break the obstruction. Subsequently, a saline wash and placement of an air bubble helped to resolve the DMD. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) However descemet membrane detachment reported less frequently after GATT surgery. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) This calls for safer methods to cut open the trabecular shelf with minimal shearing or ripping forces.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Risk factors for DMD includes preoperative patient-related factors such as age over 65 years, preexisting endothelial diseases like Fuchs dystrophy, and intrinsic descemet stromal interface abnormalities. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Intraoperative factors like clear corneal incision (small, oblique, ragged), blunt instrumentation and inadvertent damage by instruments.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Post-operative factors like genetic causes of weak adhesion, abnormality in Descemet stromal interface and endothelial disorders like FECD. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTo the best of our knowledge this is the first study conducted to document the descemet membrane detachment following GATT surgery by anterior segment OCT. Anterior segment OCT is done for the angle in the nasal, temporal, superior and inferior quadrants for all the patients on day one post-operative searching for possible Descemet membrane detachment from the incision or even during cannulation of the angle with 5\u0026thinsp;\u0026minus;\u0026thinsp;0 prolene suture. We found one case who was 70 years old male pseudophakic patient out of 30 cases (3.3%) had descemet membrane detachment in the nasal angle on day one post-operative which healed spontaneously after one week without the need for air or gas injection, which was comparable to the results of Grover et al. as they reported 2 cases out of 198 cases (0.5%). (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) This will add for the safety of GATT surgery.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eGonioscopy-assisted transluminal trabeculotomy is an effective conjunctival-sparing surgery in lowering the intraocular pressure and number of glaucoma medications for various forms of open angle glaucoma. It is a safe surgical procedure with low complications rate.Descemet membrane detachment is a rare complication post gonioscopy-assisted transluminal trabeculotomy and can heal spontaneously without surgical intervention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAS-OCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnterior Segment Optical Coherence Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBest Corrected Visual Acuity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBalanced Salt Solution\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDMD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDescemet Membrane Detachment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFECD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFuchs Endothelial Corneal Dystrophy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGoldmann Applanation Tonometry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGATT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGonioscopy-Assisted Transluminal Trabeculotomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraocular Pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJOAG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJuvenile Open-Angle Glaucoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMIGS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimally Invasive Glaucoma Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNumber of Glaucoma Medications\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSAID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Steroidal Anti-Inflammatory Drug\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOAG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOpen-Angle Glaucoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOphthalmic Viscoelastic Device\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePXG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePseudoexfoliation Glaucoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD-OCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpectral-Domain Optical Coherence Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOAG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSecondary Open-Angle Glaucoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTrabecular Meshwork\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This prospective study received approval from the ethics committee of Kasr Alainy Medical School (Cairo University) with the number (MS-275-2022), and was and was registered at clinical trial.gov under the title of (incidence of descemet membrane detachment post GATT by AS OCT) with an ID NCT05932940.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained from all individual participants included in the study. All procedures fulfilled the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eThe authors affirm that that human research participants provided informed consent for publication\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll the authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Fayrouz Aboalazayem, Marwa Soliman, Ahmed Sherif and Mohammed Attya. The first draft of the manuscript was written by Marwa Soliman and all the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript.\u0026rdquo;\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFlaxman SR, Bourne RR, Resnikoff S, Ackland P, Braithwaite T, Cicinelli MV, Zheng Y. Global causes of blindness and distance vision impairment 1990\u0026ndash;2020: a systematic review and meta-analysis. Lancet Global Health. 2017;5(12):e1221\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChauhan BC, Mikelberg FS, Balaszi AG, LeBlanc RP, Lesk MR, Trope GE. (2008)Canadian Glaucoma Study Group. Canadian Glaucoma Study: 2. risk factors for the progression of open-angle glaucoma. Arch Ophthalmol, 126(8):1030\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgis Investigators. The Advanced Glaucoma Intervention Study (AGIS) 7: the relationship between control of intraocular pressure and visual field deterioration. Am J Ophthalmol. 2000;130:429\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson M. What controls aqueous humour outflow resistance? Exp Eye Res. 2006;82(4):545\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlayanju JA, Hassan MB, Hodge DO, Khanna CL. Trabeculectomy- related complications in Olmsted County, Minnesota, 1985 through 2010. JAMA Ophthalmol. 2015;133(5):574\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConlon R, Saheb H, Ahmed II. Glaucoma treatment trends: a review. Can J Ophthalmol. 2017;52(1):114\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrancis BA, Akil H, Bert BB. Ab interno Schlemm's canal surgery. Glaucoma Surge. 2017;59:127\u0026ndash;416.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrover DS, Godfrey DG, Smith O, Feuer WJ, de Oca IM, Fellman RL. Gonioscopy-assisted transluminal trabeculotomy, ab interno trabeculotomy: technique report and preliminary results. Ophthalmology. 