Adjunctive modulation of wound healing during cataract surgery to promote survival of a previous trabeculectomy.

BACKGROUND: Trabeculectomy is a surgical treatment for glaucoma to lower intraocular pressure with high success rates; however, it is often associated with an increased rate of cataract formation. Cataract can cause symptoms such as glare in bright conditions, foggy vision, and difficulty in driving at night. Cataract extraction surgery is highly successful in improving vision, but it comes at a cost of trabeculectomy failure, with a reported risk of 30% to 40%. An additional intervention to promote trabeculectomy survival after cataract extraction is needed. This review encompassed all adjunctive therapies used at the time of cataract surgery to increase trabeculectomy survival rate. OBJECTIVES: To investigate the effect of the adjunctive modulation of wound healing during cataract surgery on the survival of a previously functioning trabeculectomy. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 4); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov; and the WHO ICTRP. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 14 April 2021. SELECTION CRITERIA: We planned to include all randomised controlled trials (RCTs) of participants who had a functioning trabeculectomy and were undergoing cataract surgery that compared any adjunctive therapy intended to modulate wound healing (such as 5-fluorouracil, mitomycin C, or anti-vascular endothelial growth factor (VEGF) therapy) with no adjuvant therapy.  DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. Our primary outcome was trabeculectomy failure at 6 months and 12 months after cataract surgery. Secondary outcomes were mean intraocular pressure difference from pre-cataract surgery baseline to 6 to 18 months post-cataract surgery; number of medications required to control eye pressure compared to before cataract surgery; bleb appearance as measured by a summation score of the Moorfields bleb grading system or other equivalent numerical grading systems; visual field progression measured by difference in mean deviation from baseline; and any complications. MAIN RESULTS: We did not identify any RCTs of adjunctive modulation of wound healing during cataract surgery to promote survival of a previous trabeculectomy. AUTHORS' CONCLUSIONS: There is a need for an RCT to investigate the role of adjuvant wound modulating therapy at the time of cataract surgery to promote survival of a functioning trabeculectomy.

Laser peripheral iridoplasty for chronic angle closure.

