Managing primary open-angle glaucoma in the setting of suboptimal surgical outcomes in the fellow eye.

A 62-year-old woman with mild myopia presented to her local optometrist for a routine examination and was found to have intraocular pressure (IOP) of 30 mm Hg in both eyes and cupped nerves. She had a family history of glaucoma in her father. She was started on latanoprost in both eyes and was referred for a glaucoma evaluation. On initial evaluation, her IOP was 25 mm Hg in the right eye and 26 mm Hg in the left eye. Central corneal thickness measured 592 µm in the right eye and 581 µm in the left eye. Her angles were open to gonioscopy without any peripheral anterior synechia. She had 1+ nuclear sclerosis with a corrected distance visual acuity (CDVA) of 20/25 in the right eye and 20/30- in the left eye and uncorrected near visual acuity of J1+ in each eye. Her nerves were 0.85 mm in the right eye and 0.75 mm in the left eye. Optical coherence tomography (OCT) showed retinal nerve fiber layer thinning and a dense superior arcuate scotoma into fixation in her right eye, and superior and inferior arcuate scotomas in her left eye (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202307000-00019/figure1/v/2023-06-26T195222Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202307000-00019/figure2/v/2023-06-26T195222Z/r/image-tiff, Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A882 and http://links.lww.com/JRS/A883). She was successively trialed on fixed combination brimonidine-timolol, dorzolamide, and netarsudil, in addition to her latanoprost, but her IOP remained in the mid- to upper 20s in both eyes. The addition of acetazolamide lowered the pressure to 19 mm Hg in both eyes, but she tolerated it poorly. Methazolamide was also attempted with similar side effects. We elected to perform left eye cataract surgery combined with 360-degree viscocanaloplasty and insertion of a Hydrus microstent (Alcon Laboratories, Inc.). Surgery was uncomplicated with IOP of 16 mm Hg on postoperative day 1 with no glaucoma medications. However, by postoperative week 3, IOP returned to 27 mm Hg, and despite restarting latanoprost-netarsudil and finishing her steroid taper, IOP remained at 27 mm Hg by postoperative week 6. Brimonidine-timolol was added back to her left eye regimen and at postoperative week 8, IOP had elevated to 45 mm Hg. Maximizing her therapy with the addition of topical dorzolamide and oral methazolamide brought her IOP back down to 30 mm Hg. At that point, the decision was made to proceed with trabeculectomy of the left eye. The trabeculectomy was uneventful. However, postoperative attempts to augment filtration were rendered less successful by extremely thick Tenon layer. At her most recent follow-up the pressure in the left eye was mid-teens with brimonidine-timolol and dorzolamide. Her right eye IOP is in the upper 20s on maximum topical therapy. Knowing her postoperative course in the left eye, how would you manage the right eye? In addition to currently available options, would you consider a supraciliary shunt such as the MINIject (iSTAR) if such a device were U.S. Food and Drug Administration (FDA)-approved?

Pharmacologic Mydriasis Secondary to Topical Glycopyrronium Tosylate Cloths: Clinical Characterization From a Multicenter Analysis.

BACKGROUND: Topical glycopyrronium tosylate (GT) is an anticholinergic medication for treatment of axillary hyperhidrosis. Pharmacologic mydriasis and anisocoria from topical GT has been reported and may be underrecognized. This study aims to clinically characterize patients presenting with pharmacologic mydriasis from exposure to this medication. METHODS: This study is a retrospective observational case series. A multicenter chart review of 16 patients diagnosed with pharmacologic mydriasis secondary to topical GT was performed. RESULTS: Eight patients (50.0%) were age 18 years and younger, and 14 patients (87.5%) were female. Unilateral mydriasis (anisocoria) occurred in 14 patients (87.5%). Fourteen patients (87.5%) did not initially volunteer topical GT as a "medication," and the history of topical GT exposure needed to be elicited with further questioning. Hand hygiene details were known for 12 patients, and all reported that they did not wash their hands after GT application. Six patients (37.5%) were soft contact lens users. One patient had possible exposure through a family member's use of the medication. Ocular symptoms were common (blurry vision [11 patients, 68.8%] and eye dryness [7 patients, 43.8%]), but systemic anticholinergic symptoms were uncommon (such as constipation [1 patient, 6.3%] and urinary symptoms [3 patients, 18.8%]). CONCLUSIONS: Mydriasis associated with topical GT seems to be a consequence of local exposure rather than systemic toxicity. Because patients may not volunteer topical GT as a medication, eliciting a history of exposure often requires further specific questioning. Soft contact lens wear and poor postapplication hand hygiene seem to be associated with mydriasis in GT use.

Open globe injury and intraocular foreign body following crossbow-related penetrating ocular trauma.

PURPOSE: To describe a case of a penetrating ocular trauma and plastic intraocular foreign body (IOFB), undetected on preoperative imaging. OBSERVATIONS: We present the findings of a 40-year-old male who sustained an open globe injury and IOFB composed of plastic following crossbow-related trauma. Preoperative detection of the IOFB was unsuccessful on clinical exam, computed tomography (CT) and ultrasonography. During extraction of the traumatic cataract, an intralenticular IOFB was discovered and removed through an enlarged limbal incision. Postoperative review revealed that a fragmented plastic "nock", from the crossbow arrow bolt, was the likely IOFB source. The bolt was produced by injection molding which may lead to trapped gas within the plastic, causing radiolucency on CT. CONCLUSIONS AND IMPORTANCE: Radiolucent plastic warrants consideration on the differential diagnosis when intraocular gas is noted on computed tomography following penetrating ocular trauma. Multimodal imaging should be considered if IOFB is suspected and not detected by CT.

