Outcomes of Selective Laser Trabeculoplasty After Prior Incisional Surgery for Open Angle Glaucoma.

PRCIS: This retrospective case series of patients with open angle glaucoma and prior trabeculectomy or tube shunt surgery found that selective laser trabeculoplasty (SLT) resulted in significant intraocular pressure (IOP) reductions in the intermediate follow-up period in select cases. PURPOSE: The purpose of this study was to assess the IOP-lowering effect and tolerability of SLT after prior trabeculectomy or tube shunt surgery. MATERIALS AND METHODS: Open angle glaucoma patients at Wills Eye Hospital who previously underwent incisional glaucoma surgery and subsequently received SLT between 2013 and 2018 were included, along with an age-matched control group. Baseline characteristics, procedural data, and post-SLT data were recorded at 1, 3, 6, 12 months, and most recent visit. The primary success of SLT treatment was defined as IOP reduction of 20% or greater without the use of additional glaucoma medications compared to pre-SLT IOP. Secondary success was defined as IOP reduction ≥20% with the use of additional glaucoma medications compared to pre-SLT IOP. RESULTS: There were 45 eyes in the study group and 45 eyes in the control group. In the study group, IOP decreased from a baseline of 19.5±4.7 mm Hg on 2.2±1.2 medications to 16.7±5.2 mm Hg ( P =0.002) on 2.2±1.1 glaucoma medications ( P =0.57). In the control group, IOP decreased from 19.5±4.2 mm Hg on 2.4±1.0 medications to 16.4±5.2 mm Hg ( P =0.003) on 2.1±1.3 medications ( P =0.36). There was no difference in IOP reduction or change in number of glaucoma medications after SLT at any postoperative visit between the 2 groups ( P ≥0.12 for all). Primary success rates at 12 months were 24.4% for the control group and 26.7% for the prior incisional glaucoma surgery group with no significant difference between the groups ( P =0.92). There were no persistent complications after SLT treatment in either group. CONCLUSION: SLT may effectively lower IOP in patients with open angle glaucoma who have had previous incisional glaucoma surgery and should be considered in select cases.

Orbital Cellulitis Following Uncomplicated Glaucoma Drainage Device Surgery: Case Report and Review of Literature.

PURPOSE: Orbital cellulitis (OC) is a rare postoperative complication of glaucoma drainage device (GDD) implantation. To date, there have only been 10 reported cases of OC following GDD implantation. CASE REPORT: Here, we report a case of OC in a 57-year-old man who developed pain, proptosis, and limited extraocular motility two days after uneventful Ahmed FP7 implantation in the right eye. Contrast-enhanced computed tomography of the orbits demonstrated fat stranding and a small fluid collection, consistent with OC. He had minimal improvement with intravenous antibiotics and ultimately underwent GDD explantation. A systematic review of the literature showed that the development of OC following GDD implantation can occur in the early or late postoperative period. Immediate hospitalization with intravenous administration of broad-spectrum antibiotics is recommended. Explantation of the infected GDD is often required for source control. CONCLUSION: OC is a rare postoperative complication of GDD implantation. Prompt evaluation and treatment are required, often combined with GDD explantation.

Predictors of Success in Selective Laser Trabeculoplasty.

PURPOSE: Selective laser trabeculoplasty (SLT) is a common procedure to lower intraocular pressure (IOP) in patients with glaucoma. However, reports are conflicting regarding what factors contribute to SLT success. The purpose of this study was to determine predictors of SLT success. DESIGN: Retrospective case series. PARTICIPANTS: All patients treated with SLT between January 1, 2012, and June 30, 2018. METHODS: Baseline, demographic, procedural, and ophthalmic examination data were recorded at the time of first SLT treatment. Intraocular pressure and medication data were recorded at all follow-up visits. MAIN OUTCOME MEASURES: Selective laser trabeculoplasty success was defined as IOP decrease of 20% or more from baseline at the 3-month, 6-month, and 12-month follow-up visits. Eyes were considered to have failed and were censored when additional SLT or glaucoma surgery was performed. Patients were excluded if they had less than 3 months of follow-up. RESULTS: A total of 997 eyes from 677 patients were included in the study. Mean age was 70.2±11.5 years. Selective laser trabeculoplasty success was achieved in 227 eyes (22.8%), whereas 770 eyes (77.2%) did not meet success criteria. Intraocular pressure before SLT was 21.9±5.2 mmHg while taking 2.0±1.2 medications in eyes with successful SLT, compared with 19.0±5.0 mmHg (P < 0.0001) while taking 2.1±1.3 medications (P = 0.52) in eyes with SLT failure. At the 1-year follow-up, mean IOP in eyes with SLT success was 14.7±3.2 mmHg with 2.0±1.2 medications, compared with 16.3±4.7 mmHg (P = 0.008) with a mean of 1.9±1.3 medications (P = 0.37) in eyes with SLT failure. Eyes with SLT success more often showed greater angle pigment (P = 0.03). Age, glaucoma severity, total SLT power, type of glaucoma, severity of glaucoma, visual field mean defect, and retinal nerve fiber layer thickness were not found to correlate with success. No difference was found between the rate of success based on treatments before SLT, whether surgical or medical. CONCLUSIONS: In this large cohort of eyes undergoing SLT, greater IOP and angle pigment before SLT correlated positively with SLT success. Age, total SLT power, severity of glaucoma, and prior treatments were not associated with SLT success or failure.