BACKGROUND: In at least a third of primary angle closure cases, appositional angle closure persists after laser peripheral iridotomy, and further intervention may be considered. Laser peripheral iridoplasty (LPIp) can be used in treating chronic angle closure when angle closure persists after laser peripheral iridotomy. Previous reviews have found insufficient data to determine its clinical effectiveness, compared to other interventions. This is an update of a Cochrane Review first published in 2008 and updated in 2012. It examines all studies to date to establish whether LPIp shows any effectiveness over other available treatment options. OBJECTIVES: To assess the effectiveness of laser peripheral iridoplasty in the treatment of people with chronic angle closure, when compared to laser peripheral iridotomy, medical therapy or no further treatment. SEARCH METHODS: We searched various electronic databases. The date of the search was 20 December 2020. SELECTION CRITERIA: We included only randomised controlled trials (RCTs) assessing the use of LPIp in cases of suspected primary angle closure (PACS), confirmed primary angle closure (PAC), or primary chronic angle-closure glaucoma (PACG). We applied no restrictions with respect to gender, age or ethnicity of participants. Trials evaluating LPIp for acute attacks of angle closure were not eligible. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two authors independently assessed studies for risk of bias using Cochrane's 'risk of bias' tool. We collected adverse effects information from the trials. MAIN RESULTS: We included four RCTs involving 252 participants (276 eyes). In total, three different methods of intervention were used and 15 outcomes reported, with different time points. We used narrative synthesis to describe the majority of the findings, as meta-analysis was only possible for a limited number of outcomes due to the variation in study design and outcomes assessed. Study Characteristics Participants were adults recruited from outpatient settings in the UK, Singapore, China and Korea with either PACS, PAC or PACG. All studies compared argon LPIp (as either a primary or secondary procedure) to an alternative intervention or no further treatment. Three studies were of parallel group design, and one within-person, randomised by eye. All studies showed elements of high risk of bias. Due to the nature of the intervention assessed, a lack of masking of both participants and assessors was noted in all trials. Findings Laser peripheral iridoplasty with iridotomy versus iridotomy alone as a primary procedure Two RCTs assessed the use of argon LPIp as a primary procedure with peripheral iridotomy, compared with peripheral iridotomy alone. However, neither study reported data for the primary outcome, disease progression. Argon LPIp showed no evidence of effect on: final mean intraocular pressure (IOP) at 3 months and 12 months (mean difference (MD) 0.39 mmHg, 95% confidence interval (CI) -1.07 to 1.85; I2 = 38%; 2 studies, 174 participants; low-certainty evidence); further surgical or laser intervention at 12 months (risk ratio (RR) 1.21, 95% CI 0.66 to 2.21; 1 study, 126 participants; low-certainty evidence); or mean number of additional medications required at 12 months (MD 0.10, 95% CI -0.34 to 0.54; 1 study, 126 participants; low-certainty evidence). Complications were assessed at 3 to 12 months (2 studies, 206 participants; low-certainty evidence) and found to be mild and uncommon, with comparable levels between groups. The only severe complication encountered was one case of malignant glaucoma in one study's argon LPIp group. Quality of life measures were not assessed. In the other study, investigators found that argon LPIp showed no evidence of effect on final mean anterior segment optical coherence tomography (AS-OCT) measurements, including anterior chamber depth (MD 0.00 mm, 95% CI -0.10 to 0.10; 24 participants, 48 eyes; very low-certainty evidence). Laser peripheral iridoplasty as a secondary procedure versus no treatment One RCT assessed the use of argon LPIp as a secondary procedure compared with no further treatment in 22 participants over three months. Disease progression, additional medications required, complications, further surgical or laser intervention, and quality of life outcomes were not assessed. There was only very low-certainty evidence regarding final maximum IOP value (MD -1.81 mmHg, 95% CI -3.11 to -0.51; very low-certainty evidence), with no evidence of effect on final minimum IOP values (MD -0.31 mmHg, 95% CI -1.93 to 1.31; very low-certainty evidence). The evidence is very uncertain about the effect of argon LPIp on AS-OCT parameters. The trial did not report AS-OCT measurements for the control group. Laser peripheral iridoplasty as a secondary procedure versus medication One RCT assessed the use of argon LPIp as a secondary procedure compared with travoprost 0.004% in 80 participants over 12 months. The primary outcome of disease progression was reported for this method: argon LPIp showed no evidence of effect on mean final cup/disk ratio (MD -0.03, 95% CI -0.11 to 0.05; low-certainty evidence). Argon LPIp showed no evidence of effect for: mean change in IOP (MD -1.20 mmHg, 95% CI -2.87 to 0.47; low-certainty evidence) or mean number of additional medications (MD 0.42, 95% CI 0.23 to 0.61; low-certainty evidence). Further surgical intervention was required by one participant in the intervention group alone, with none in the control group  (low-certainty evidence). No serious adverse events were reported, with mild complications consisting of two cases of 'post-laser IOP spike' in the argon LPIp group. Quality of life measures were not assessed. The evidence is very uncertain about the effect of argon LPIp on AS-OCT parameters. The trial did not report AS-OCT measurements for the control group. Adverse events Availability of data were limited for adverse effects. Similar rates were observed in control and intervention groups, where reported. Serious adverse events were rare. AUTHORS' CONCLUSIONS: After reviewing the outcomes of four RCTs, argon LPIp as an intervention may be no more clinically effective than comparators in the management of people with chronic angle closure. Despite a potential positive impact on anterior chamber morphology, its use in clinical practice in treating people with chronic angle closure is not supported by the results of trials published to date. Given these results, further research into LPIp is unlikely to be worthwhile.

Artificial Intelligence Algorithms to Diagnose Glaucoma and Detect Glaucoma Progression: Translation to Clinical Practice.

Purpose: This concise review aims to explore the potential for the clinical implementation of artificial intelligence (AI) strategies for detecting glaucoma and monitoring glaucoma progression. Methods: Nonsystematic literature review using the search combinations "Artificial Intelligence," "Deep Learning," "Machine Learning," "Neural Networks," "Bayesian Networks," "Glaucoma Diagnosis," and "Glaucoma Progression." Information on sensitivity and specificity regarding glaucoma diagnosis and progression analysis as well as methodological details were extracted. Results: Numerous AI strategies provide promising levels of specificity and sensitivity for structural (e.g. optical coherence tomography [OCT] imaging, fundus photography) and functional (visual field [VF] testing) test modalities used for the detection of glaucoma. Area under receiver operating curve (AROC) values of > 0.90 were achieved with every modality. Combining structural and functional inputs has been shown to even more improve the diagnostic ability. Regarding glaucoma progression, AI strategies can detect progression earlier than conventional methods or potentially from one single VF test. Conclusions: AI algorithms applied to fundus photographs for screening purposes may provide good results using a simple and widely accessible test. However, for patients who are likely to have glaucoma more sophisticated methods should be used including data from OCT and perimetry. Outputs may serve as an adjunct to assist clinical decision making, whereas also enhancing the efficiency, productivity, and quality of the delivery of glaucoma care. Patients with diagnosed glaucoma may benefit from future algorithms to evaluate their risk of progression. Challenges are yet to be overcome, including the external validity of AI strategies, a move from a "black box" toward "explainable AI," and likely regulatory hurdles. However, it is clear that AI can enhance the role of specialist clinicians and will inevitably shape the future of the delivery of glaucoma care to the next generation. Translational Relevance: The promising levels of diagnostic accuracy reported by AI strategies across the modalities used in clinical practice for glaucoma detection can pave the way for the development of reliable models appropriate for their translation into clinical practice. Future incorporation of AI into healthcare models may help address the current limitations of access and timely management of patients with glaucoma across the world.

