ination cataract surgery and MIGS devices dramatically lower IOP levels and reduced the number of medications used in recent studies and are increasingly becoming the mainstay treatment for mild to moderate glaucoma. 19 The HORIZON study showed excellent IOP lowering in the cataract surgery-alone group from 25.3 ± 2.9 to 19.3 ± 4.2 mmHg. This was significantly enhanced in the combined cataract surgery and Hydrus microstent implantation group to 17.5 ± 3.9 mmHg. 20 The COMPARE study showed that patients with Hydrus microstent used fewer medications with a high surgical success rate compared with the 2-iStent device group (preoperative IOP 2-iStent 19.1 ± 3.6 mmHg, Hydrus 19.0 ± 2.5 mmHg; 12-month 2-iStent IOP 18.1 ± 3.7 mmHg, Hydrus 17.3 ± 3.7 mmHg). 21 Although clinical trials with a 2-year follow-up period showed efficacy of Hydrus microstent, the real-world efficacy of Hydrus microstent has not been studied in a predominately Black and Afro-Latinx population. Hydrus is currently Food and Drug Administration (FDA) approved in the United States for use together with cataract surgery for patients with mild to moderate open-angle   All patients had a full ophthalmological assessment that included visual acuity (VA), Goldmann applanation tonometry, slit-lamp examination, gonioscopy, optic nerve assessment with Zeiss Cirrus 5000 HD-OCT, and visual field (VF) examination with Zeiss Humphrey Visual Field Analyzer 3 (Dublin, California, USA). The indications for Hydrus microstent glaucoma surgery were to reduce IOP and to reduce reliance on IOP-lowering medications at the time of cataract surgery in eyes with significant cataract (cortical and nuclear sclerosis grades 1-4) and medically treated glaucoma while avoiding the formation of a filtering bleb and its associated risk profile. We included consecutive cases that were done with open angles or partially open angles with indentation gonioscopy in the nasal quadrant. We excluded patients who had uveitic, neovascular glaucoma, and angle closure without the TM visible on indentation gonioscopy.
The main outcome measures were IOP reduction and decrease in ocular hypotensive medications after the surgery. Safety was evaluated by tabulating both solicited and unsolicited adverse events from the intraoperative period through the last follow-up. The patients were stratified into subgroups: mild, moderate, and advance based on the Hodapp-Parrish-Anderson criteria to assess the efficacy of phacoemulsification and Hydrus microstent.
All glaucoma medications were stopped in the operative eye on the day of surgery. After the procedure, patients were prescribed prednisolone acetate 1% (Allergan, Dublin, Ireland) ophthalmic solution one drop every 6 h, ofloxacin 0.3% (Rising, Saddle Brook, New Jersey, USA) one drop every 6 h, and ketorolac 0.5% (Allergan, Dublin, Ireland) one drop every 8 h. Baseline and operative data were reviewed prior to the day of surgery, and the clinical course was assessed at day 1, 1, 3, and 6 months, postoperatively. Individual IOP goals were tailored to each individual patient postoperatively, and IOP-lowering medications were withdrawn or added as deemed necessary.

Statistics
The hypothesis is that cataract surgery combined with the Hydrus microstent implant would reduce glaucoma medicine burden and maintain lower IOP. Data analysis was done with Microsoft excel (Microsoft, Redmond, Washington, USA) and Prism GraphPad (GraphPad, Seattle, Washington, USA). We used a paired t test for analysis. In this study, the significance threshold was set at p ⩽ 0.05.

Instrument
The Hydrus microstent ( Figure 3) is a biocompatible material made of nickel-titanium alloy and thermally set to fit the curvature of the Schlemm canal. It is made to be placed ab interno through the TM into the Schlemm canal ( Figure 4) with the inlet residing in the anterior chamber (AC). The Hydrus microstent is able to dilate and scaffold a quadrant of the Schlemm canal upon placement. The device is able to drain aqueous through the resistant TM into the collecting channels via the Schlemm canal. 19

