Müllerotomy with anterior graded Müller muscle disinsertion for Graves upper eyelid retraction: validation of surgical outcomes using Bézier curves.

PURPOSE: To assess with Bézier curves the outcomes of Müllerotomy with anterior graded Müller muscle disinsertion for the treatment of Graves upper eyelid retraction (UER). METHODS: Eighty-six eyelids of 52 inactive GO patients operated from November 2018 to June 2021 were included in this study. All measurements were performed on Bézier curves adjusted to the upper lid contour with a previously validated algorithm. Lid contour was classified regarding grade of superposition (GS) as excellent (GS > 90%), good (GS 85-90%) or poor (< 85%). Surgical success was defined as complete or partial if postoperative grade of asymmetry was < 10% with an excellent or good lid contour, respectively. RESULTS: The mean age was 51 ± 10.4 years with a range from 31 to 78 years and a mean follow-up of 14.4 ± 7.4 months. There was a significant improvement of median GS (p < 0.0001) from preoperative (74.3%; 10.7 IQR) to postoperative values (91.7%; 6.3 IQR). A normalization of postoperative contour peak (- 0.69; 1.27 SD) and MPLD90 (4.2 mm; 0.8 SD) was noticed (p < 0.0001). Postoperative lid contour was excellent in 62 (72%), good in 16 (19%) and poor in 8 eyelids (9%). Surgical success was achieved in 42 patients (81%), from which 34 (81%) were complete. Reintervention was required in 14 eyelids (16%). CONCLUSIONS: Measuring surgical outcomes with Bézier curves allows an automated, complete and objective assessment, giving more consistency to our data compared to previous reports. Müllerotomy with graded Müller muscle disinsertion is a safe and effective procedure for Graves UER, offering predictable results.

Enhanced Depth Imaging Optical Coherence Tomography Technology Reveals a Significant Association Between Optic Nerve Drusen Anterior Displacement and Retinal Nerve Fiber Layer Thinning Over Time.

BACKGROUND: Optic disc drusen (ODD) are a dynamic phenomenon, and their appearance, size, and relative location may change. The purpose of this study is to evaluate and quantify the longitudinal changes of buried ODD with enhanced depth imaging (EDI) optical coherence tomography (OCT) over time. METHODS: ODD were analyzed with Spectralis OCT (Heidelberg Engineering, Heidelberg, Germany) and EDI technology. The peripapillary retinal nerve fiber layer (RNFL) thickness was also measured. The size and depth of ODD were compared between the baseline and study visit (at least 2 years of follow-up), and the changes were correlated with mean RNFL thickness. The repeatability, coefficient of variation, and cutoff values for size and depth on EDI-OCT were calculated. RESULTS: Of 21 previously identified patients with ODD, only 12 patients (21 eyes) met the most recent diagnostic criteria according to the ODD Studies Consortium recommendations for using OCT-EDI technology. The 21 eyes were reanalyzed after a mean period of 44.7 ± 13.2 months (range: 24-71 months). Overall, 132 ODD were evaluated with a mean of 6.1 ± 2.5 ODD per eye and 1.9 ± 1.1 ODD per scan. Overall, we found a significant forward movement of the drusen between visits (P = 0.01). Most drusen (67.4%) moved anteriorly, and in approximately one-third (35.6%), this displacement exceeded the cutoff value (64.28 µm). Furthermore, we found a significant correlation between ODD shallowing and RNFL thinning during the follow-up (P ≤ 0.03; R ≥ 0.370). We did not find any significant changes in size measurements (P = 0.10) over time. CONCLUSIONS: In approximately one-third of buried ODD, a significant anterior movement occurred over 2 years of follow-up, and this movement was associated with significant RNFL thinning. By contrast, no significant change was detected in the size of the buried ODD.

Real-World Clinical Experience With Idebenone in the Treatment of Leber Hereditary Optic Neuropathy.