Automated Registration of Multimodal Optic Disc Images: Clinical Assessment of Alignment Accuracy.

PURPOSE: To determine the accuracy of automated alignment algorithms for the registration of optic disc images obtained by 2 different modalities: fundus photography and scanning laser tomography. MATERIALS AND METHODS: Images obtained with the Heidelberg Retina Tomograph II and paired photographic optic disc images of 135 eyes were analyzed. Three state-of-the-art automated registration techniques Regional Mutual Information, rigid Feature Neighbourhood Mutual Information (FNMI), and nonrigid FNMI (NRFNMI) were used to align these image pairs. Alignment of each composite picture was assessed on a 5-point grading scale: "Fail" (no alignment of vessels with no vessel contact), "Weak" (vessels have slight contact), "Good" (vessels with <50% contact), "Very Good" (vessels with >50% contact), and "Excellent" (complete alignment). Custom software generated an image mosaic in which the modalities were interleaved as a series of alternate 5×5-pixel blocks. These were graded independently by 3 clinically experienced observers. RESULTS: A total of 810 image pairs were assessed. All 3 registration techniques achieved a score of "Good" or better in >95% of the image sets. NRFNMI had the highest percentage of "Excellent" (mean: 99.6%; range, 95.2% to 99.6%), followed by Regional Mutual Information (mean: 81.6%; range, 86.3% to 78.5%) and FNMI (mean: 73.1%; range, 85.2% to 54.4%). CONCLUSIONS: Automated registration of optic disc images by different modalities is a feasible option for clinical application. All 3 methods provided useful levels of alignment, but the NRFNMI technique consistently outperformed the others and is recommended as a practical approach to the automated registration of multimodal disc images.

Development and validation of a standardized tool for reporting retinal findings in abusive head trauma.

PURPOSE: To develop and validate a robust standardized reporting tool for describing retinal findings in children examined for suspected abusive head trauma. DESIGN: A prospective interobserver and intraobserver agreement study. METHOD: An evidence-based assessment pro forma was developed, recording hemorrhages (location, layer, severity) and additional features. Eight consultant pediatric ophthalmologists and 7 ophthalmology residents assessed a series of 105 high-quality RetCam images of 21 eyes from abusive head trauma cases with varying degrees of retinal hemorrhage and associated findings. The pediatric ophthalmologists performed a repeat assessment of the randomized images. The images were observed simultaneously with standardized display settings. Interobserver and intraobserver agreement was assessed using free-marginal multirater kappa, intraclass correlation coefficients, and concordance coefficients. RESULTS: Almost-perfect interobserver agreement was observed for residents and pediatric ophthalmologists recording the presence and number of fundus hemorrhages (intraclass correlation coefficients 0.91 and 0.87, respectively) and the location of hemorrhages (concordance coefficients 0.86 and 0.85, respectively). Substantial agreement was observed by both groups regarding size of hemorrhage (concordance coefficients 0.73 and 0.76), moderate agreement for hemorrhage morphology (concordance coefficients 0.53 and 0.52), and other findings (concordance coefficients 0.48 and 0.59). Intraobserver agreement for pediatric ophthalmologists varied by question, ranging from substantial to perfect for the presence, number, location, size, and morphology of fundus hemorrhage. CONCLUSION: We have developed and validated a standardized clinical reporting tool for ophthalmic findings in suspected abusive head trauma, which has excellent interobserver and intraobserver agreement among consultant specialists and residents. We suggest that its use will improve standardized clinical reporting of such cases.

Laser peripheral iridoplasty for angle-closure.

BACKGROUND: Angle-closure glaucoma is a leading cause of irreversible blindness in the world. Treatment is aimed at opening the anterior chamber angle and lowering the IOP with medical and/or surgical treatment (e.g. trabeculectomy, lens extraction). Laser iridotomy works by eliminating pupillary block and widens the anterior chamber angle in the majority of patients. When laser iridotomy fails to open the anterior chamber angle, laser iridoplasty may be recommended as one of the options in current standard treatment for angle-closure. Laser peripheral iridoplasty works by shrinking and pulling the peripheral iris tissue away from the trabecular meshwork. Laser peripheral iridoplasty can be used for crisis of acute angle-closure and also in non-acute situations.   OBJECTIVES: To assess the effectiveness of laser peripheral iridoplasty in the treatment of narrow angles (i.e. primary angle-closure suspect), primary angle-closure (PAC) or primary angle-closure glaucoma (PACG) in non-acute situations when compared with any other intervention. In this review, angle-closure will refer to patients with narrow angles (PACs), PAC and PACG. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 12), MEDLINE (January 1950 to January 2012), EMBASE (January 1980 to January 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to January 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 5 January 2012. SELECTION CRITERIA: We included only randomised controlled trials (RCTs) in this review. Patients with narrow angles, PAC or PACG were eligible. We excluded studies that included only patients with acute presentations, using laser peripheral iridoplasty to break acute crisis. DATA COLLECTION AND ANALYSIS: No analysis was carried out as only one trial was included in the review. MAIN RESULTS: We included one RCT with 158 participants. The trial reported laser peripheral iridoplasty as an adjunct to laser peripheral iridotomy compared to iridotomy alone. The authors report no superiority in using iridoplasty as an adjunct to iridotomy for IOP, number of medications or need for surgery. AUTHORS' CONCLUSIONS: There is currently no strong evidence for laser peripheral iridoplasty's use in treating angle-closure.