Outcomes of Ahmed Glaucoma Valve Implantation With Viscoelastic Fill at Both Beginning and End of Surgery.

PRéCIS:: Intracameral injection of viscoelastic at the beginning of Ahmed FP7 implantation did not reduce early postoperative complication rates. PURPOSE: To evaluate early postoperative complication rates after a modified technique in which the anterior chamber (AC) is filled with viscoelastic at the beginning of Ahmed FP7 implantation before conjunctival peritomy. SUBJECTS AND METHODS: A retrospective chart review was performed of eyes that underwent Ahmed FP7 implantation with or without viscoelastic fill to ~20 mm Hg by finger tension by a single surgeon (M.R.M). Viscoelastic prevented the AC from becoming shallow at any time during surgery, and additional viscoelastic was injected into the AC at the end of surgery to achieve a final intraocular pressure (IOP) of 20 mm Hg. RESULTS: A total of 159 eyes of 159 patients were included. Mean age was 76.4±10.4 years. Mean preoperative IOP was 30.3±9.7 mm Hg on 2.7±1.2 glaucoma medications. On postoperative day 1, there was an IOP spike ≥30 mm Hg in 0% of patients. Within the first postoperative month, hypotony (<5 mm Hg) occurred in 19 (21.8%) eyes that received viscoelastic fill compared with 5 (13.2%) eyes that did not receive viscoelastic fill (P=0.26). During the early postoperative period (≤3 mo), there was no difference in AC depth, microhyphema, choroidal effusion, or leakage between the 2 groups (P≥0.30 for all). There was a higher rate of layered hyphemas in the viscoelastic-fill group at postoperative week 1 (P=0.01). At 3-month follow-up, mean IOP was 14.9±5.5 mm Hg on 1.6±0.8 medications in the viscoelastic-fill group and 16.0±5.2 mm Hg on 1.0±1.2 medications in the nonviscoelastic-fill group (IOP P=0.35). Compared with baseline, change in IOP at 3 months was similar between both groups (P=0.15). Rates of additional medications and procedures did not differ between the 2 groups at any postoperative visit. CONCLUSIONS: Early intracameral injection of viscoelastic during Ahmed glaucoma valve implantation did not reduce early postoperative complication rates.

Outcomes of trabecular microbypass surgery: Comparison of resident trainees and attending surgeons.

PURPOSE: To determine the efficacy, safety, and surgical outcomes of trabecular microbypass stent (iStent) surgery performed by resident trainees and attending surgeons. SETTING: Wills Eye Hospital, Philadelphia, Pennsylvania, USA. DESIGN: Retrospective case series. METHODS: Records of all patients who had microbypass stent surgery by a resident at Wills Eye Hospital were retrospectively reviewed. The attending-performed group included any patient who had a microbypass stent implanted by an attending surgeon on the same day a resident case was performed. RESULTS: Between 2016 and 2018, 31 microbypass stents were implanted by a resident supervised by an attending and 93 microbypass stents were implanted by an attending surgeon on the day a resident case was performed. The mean follow-up was 16.2 months ± 17.9 (SD). The mean intraocular pressure (IOP) decreased from 16.0 ± 4.6 mm Hg at baseline to 14.0 ± 3.1 mm Hg at most recent follow-up visit in the resident group (P = .02) and from 17.5 ± 4.8 mm Hg to 15.1 ± 4.3 mm Hg, respectively, in the attending group (P < .001). The final mean IOP and mean number of hypotensive medications were similar between the 2 groups (P = .83 and P = .12, respectively). Self-resolving hyphema occurred in 1 resident case and 2 attending cases. The resident group had 1 case of iridodialysis, which did not require additional surgery. One eye in the attending group ultimately required a trabeculectomy. CONCLUSION: Microbypass stent implantation by resident trainees with attending supervision had similar efficacy and safety as surgery performed by attending surgeons.

XEN Gel Stent to Treat ICE Syndrome: 4 Cases.

PRéCIS:: This case series reports safe, effective implantation of XEN gel stents to treat iridocorneal endothelial (ICE) syndrome. The stents continue to function well and have not been occluded by membranes or peripheral anterior synechiae, but continued follow-up is necessary. PURPOSE: ICE syndrome-related glaucoma is often refractory to medical treatment, and traditional surgical treatment has lower success rates than typical for other types of glaucoma. We present a series of patients who were treated with XEN gel stent implantation. PATIENTS AND METHODS: Retrospective case series of 4 patients with ICE syndrome who underwent XEN with subconjunctival mitomycin C injection. RESULTS: Average preoperative intraocular pressure was 28.5 mm Hg on 3.8 glaucoma medications, and average postoperative intraocular pressure was 10.5 mm Hg on 1.0 medication. No patients required return to the operating room for additional procedures over an average of 6.9 months of follow-up. One patient had shallow anterior chamber that resolved with conservative management. Another had shallow anterior chamber that resolved with anterior chamber reformation with viscoelastic and developed nonappositional choroidal effusions that had resolved at most recent follow-up of 7 months after surgery. No XEN implants have been occluded by membrane formation or peripheral anterior synechiae. CONCLUSIONS: XEN is a safe and effective option for surgical management of ICE syndrome-related glaucoma. Further follow-up surveillance is necessary.