BACKGROUND: Leber hereditary optic neuropathy (LHON) leads to bilateral central vision loss. In a clinical trial setting, idebenone has been shown to be safe and to provide a trend toward improved visual acuity, but long-term evidence of effectiveness in real-world clinical practice is sparse. METHODS: Open-label, multicenter, retrospective, noncontrolled analysis of long-term visual acuity and safety in 111 LHON patients treated with idebenone (900 mg/day) in an expanded access program. Eligible patients had a confirmed mitochondrial DNA mutation and had experienced the onset of symptoms (most recent eye) within 1 year before enrollment. Data on visual acuity and adverse events were collected as per normal clinical practice. Efficacy was assessed as the proportion of patients with either a clinically relevant recovery (CRR) or a clinically relevant stabilization (CRS) of visual acuity. In the case of CRR, time to and magnitude of recovery over the course of time were also assessed. RESULTS: At time of analysis, 87 patients had provided longitudinal efficacy data. Average treatment duration was 25.6 months. CRR was observed in 46.0% of patients. Analysis of treatment effect by duration showed that the proportion of patients with recovery and the magnitude of recovery increased with treatment duration. Average gain in best-corrected visual acuity for responders was 0.72 logarithm of the minimal angle of resolution (logMAR), equivalent to more than 7 lines on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Furthermore, 50% of patients who had a visual acuity below 1.0 logMAR in at least one eye at initiation of treatment successfully maintained their vision below this threshold by last observation. Idebenone was well tolerated, with most adverse events classified as minor. CONCLUSIONS: These data demonstrate the benefit of idebenone treatment in recovering lost vision and maintaining good residual vision in a real-world setting. Together, these findings indicate that idebenone treatment should be initiated early and be maintained more than 24 months to maximize efficacy. Safety results were consistent with the known safety profile of idebenone.

Reduced Peripapillary and Macular Vessel Density in Unilateral Postgeniculate Lesions With Retrograde Transsynaptic Degeneration.

BACKGROUND: Retrograde transsynaptic degeneration (RTSD) of the retinal ganglion cells and retinal nerve fiber layer after postgeniculate injury has been well documented, but to the best of our knowledge, associated retinal microvascular changes have not been examined. The purpose of our study was to assess vessel density (VD) at macular and peripapillary regions in patients with RTSD. METHODS: Cross-sectional study including 16 patients with homonymous visual field defects secondary to unilateral postgeniculate visual pathway injury and 18 age-matched controls. All participants were examined with AngioVue optical coherence tomography angiography to measure the peripapillary vessel density and macular vessel density (pVD/mVD) as well as the peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell complex (GCC) thicknesses. The pRNFL and macular ganglion cell-inner plexiform layer (GCIPL) thicknesses also were evaluated using Cirrus OCT. A normalized asymmetry score (NAS) was calculated for GCIPL and GCC thickness, and mVD. RESULTS: Average pRNFL and macular GCIPL/GCC thicknesses were significantly thinner in both eyes of patients compared with control eyes (all P ≤ 0.05). Eight patients (50%), who showed a RTSD of the GCIPL map, had a relative thinning of the GCIPL/GCC ipsilateral to the brain lesion in both eyes (represented by a positive GCIPL-NAS/GCC-NAS). The mean pVD and mVD also were significantly reduced in patients (all P ≤ 0.05). There was a strong correlation between GCIPL-NAS/GCC-NAS and mVD-NAS index in both eyes (all r > 0.7, P = 0.001). Furthermore, there was a similar spatial pattern of damage for the macular GCC thickness and VD values. CONCLUSIONS: We demonstrated a significant VD decrease in peripapillary and macular areas of patients with RTSD because of postgeniculate lesions. The structural and microvascular asymmetry indexes were significantly correlated. These findings provide new insights regarding transsynaptic degeneration of the visual system.

Reduction of Peripapillary Vessel Density by Optical Coherence Tomography Angiography from the Acute to the Atrophic Stage in Non-Arteritic Anterior Ischaemic Optic Neuropathy.

