Ab Interno Trabeculectomy With The Kahook Dual Blade In A Monocular Patient With Mucous Membrane Pemphigoid And Refractory Open Angle Glaucoma

To describe a monocular patient with ocular mucous membrane pemphigoid (MMP) and open angle glaucoma refractory to medical treatment, who was successfully managed with ab interno goniotomy at the time of cataract surgery.

A 63-year-old woman with history of severe MMP presented with disease exacerbation in both eyes. Her vision was 20/80 in the right eye and light perception in the left eye. Total limbal stem cell deficiency with conjunctivalization of the cornea was present in the left eye. Symblepharon formation, trichiasis and forniceal foreshortening were seen in the right eye. 

Following aggressive systemic immunosuppressive therapy with corticosteroids and cyclophosphamide, the patient's cataract quickly matured in the right eye and the intraocular pressure rose to 35 mmHg on maximal medical therapy. Due to the high risk of ocular MMP exacerbation with traditional glaucoma filtration surgery, decision was made to proceed with cataract surgery combined with ab interno goniotomy using the Kahook Dual Blade. There were no intraoperative complications. Post-operatively, the patient experienced an epithelial defect that resolved within 6 weeks. The intraocular pressure has remained in the 12 - 14 mm Hg range without any glaucoma drops, over a total follow up of 3 years. 

Ab interno goniotomy using the Kahook Dual Blade could be a safe and effective surgical procedure for ocular MMP patients with concomitant primary open angle glaucoma. It can significantly reduce intraocular pressure and medication burden in MMP cases where any type of conjunctival surgery may induce disease flare up.