Oral acetazolamide for intraocular pressure lowering: balancing efficacy and safety in ophthalmic practice.

Introduction: Systemic acetazolamide is an efficacious adjunct to topical therapy to lower intraocular pressure (IOP) in glaucomatous eyes. This article aims to provide a comprehensive review for how best to use the agent in ophthalmic practice.Areas covered: This article will review the history, mechanism of action, methods of observing efficacy, indications for IOP lowering, side effects, allergy information including discussion of limited cross-reactivity between antimicrobial and non-antimicrobial sulfonamides, formulations, dosing and monitoring of acetazolamide. To select articles for this review, an electronic search was conducted using the PubMed database and cross-referencing was conducted for relevant literature.Expert opinion: The benefits of oral carbonic anhydrase inhibitor therapy can outweigh the risks in many circumstances. It is important that eye care practitioners work together with a patient's primary care practitioner to monitor for and mitigate risks. Greater education is needed with regard to the allergy profile of these powerful agents. Though not often a first-line option, oral carbonic anhydrase inhibitors remain pivotal and play in important role in delivery of eye care.

Association of Surgical Setting and Deployment of a New Electronic Health Record With Ophthalmic Operative Times.

IMPORTANCE: Determining the association of surgical setting and implementation of a new electronic health record (EHR) system with ophthalmic operative times is important for surgical planning and resource allocation. OBJECTIVE: To assess the associations of surgical setting and EHR system replacement with operative times for ophthalmic surgery. DESIGN, SETTING, AND PARTICIPANTS: This case series included ophthalmic surgeries from July 2015 to November 2016 in 2 ambulatory surgical centers and 1 hospital outpatient department in a single academic eye institute. Operative times from consecutive surgical cases performed by board-certified ophthalmologists were extracted from 2 EHR systems. Those performed after replacement EHR system implementation were divided into three 50-day time categories (immediate posttransition, intermediate posttransition, and late posttransition periods). Multivariable regression analyses assessed the associations of surgical setting (hospital outpatient department vs ambulatory surgical center) with total operating room times for comparable surgeons performing cataract surgery and deployment of a new EHR system in the OR on several operative time measures. Data were evaluated from November 2016 to March 2018. MAIN OUTCOMES AND MEASURES: Room duration, procedure duration, turnaround time, and total OR time. RESULTS: A total of 11 064 cases performed by 76 surgeons were included in this analysis. The mean total OR time was 2.9 (95% CI, 0.5-5.4; P = .02) minutes longer in the immediate posttransition period and 1.2 (95% CI, 0.1-2.2; P = .04) minutes longer in the intermediate posttransition period relative to surgeries performed before EHR system replacement. No difference in the total OR time was found between the late posttransition and pretransition periods. Relative to ambulatory surgical centers, the mean total OR time was 15.9 (95% CI, 14.7-17.0) minutes longer, and the mean turnaround time was 5.1 (95% CI, 4.3-6.0) minutes longer at the hospital outpatient department for comparable surgeons performing cataract surgery (P < .001 for both). CONCLUSIONS AND RELEVANCE: The mean total OR time per case lengthened after the replacement of an EHR system in the OR, but this increase was small (shorter than 3 minutes) and limited to surgeries performed during the first 100 days after the EHR system transition. Modeling to assess surgical setting demonstrated all operative time measures were longer for cataract cases performed at the hospital outpatient department relative to those at ambulatory surgical centers. These data have implications for the fiscal and logistical management of ophthalmic surgery.

Systematic review of outcomes following observational and operative endoscopic middle ear surgery.

OBJECTIVES: Middle ear surgery increasingly employs endoscopes as an adjunct to or replacement for the operative microscope. We provide a systematic review of endoscope applications in middle ear surgery with an emphasis on outcomes, including the need for conversion to microscope, audiometric findings, length of follow-up, as well as disease-specific outcomes. DATA SOURCES: PubMed, Embase, and Cochrane CENTRAL database. METHODS: A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. Articles were categorized based on study design, indication, and use of an endoscope either as an adjunct to or as a replacement for a microscope. Qualitative and descriptive analyses of studies and outcomes data were performed. RESULTS: One-hundred three articles met inclusion and exclusion criteria. Of the identified articles, 38 provided outcomes data. The majority of these studies were moderate quality, retrospective, case-series reports. The indications for use of the endoscope were broad, with the most common being resection of cholesteatoma. In cholesteatoma surgery, endoscope approaches routinely identified residual cholesteatoma in primary and second-look cases. Other outcomes, including robust audiometric data, operating room times, wound healing, and quality of life surveys were not well described. CONCLUSIONS: Endoscopes have consistently been used as an adjunct to the microscope to improve visualization of the tympanic cavity. Recent reports utilize the endoscope exclusively during surgical dissection; however, data comparing patient outcomes following the use of an endoscope to a microscope are lacking. Areas in need of additional research are highlighted. LEVEL OF EVIDENCE: NA