PURPOSE: To analyse superficial peripapillary vascularization in non-arteritic anterior ischaemic optic neuropathy (NAION) at acute and atrophic (3 months) stage. PROCEDURES: Prospective case-control study including 6 patients with NAION and 10 age-matched healthy controls evaluated with optical coherence tomography angiography (OCT-A; Angioplex-Cirrus) at acute and atrophic stage. Apart from the -commercially provided measurements for vessel density (VD) and perfusion density (PD), a custom image analysis was used to quantify the peripapillary capillary density (PCD). RESULTS: NAION-group demonstrated a significant decrease in the PCD, VD and PD compared with fellow unaffected and control groups at acute and atrophic stage. At 3 months, the average and the temporal sector in PCD correlated with logMAR VA (-0.943, p = 0.005 and -0.829, p = 0.042 for average and temporal sectors respectively) and with MD (0.943, p = 0.005; and 0.899; p = 0.015, respectively). Over 3 months, there was a significant PCD reduction at the temporal sector and at the inner circle in VD and PD, which correlated with ganglion cell-inner plexiform layer (GCIPL) thinning over the 3 months period after the acute NAION (0.749, p = 0.020; 0.885, p = 0.002; 0.767, p = 0.016 respectively). CONCLUSION: Both strategies demonstrated a significant peripapillary microvascular dropout in NAION, but the customized analysis detected them -earlier. A progressive vessel reduction occurs within the first 3 months, which correlates with GCIPL thinning.

Automated Evaluation of Choroidal Thickness and Minimum Rim Width Thickness in Nonarteritic Anterior Ischemic Optic Neuropathy.

BACKGROUND: The aim of this study was to evaluate and compare peripapillary choroidal thickness (pCT) and macular choroidal thickness (CT), Bruch membrane opening-minimum rim width (BMO-MRW), retinal nerve fiber layer (RNFL) thickness, and optic disc area among nonarteritic anterior ischemic optic neuropathy (NAION) eyes, the contralateral unaffected eyes, and healthy control eyes. METHODS: Twenty-six patients diagnosed with NAION (29 affected and 21 unaffected eyes) and 29 healthy matched control individuals (29 eyes) were analyzed by swept-source optical coherence tomography. All participants underwent scanning by Spectralis optical coherence tomography to analyze BMO-MRW, RNFL thickness, and optic disc area. RESULTS: Mean pCT in the NAION eyes, unaffected fellow eyes, and the control group was 130.5 ± 72.1 µm, 149.6 ± 75.7 µm, and 103.7 ± 36.7 µm, respectively (analysis of variance [ANOVA], P = 0.04). Mean macular CT in the NAION eyes, unaffected fellow eyes, and the control group was 226.1 ± 79.8 µm, 244.6 ± 81.4 µm, and 189.9 ± 56.4 µm, respectively (ANOVA, P = 0.03). Mean and all sectorial RNFL and BMO-MRW thickness values were significantly thinner in the NAION eyes vs the unaffected fellow and control eyes (P ≤ 0.00). The unaffected fellow eyes in NAION patients showed a significantly thicker average and sectorial BMO-MRW values than control eyes (P ≤ 0.02) except for the nasal sector (P = 0.09). Mean optic disc area derived from BMO analysis was not significantly different among groups (ANOVA, P = 0.86). CONCLUSIONS: The fellow unaffected eyes in patients with NAION showed significantly thicker mean peripapillary and macular choroidal and BMO-MRW thicknesses than disease-free control eyes. No differences in the mean optic disc area were found. Both a thick peripapillary choroid and a thick neuroretinal rim might contribute to the development of NAION or possibly be a secondary phenomenon.

Relationship between lamina cribrosa displacement and trans-laminar pressure difference in papilledema.