Procedure
Patients were administered preoperative prednisolone acetate 1% (Allergan, Dublin, Ireland) QID and ofloxacin (Rising, Saddle Brook, NJ, USA) QID starting 3 days prior to surgery. After the eye was prepped with betadine and draped, topical anesthesia was applied, and a clear corneal phacoemulsification was performed with implantation of an intraocular lens. Endocoat (Abbott, Chicago, Illinois, USA) was placed in the eye to deepen the angle. A paracentesis was made 2.5 clock hours to the right of the corneal incision and Endocoat was placed on the cornea. The patient's head was tilted away from the surgeon about 45°, and the microscope was tilted toward the surgeon about 45°. A direct gonio lens (Katena, Troy Hills, New Jersey, USA) was placed on the eye, and the microscope was focused down to obtain a direct view of the nasal angle structures. If peripheral anterior synechiae partially obstructed the view of the TM, a cyclodialysis spatula was used to gently perform goniosynechialysis for 1-2 clock hours to expose the TM. The presence of viscoelastic served as a tamponade for any heme and preserved visibility. The Hydrus microstent was passed into the AC through the paracentesis. Using the device injector, the TM was incised with the tip of the delivery cannula and the microstent was threaded into the Schlemm's canal (SC) over a span of approximately 90°. Upon visual confirmation of proper device positioning in the canal, the delivery system was withdrawn and the ophthalmic viscosurgical device removed and replaced with a balanced salt solution. Intracameral injection of diluted Vigamox (Alcon, Geneva, Switzerland) with the balanced saline solution 50/50 1cc was given via the paracentesis at the end of the procedure. In all patients, we noticed the angle was open nasally after cataract surgery or was opened partially with synechialysis with a cyclodialysis spatula 1-2 clock hours for Hydrus insertion.

Results
A total of 76 patients were included in the study. Baseline characteristics of study patients are presented in Table 1. The mean age for the study participants was 70.7 ± 9.4 years. Women outnumbered men in the ratio of 1.17:1.0, and the left eye-to-right eye procedure ratio was 1.05:1.0. The mean baseline preoperative IOP was 14.7 ± 3.7 mmHg with a mean use of 2.6 ± 1.5 ocular hypotensive medications. Of all the patients, 98% were using one or more ocular hypotensive medication and 31.6% were using four or more medications (Table 1).
At each postoperative visit, there was a significant drop in the number of medications compared with preoperative values. There was significant decrease in IOP at postoperative day 1 and 3 months only (p < 0.00010; p = 0.0022, respectively;    BCVA, best-corrected visual acuity; IOP, intraocular pressure; n, number of patients; SD, standard deviation. and 11.4% at 6 months. The moderate group saw a reduction in the number of medications: 95% at 1 month, 71.5% at 3 months, and 77.7% at 6 months. Patients in this group saw a 16.7% reduction in IOP at postoperative day 1 with a return to baseline mean IOP at 1 month, 5.8% drop at 3 months, and 6.5% drop at 6 months. The advance glaucoma group had the least reduction in number of medications at 3 months (67.7%) and 6 months (64.5%). The mean IOP saw a 26.4% reduction at postoperative day 1, a decrease of 11.8% at 3 months, and 3.5% at 6 months ( Table 3).
The number of all patients on no medications increased from 2.6% at baseline to 72.4% at 6 months (mild 79.4%, moderate 70.8%, and advance 50.0%; Table 4).
Adverse events were non-sight threatening and self-limited. Generally, only trace blood refluxed into the AC upon insertion of the Hydrus microstent and resolved spontaneously in all cases typically within the first postoperative week. Postoperatively, IOP spikes (IOP increase greater than 10 mmHg or IOP ⩾ 30 mmHg), mild posterior capsule opacification, hyphema, iris adhesion/ block, peripheral anterior synechiae, transient corneal edema, cystoid macular edema (CME), device malposition, and obstruction were noted. No adverse events required secondary interventions (Table 5).

Discussion
Elevation in IOP is often associated with the progression of glaucoma. Aggressive control of IOP has been suggested for the control of VF progression. 22 The increasing costs of medications, lack of access globally, nonadherence to ocular medications, and the emergence of MIGS make Hydrus microstent study particularly important. Our study patients, Blacks and Afro-Latinx, have a higher rate of blindness from glaucoma compared with White Latinx and White persons. 23 In addition, the literature on MIGS in predominantly Black   damage to collector channels and aqueous veins that lead to the