2014;121(4):855\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAboalazayem F, Elhusseiny AM, El Sayed YM. Gonioscopy Assisted Transluminal Trabeculotomy: A Review. Curr Eye Res. 2022;48(4):329\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrover DS, Smith O, Fellman RL, Godfrey DG, Butler MR, de Oca IM, Feuer WJ. Gonioscopy assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy for the treatment of primary congenital glaucoma and juvenile open angle glaucoma. Br J Ophthalmol. 2015;99(8):1092\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrover DS, Smith O, Fellman RL, Godfrey DG, Gupta A, Montes de Oca I, Feuer WJ. Gonioscopy-assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy: 24 months follow-up. J Glaucoma. 2018;27(5):393\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo CY, Qi XH, Qi JM. Systematic review and meta-analysis of treating open angle glaucoma with gonioscopy-assisted transluminalm trabeculotomy. Int J Ophthalmol. 2020;13(2):317.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarkisian SR, Mathews B, Ding K, Patel A, Nicek Z. 360 ab-interno trabeculotomy in refractory primary open-angle glaucoma. Clin Ophthalmol (Auckland NZ). 2019;13:161.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi Y, Wang H, Oatts JT, Xin C, Yin P, Zhang L, Tian J, Zhang Y, Cao K, Han Y, Wang N. A prospective study of intraocular pressure spike and failure after gonioscopy-assisted transluminal trabeculotomy in juvenile open-angle glaucoma: a prospective study of GATT in JOAG. Am J Ophthalmol. 2022;236:79\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis RA, von Wolff K, Tetz M, Koerber N, Kearney JR, Shingleton BJ, Samuelson TW. Canaloplasty: circumferential viscodilation and tensioning of Schlemm canal using a flexible microcatheter for the treatment of open- angle glaucoma in adults: two year interim clinical study results. J Cataract Refractive Surg. 2009;35(5):814\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao A, Khan SM, Mukherjee S. Causes of Immediate and Early IOP Spikes After Circumferential Gonioscopy-Assisted Transluminal Trabeculotomy Using ASOCT. Clinical Ophthalmology; 2003. pp. 313\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenatti CA, Tsao JZ, Afshari NA. Descemet membrane detachment during cataract surgery: etiology and management. Curr Opin Ophthalmol. 2017;28(1):35\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChow VW, Agarwal T, Vajpayee RB, Jhanji V. (2013) Update on diagnosis and management of Descemet's membrane detachment. Curr Opin Ophthalmol, (4):356\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTitiyal JS, Kaur M, Singh A, Arora T, Sharma N. Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in white cataract. Clin Ophthalmol. 2016;22:1357\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable (1): Baseline characteristics of the study population. Patient\u0026rsquo;s age, diagnosis. \u0026nbsp;values (n=30)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(mean (SD))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e49.4 (19.34)\u003c/p\u003e\n \u003cp\u003eRange: 18-75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePOAG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e17 (56.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eJOAG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e7 (23.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUveitis OAG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e1 (3.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSilicone induced glaucoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePXG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eInflammatory glaucoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative IOP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e24.63 (7.26) mmHg\u003c/p\u003e\n \u003cp\u003eRange: 14-40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative medications number\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026nbsp;\u003c/strong\u003e(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e2.37 (1.33)\u003c/p\u003e\n \u003cp\u003eRange: 0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative BCVA Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.28 (0.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative cup to disc ratio\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.82 (0.19)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable (2): Comparison between preoperative and one year postoperative\u003c/p\u003e\n\u003cp\u003eIntraocular pressure measurement by GAT and NGM (number of Glaucoma medications).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003ePre-operative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003ePost-operative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eIOP\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e24.73 (6.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e14.1 (3.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eMedications number\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e2.37 (1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e0.87 (1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\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":"GATT, Descemet membrane detachment, open-angle glaucoma","lastPublishedDoi":"10.21203/rs.3.rs-8090124/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8090124/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo determine the incidence of Descemet membrane detachment (DMD) following gonioscopy-assisted transluminal trabeculotomy (GATT) using anterior segment optical coherence tomography (AS-OCT) in patients with open-angle glaucoma.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective clinical study included 30 eyes treated with GATT between June 2022 and January 2023. All patients were examined with spectral-domain AS-OCT (Optovue RTVue; Optovue Inc., Fremont, CA, USA) on the first postoperative day to assess for DMD. In cases where DMD was detected, AS-OCT imaging was repeated after one week to evaluate for spontaneous resolution.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDMD occurred in 1 of the 30 eyes (3.3%), indicating a low incidence following GATT. Significant reductions were observed between pre- and postoperative intraocular pressure (IOP) and the number of glaucoma medications. Postoperative hyphema occurred in 20% of cases and resolved spontaneously within one week. Complete surgical success was achieved in 60% of eyes, while qualified success was noted in 30%, and 10% were classified as failures. IOP spikes were recorded in 3 eyes (10%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe incidence of Descemet membrane detachment following GATT was low, supporting the procedure as a safe surgical option for patients with open-angle glaucoma.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003e The study was approved by the Ethics Committee of Kasr AlAiny Medical School, Cairo University, and registered at ClinicalTrials.gov (NCT05932940) on 7th of May 2023\u003c/p\u003e","manuscriptTitle":"Incidence of Descemet Membrane Detachment post Gonioscopy-Assisted Transluminal Trabeculotomy in patients with Open Angle Glaucoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 09:30:24","doi":"10.21203/rs.3.rs-8090124/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":"7332061b-1319-40de-8813-7de9cdabf287","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T10:27:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 09:30:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8090124","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8090124","identity":"rs-8090124","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}