PURPOSE: The purpose of this study was to describe morphological changes in lamina cribrosa (LC), prelaminar tissue thickness (PTT) and Bruch's membrane opening (BMO) in eyes affected by papilledema and correlate them with trans-LC-pressure difference (TLCD). METHODS: This was a prospective study, including twelve eyes newly diagnosed of papilledema. Eyes underwent scanning with Spectralis-OCT with enhanced depth imaging to compare BMO, anterior LC surface position (LC depth-LCD-) and PTT before and after oedema resolution. Correlation analysis between these parameters and TLCD was performed. RESULTS: TLCD inversely correlated with LCD at baseline and directly with LC reversal movement after lowering cerebrospinal fluid pressure (CSFP) (ρSpearman: -0.739, p = 0.006; ρSpearman: 0.844, p = 0.001 respectively). At onset, RNFL thickening and BMO were significantly larger in eyes with TLCD > -9.2 mmHg (group 2) compared with TLCD < -9.2 mmHg (group 1) [p = 0.007, p = 0.041 respectively]. A significant RNFL and BMO shrinking were observed, but they were significantly larger in group 2. The magnitude of LC displacement following oedema resolution was significantly larger and in the opposite direction in group 2 vs group 1 (-68.7 µm vs 19.5 µm, p = 0.016). TLCD correlated with RNFL thickening at baseline (ρSpearman: 0.667, p = 0.018) and with RNFL thinning at last visit (ρSpearman: 0.673, p = 0.017). TLCD correlated with mean deviation (MD) (ρSpearman: 0.712, p = 0.014) and visual field index (VFI) (ρSpearman: -0.657, p = 0.028) at onset. MD and VFI were worse in group 2. CONCLUSIONS: LC position was significantly related to TLCD in papilledema. Eyes with higher TCLD showed significantly larger backward LC movement, BMO shrinking and RNFL thinning after lowering CSFP compared with eyes with lower TLCD, where LC movement occurred in the opposite direction.

Ganglion cell layer analysis unmasks axonal loss in anterior optic neuritis.

Optical coherence tomography is a valuable tool for evaluating patients with neuro-ophthalmic disorders. In the acute phase of anterior optic neuritis (ON), peripapillary retinal nerve fiber layer (pRNFL) measurements can underestimate the amount of damage as axonal swelling could mask the true degree of RNFL loss. Contrary to pRNFL evaluation, we hypothesize that macular ganglion cell layer analysis could detect true neuronal loss before swelling resolution in anterior ON. We describe 4 patients with anterior ON in whom ganglion cell layer and inner plexiform layer (GCIPL) thinning was detected earlier than pRNFL loss. GCIPL analysis may provide more accurate information than pRNFL thickness and serve as an early structural indicator of irreversible neuronal loss.

A comparison of false positives in retinal nerve fiber layer, optic nerve head and macular ganglion cell-inner plexiform layer from two spectral-domain optical coherence tomography devices.

BACKGROUND: The incidence of false positive (FP) results of optic coherence tomography (OCT) retinal nerve fiber layer (RNFL) color code in healthy subjects can be very high with Cirrus OCT. Recent evidence has shown that OCT parameters derived from macular ganglion cell-inner plexiform layer (GCIPL) have excellent ability to discriminate between normal eyes and eyes with early glaucoma. METHODS: This was a prospective, cross-sectional study. One hundred eyes from 50 healthy volunteers underwent circumpapillary scanning by Cirrus and Spectralis OCT and macular scanning using Cirrus OCT. FP rates for each of the OCT parameters, using predefined criteria for an abnormal test were calculated. Comparative analysis was performed using the McNemar test. A generalized estimating equations model (GEE) was used to compare demographic and clinical factors between the eyes with normal findings and eyes with abnormal results. RESULTS: The overall RNFL color-code FP rate was significantly higher for Cirrus (39 %) than for Spectralis (18 %) (P = 0.000). The Spectralis RNFL FP rate showed no significant difference when compared to the FP rate by Cirrus GCIPL (13 %) and ONH (11 %) analysis. Axial length, mean spherical equivalent, presence of peripapillary atrophy, and tilted disc were significantly related to the RNFL FP occurrence displayed by both devices. CONCLUSIONS: Spectralis might be more specific than Cirrus when evaluating the RNFL thickness for Caucasians and moderate myopic population. GCIPL and ONH analysis might be more useful than RNFL thickness to evaluate this population using Cirrus OCT.