Rapid Intraocular Tube Trimming for Glaucoma Drainage Implant Devices.

PURPOSE: To describe a new approach for shortening silicone tubes of glaucoma drainage devices (GDDs). MATERIALS AND METHODS: A retrospective intervention case series describing 3 patients undergoing the same treatment at a single institutional center RESULTS:: Three patients underwent successful ab interno trimming of GDD silicone tubes without complication CONCLUSIONS:: This technique allows for rapid and successful shortening of GDD tubes via an ab interno approach avoiding risks of traditional glaucoma tube trimming approaches.

Retinal Ganglion Cell and Inner Plexiform Layer Loss Correlate with Visual Acuity Loss in LHON: A Longitudinal, Segmentation OCT Analysis.

PURPOSE: Describe changes in the retina as vision loss progresses in Leber's Hereditary Optic Neuropathy (LHON) using spectral-domain optical coherence tomography (SD-OCT) autosegmentation, and determine if relationship exists between retinal changes and vision loss. METHODS: From patient records we identified nine LHON patients who underwent periodic neuro-ophthalmologic examinations and high-resolution SD-OCT as part of their care. We describe the impact of LHON progression on each retinal layer, and the relationship between these structural changes and visual acuity using generalized estimating equations and nonparametric tests. RESULTS: The thickness of the ganglion cell layer (GCL) and inner plexiform layer (IPL) decreased immediately or soon after symptom onset, and this decrease was associated with worsening vision: in the GCL a 1-mm3 volume loss was associated with a 3.2 increase in logMAR visual acuity (95% confidence interval [CI]: 2.1-4.1); in the IPL a 1-mm3 volume loss was associated with a 4.9 increase in visual acuity (95%CI: 6.5-3.2). The retinal nerve fiber layer (RNFL) also thinned, but not until after the GCL and IPL, and only in the papillomacular bundle (PMB) and temporal layers was thinning associated with vision loss. CONCLUSIONS: For the first time these analyses describe a structure-function relationship between the retinal changes that occur in LHON patients as their disease progresses and vision worsens. The structural changes in the GCL, IPL, and RNFL preceded structural changes in the other retinal layers. This analysis suggests that the first 6 months after diagnosis define a target for therapeutic intervention, and this can inform treatment guidelines for ongoing therapeutic trials.

Homonymous hemianopia due to Erdheim-Chester disease.

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis typically affecting multiple organ systems. We report 2 patients who presented with homonymous hemianopia and were ultimately diagnosed with biopsy-confirmed ECD. We review the spectrum of ECD and its treatment as well as histopathological and immunohistochemical differentiation from other histiocytic disorders.

Alternating Skew Deviation from Traumatic Intracranial Hypotension.

A 56-year-old woman developed progressive headache, mental status changes, and diplopia after trauma. She was diagnosed with alternating skew deviation caused by intracranial hypotension. This is the first case of alternating skew deviation reported from intracranial hypotension and perhaps a differential pressure between intracranial and intraspinal spaces plays a role in the development of these findings.

Relationship of central corneal thickness to postural IOP changes in patients with and without glaucoma in southern India.

To evaluate the relationship of central corneal thickness to the changes in intraocular pressure (IOP) in the sitting and supine position. Observational case-control study. The study group included Primary open-angle and chronic angle closure glaucoma patients. The control group consisted of patients without glaucoma seen for their routine eye examination. Central corneal thickness was measured by ultrasound pachymetry. Patients were then randomized to IOP measurement by Tonopen either sitting or supine after maintaining that position for 5 min. The position was then reversed and IOP measurements taken again after 5 min. Main outcome measure was change in IOP. One hundred and eighty-two eyes (90 in cases and 92 in controls) were examined. The mean CCT was 538.11 ± 37.17 µm in the study group and 545.34 ± 36.01 µm in the control group (P = 0.185). The mean IOP in the sitting position was 19.54 ± 5.39 mmHg in cases and 14.82 ± 4.01 in controls (P < 0.001). The mean IOP in the supine position was 20.51 ± 5.48 mmHg in cases and 16.02 ± 3.24 in controls (P < 0.001). Mean IOP change from sitting to supine was statistically significant in both groups (P < 0.001 for both). Postural change was greater in cases than controls (P = 0.020). There was no correlation between postural IOP change and CCT in cases (r = 0.143, P = 0.180) and controls (r = 0.096, P = 0.362). Postural IOP change is greater in glaucoma patients than non-glaucomatous patients. There was no correlation between postural IOP change and CCT.