Oxane HD and retinal detachment surgery in routine clinical practice.

BACKGROUND/AIMS: To assess the outcomes and complications of endotamponade with Oxane HD following retinal detachment repair. METHODS: Retrospective consecutive case series of inferior retinal detachment with Oxane HD endotamponade within a 3-year period. RESULTS: Case notes for 18 eyes of 18 patients were reviewed. Four (22.2%) were total retinal detachments and 13 (72.2%) had proliferative vitreoretinopathy. The mean Oxane HD endotamponade and follow-up durations were 27 ± 38 and 66 ± 39 weeks, respectively. The eventual anatomic success rate was 77.8%, but without any significant difference in vision. Postoperative complications occurred in 14 (77.8%), including emulsification (6 eyes; 33.3%), epiretinal membrane (5 eyes; 27.8%), and posterior capsular opacification (4 eyes; 22.2%). Of the 14 eyes requiring intraoperative perfluorodecalin, 12 (85.7%) developed complications; all 5 (100%) eyes with direct exchange of perfluorodecalin with Oxane HD developed complications. CONCLUSION: Although useful for inferior retinal detachments, Oxane HD was associated with a relatively high rate of emulsification when compared to other series. Our series also suggests that prior use of perfluorodecalin intraoperatively, and in particular direct exchange of perfluorodecalin with Oxane HD, may be associated with an increased risk of intraocular complications.

Laser peripheral iridoplasty for angle-closure.

BACKGROUND: Angle-closure glaucoma is a leading cause of irreversible blindness in the world. Treatment is aimed at opening the anterior chamber angle and lowering the IOP with medical and/or surgical treatment (e.g. trabeculectomy, lens extraction). Laser iridotomy works by eliminating pupillary block and widens the anterior chamber angle in the majority of patients. When laser iridotomy fails to open the anterior chamber angle, laser iridoplasty may be recommended as one of the options in current standard treatment for angle-closure. Laser peripheral iridoplasty works by shrinking and pulling the peripheral iris tissue away from the trabecular meshwork. Laser peripheral iridoplasty can be used for crisis of acute angle-closure and also in non-acute situations. OBJECTIVES: To assess the effectiveness of laser peripheral iridoplasty in the treatment of narrow angles (i.e. primary angle-closure suspect), primary angle-closure (PAC) or primary angle-closure glaucoma (PACG) in non-acute situations when compared with any other intervention. In this review, angle-closure will refer to patients with narrow angles, PAC and PACG. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library), MEDLINE, EMBASE and LILACS (Latin American and Caribbean Literature on Health Sciences). The databases were last searched on 11 February 2008. SELECTION CRITERIA: Only randomised controlled trials (RCTs) were eligible for inclusion in this review. Patients with narrow angles, PAC or PACG were eligible. Studies that included only patients with acute presentations, using laser peripheral iridoplasty to break acute crisis were excluded. DATA COLLECTION AND ANALYSIS: No analysis was carried out due to lack of trials. MAIN RESULTS: There were no RCTs assessing laser peripheral iridoplasty in the non-acute setting of angle-closure. AUTHORS' CONCLUSIONS: There is currently no strong evidence for laser peripheral iridoplasty's use in treating angle-closure.

Management of recurrent epistaxis in an anticoagulated patient by temporarily closing the nares with sutures.

We describe an unusual case of recurrent, refractory anterior epistaxis in an 86-year-old man with two mechanical heart valves who was on permanent warfarin therapy. His numerous episodes of epistaxis were incited by chronic nose-picking and strong nose-blowing, practices that he continued to engage in despite repeated medical advice to stop. Stopping his anticoagulation therapy was not considered as a management option because of an unacceptably high risk that this would lead to a thromboembolic event. Eventually, we temporarily sutured his nares closed, and his nosebleeds ceased. The suturing was performed in the ward with local anesthesia. This procedure was simple to perform,fairly well tolerated, easily reversible, and highly effective.