Measurement of retinal nerve fiber layer and macular ganglion cell-inner plexiform layer with spectral-domain optical coherence tomography in patients with optic nerve head drusen.

PURPOSE: To evaluate the effect of optic nerve head drusen (ONHD) on the retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) using Cirrus optical coherence tomography (OCT). METHODS: Fifty-seven eyes of thirty patients with ONHD and thirty-eight eyes of twenty age-matched and sex-matched control subjects underwent circumpapillary and macular scanning using Cirrus OCT. The percentages of eyes with abnormal GCIPL and RNFL values according to the Cirrus normative data were analysed and compared. RESULTS: Overall, eyes with ONHD showed abnormally reduced values for average and minimum GCIPL thicknesses in 35 % and 45 % of cases compared to 2 % for both values in control eyes (P < 0.001). Average RNFL thickness comparison between eyes with ONHD and normal eyes revealed abnormal thinning in 33 % vs. 0 %, respectively (p = 0.002). The percentage of abnormal thinning increased with higher grades of ONHD for all the parameters evaluated, so that in grade III drusen, values were abnormally reduced in 80 % of eyes in all three analyses. Regarding buried ONHD, 30 % and 4 % of eyes had an abnormally reduced minimum GCIPL and average RNFL thickness, respectively. Furthermore, 26 % of these eyes had abnormal GCIPL exams with a normal or increased RNFL thickness. CONCLUSIONS: Both RNFL and GCIPL analysis reveal significant thinning in eyes with ONHD directly correlated with drusen severity. In buried ONHD, the abnormality rate was significantly higher with GCIPL compared to RNFL evaluation, suggesting that GCIPL analysis might be an early structural indicator of neuronal loss in the setting of thickened RNFL.

Preservative-Free Bimatoprost 0.01% Ophthalmic Gel for Glaucoma Therapy: A Phase III Randomized Controlled Trial.

PRCIS: Noninferiority of efficacy was demonstrated for a preservative-free bimatoprost 0.01% compared with BAK-containing bimatoprost 0.01% following a 12-week treatment period in patients with open angle glaucoma or ocular hypertension. Improved tolerability, in particular conjunctival hyperemia, was also observed. PURPOSE: To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of a preservative-free bimatoprost 0.01% ophthalmic gel (PFB 0.01% gel) compared with preserved bimatoprost 0.01% (PB 0.01%). DESIGN: Phase III, international, multicenter, randomized, 2-parallel group, investigator-masked, 3-month treatment duration. METHODS: Patients with glaucoma or ocular hypertension were randomized after a 7-week run-in/washout period to receive once-daily PFB 0.01% gel (n=236) or PB 0.01% (n=249) for 3 months. The primary efficacy measure was changed from baseline in IOP at week 12. Safety measures included adverse events (AEs) and assessment of conjunctival hyperemia. RESULTS: The mean changes from baseline in IOP at week 12 in the PFB 0.01% gel and PB 0.01% were -9.72±2.97 and -9.47±3.06 mm Hg, respectively, at 8 am , -9.41±3.03 and -9.19±3.12 mm Hg at 10 am , and -8.99±3.36 and -8.54±3.44 mm Hg at 4 pm . Noninferiority of PFB 0.01% gel to PB 0.01% was demonstrated at week 12 based on predetermined criteria (upper 95% CI margin of 1.5 mmHg at all time points). The most frequently reported AE was conjunctival hyperemia; 13 (5.5%) patients with PFB 0.01% gel and 17 (6.8%) patients with PB 0.01%. The percentage of patients experiencing a worsening from baseline in conjunctival hyperemia score was lower with PFB 0.01% gel compared to PB 0.01% at week 6 (20.1% vs. 29.3%, respectively) and week 12 (18.3% vs. 30.4%, respectively). CONCLUSIONS: PFB 0.01% ophthalmic gel has the same efficacy in lowering IOP as PB 0.01% and demonstrated less aggravation of conjunctival hyperemia at weeks 6 and 12.

Comparison of corneal haze and visual outcome in primary DSAEK versus DSAEK following failed DMEK.

BACKGROUND: Descemet membrane endothelial keratoplasty (DMEK) is being proposed as the procedure of choice in corneal endothelial disease as it achieves better visual and refractive outcomes than Descemet stripping automated endothelial keratoplasty (DSAEK). Nevertheless, primary graft failure is frequent, especially during the learning curve, and secondary back-up procedure consists on DSAEK. We aim to compare corneal haze and visual acuity of patients undergoing primary DSAEK vs. patients undergoing DSAEK as a back-up procedure after primary DMEK failure. METHODS: This study is a comparative case series that included 19 eyes from 16 patients with early stages of corneal failure and limitation of daily activities after primary DSAEK or secondary DSAEK. A control group of non-operated corneas included 10 aged-matched normal eyes. The study was conducted at University Hospital Ramón y Cajal and Vissum Hospital, Madrid, Spain. Corneal densitometry readings and postoperative best-corrected visual acuity in subjects with primary and secondary DSAEK were recorded 6 months after the surgery using the Pentacam Scheimpflug system (Oculus, inc.,Wetzlar, Germany). RESULTS: In primary DSAEK median densitometry values (range) were statistically significantly higher (p < 0.05) than normal subjects for the full thickness, posterior and anterior part of the paracentral cornea; and the anterior part of the central cornea. In secondary DSAEK, median densitometry values were statistically significantly higher than normal subjects at all levels of the central and paracentral cornea. In secondary DSAEK, median densitometry values (range) were statistically significantly higher than in primary DSAEK in the full-thickness, anterior part and interface of the central cornea and in the full-thickness and posterior part of the paracentral cornea. Median visual acuity between groups (p = 0.47) was statistically better for the primary DSAEK group, which also had a higher percentage of patients achieving BCVA of ≥ 20/40 and ≥ 20/25 than the secondary DSAEK group (100% vs. 62% and 60% vs. 0% respectively). CONCLUSIONS: There is an increase in central corneal light scattering after secondary DSAEK performed after a failed DMEK as compared to primary DSAEK. This has a negative impact on final visual acuity that needs to be considered in each patient when starting DMEK surgery.

Bézier curves as a total approach to measure the upper lid contour: redefining clinical outcomes in palpebral surgery.

AIMS: To define and quantify the upper lid contour by adapting Bézier curves with a newly developed software in normal subjects, assessing their reliability. METHODS: Fifty eyes of 50 healthy patients with no ocular pathology were included in this study from October 2020 to November 2020. All measurements were performed on Bézier curves adjusted to the upper lid contour. An original software was used to measure the radial and vertical midpupil-to-lid margin distances (MPLD), temporal-to-nasal (T/N) ratios, contour peak location and grade of superposition (GS) and asymmetry (GA) indexes. We calculated differences in the variables measured regarding age, gender or the side of the eye being assessed. RESULTS: The mean Bézier curve showed an excellent level of inter-rater reliability (intraclass correlation coefficient of 0.99). The median GS index of each eyelid to the mean Bézier curve was 95.4%, 8.5 IQR, and the median GA index was 3%, 3.4 IQR. The mean contour peak location was -0.35 mm, SD 0.45. Overall, the mean central MPLD was 4.1 mm, SD 0.6. No significant differences were found between male and female patients in variables derived from Bézier curves. CONCLUSION: Bézier curves may become a very useful tool for the assessment of upper lid contour, contour peak and symmetry. GS and GA indexes, along with the T/N area ratio are potential outcomes for this purpose. All current variables can be obtained just from one single Bézier curve measurement. Our results offer an in-depth exhaustive description of these variables and their distribution in the normal population.

Postoperative drift and dose-response of strabismus surgery in thyroid eye disease: predicting desired outcomes with intraoperative adjustable sutures.

OBJECTIVE: To report outcomes of strabismus surgery in thyroid eye disease using intraoperative bow-knot adjustable sutures under topical anaesthesia and calculate prediction models for surgical correction and postoperative drift depending on surgical dose-response. METHODS: We retrospectively reviewed patients operated on from 2016 to 2021. A satisfactory outcome was defined as no diplopia with maintenance of vertical (<5 PD) and horizontal (<10 PD) stable alignment at primary gaze. Subjective diplopia corrected with prisms within successful motor alignment was defined as a fair result. Otherwise, the result was considered to be poor. RESULTS: A total of 73 patients were included (60 females, 82%). Mean preoperative horizontal and vertical deviations were 26.9 PD (19.1 SD), and 11.8 PD (7.6 SD), respectively. Mean horizontal drift was -3.2 PD (5.2 SD), whereas mean vertical drift was -3.4 PD (3.3 SD). A linear regression established a dose-response of 2.37 PD/mm for each medial rectus recession (p < 0.0001; r2 = 0.777) and 3.75 PD/mm for unilateral inferior rectus recession (p < 0.0001; r2 = 0.922). Final success rate was satisfactory in 62 patients (85%), fair in 7 patients (10%), and poor in 4 patients (5%). CONCLUSIONS: Muscle recession with intraoperative adjustable sutures is effective for the treatment of thyroid eye disease strabismus. Predictable dose-responses could be achieved with a drift toward overcorrection. Undercorrection proportional to the planned surgical dose should be the immediate postoperative target of choice. Other variables such as orbital decompression and concurrent vertical and horizontal surgery do not correlate with dose-response and postoperative drift. However, further studies are necessary to validate our findings.

Changes in eyelid position after glaucoma filtering surgery.

BACKGROUND: While ptosis is a well-known consequence of glaucoma surgery, some isolated case reports point to the possibility of upper eyelid retraction occurring after glaucoma surgery. This study aims to analyze the occurrence of ptosis and eyelid retraction after glaucoma surgery and to evaluate factors contributing to these palpebral fissure changes. METHODS: Cross-sectional study including 100 eyes of 100 patients that had undergone unilateral glaucoma surgery. Upper eyelid height in the operated eye was measured by digital photography and compared with the fellow, non-operated eye. The main outcome was to determine if ptosis or retraction occurred in the operated eye in comparison with the fellow eye. The secondary outcome was to determine if any variable was associated with ptosis or retraction. A clinically significant difference (either toward ptosis or retraction) was defined as a difference ≥1 mm between both eyes. RESULTS: Of 100 eyes included 81 (81%) showed no change in eyelid height (-0.133 mm ± 0.496), 11 (11%) showed ptosis (-1.348 mm ± 0.387) and 8 eyes (8%) showed retraction (1.705 ± 0.634). A statistically significant relation was found between ptosis and pseudoexfoliation glaucoma (p = 0.003). A trend toward lower postoperative IOP and higher conjunctival blebs was found in eyes with postoperative eyelid retraction. CONCLUSIONS: Eyelid retraction was present in 8% of patients and ptosis in 11%. Patients with eyelid retraction showed around a 3 mmHg lower postoperative IOP than eyes without retraction. The presence of pseudoexfoliation may be a risk factor for this complication. A prospective study with a large number of patients would be required to confirm these results.

Recommendations for ophthalmologic practice during the easing of COVID-19 control measures.

In the context of the COVID-19 pandemic, this paper provides recommendations for medical eye care during the easing of control measures after lockdown. The guidelines presented are based on a literature review and consensus among all Spanish Ophthalmology Societies regarding protection measures recommended for the ophthalmologic care of patients with or without confirmed COVID-19 in outpatient, inpatient, emergency and surgery settings. We recommend that all measures be adapted to the circumstances and availability of personal protective equipment at each centre and also highlight the need to periodically update recommendations as we may need to readopt more restrictive measures depending on the local epidemiology of the virus. These guidelines are designed to avoid the transmission of SARS-CoV-2 among both patients and healthcare staff as we gradually return to normal medical practice, to prevent postoperative complications and try to reduce possible deficiencies in the diagnosis, treatment and follow-up of the ophthalmic diseases. With this update (5th ) the Spanish Society of Ophthalmology is placed as one of the major ophthalmology societies providing periodic and systematized recommendations for ophthalmic care during the COVID-19 pandemic.

Comparison between phaco-deep sclerectomy and phaco-deep sclerectomy reconverted into phaco-trabeculectomy: series of fellow eyes.

BACKGROUND: To evaluate and compare the results and complications after uneventful phaco-deep sclerectomy in one eye with intended phaco-deep sclerectomy converted to phaco-trabeculectomy in the fellow eye. METHODS: In this retrospective study, we analyzed thirty-two eyes of sixteen patients in which bilateral phaco-deep sclerectomy was planned but one eye was converted to phaco-trabeculectomy after perforation of the trabeculo-Descemet's membrane. Visual acuity (VA), slit-lamp examinations, intraocular pressure (IOP), and the number of glaucoma medications were recorded preoperatively and postoperatively at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. The postoperative complications were recorded. Comparisons between the two groups were performed. RESULTS: The IOP was significantly lower in both groups at every postoperative visit. The postoperative IOP and VA levels did not differ significantly between the groups. However, at the last postoperative visit, eyes that underwent uneventful phaco-deep sclerectomy required fewer glaucoma medications than eyes converted to phaco-trabeculectomy (P = 0.04). At 24 months, the group that underwent uneventful phaco-deep sclerectomy had a higher complete success rate (P = 0.01). Immediate postoperative complications such as hyphema, a shallow anterior chamber, or a choroidal detachment occurred more frequently in eyes converted to phaco-trabeculectomy, although the difference did not reach significance. CONCLUSIONS: There were no differences in VA or IOP control between uneventful phaco-deep sclerectomy and phaco-deep sclerectomy converted to phaco-trabeculectomy. However, fewer drugs were needed to successfully control IOP and the rate of complications was lower if phaco-deep sclerectomy was completed uneventfully.

Quantitative evaluation of anterior chamber changes after iridotomy using Pentacam anterior segment analyzer.

PURPOSE: To evaluate changes in anterior chamber morphology with the Pentacam anterior segment analyzer and gonioscopy after laser peripheral iridotomy (LPI) in patients with primary angle closure glaucoma and narrow angle and to compare central corneal thickness measurements performed with Pentacam and ultrasound pachymetry. METHODS: Twenty eyes of 20 patients were enrolled in this prospective interventional study. Before and after LPI, volume, angle, and central and peripheral depth of anterior chamber was quantified with Pentacam. Central corneal thickness was measured with Pentacam and ultrasound pachymetry. RESULTS: Mean central corneal thickness as measured with Pentacam pachymetry was slightly lower than the measurements provided by ultrasonic pachymetry (551.9 microm, range 509-659, versus 556.8 microm, range 520-644) (p=0.93) with an intraclass correlation coefficient of 0.92. Anterior chamber angle increased from 20.32 (standard deviation [SD] 4.2) to 22.31 degrees (SD 3.9). Anterior chamber central depth increased significantly from 1.79 mm (SD 0.22) to 1.85 mm (SD 0.21) and volume changed from 72.18 mm (SD 16.82) to 89.12 mm (SD 12.3), p=0.001. Gonioscopy showed that Shaffer angle widened significantly in all quadrants. Mean intraocular pressure changed from 20.8 mmHg to 18.3 mmHg after LPI (p<0.05). CONCLUSIONS: In patients with primary angle closure glaucoma and narrow angles, anterior chamber volume, angle, and central and peripheral depth, measured with Pentacam, increase significantly after LPI.