Intraocular Pressure Before and After Corneal Refractive Surgery: A Prospective Comparison of Corvis ST and Ocular Response Analyzer.

PRECIS: The study showed that Corvis ST's bIOP and ORA's IOPcc do not agree well, before or after PRK, and may not be used interchangeably. bIOP remained unchanged after PRK. PURPOSE: To evaluate the agreement between the biomechanically-corrected intraocular pressure (bIOP) measured by the Corvis-ST and the cornea-compensated IOP (IOPcc) measured by the Ocular Response Analyzer (ORA) before and after photorefractive keratectomy (PRK). METHODS: In this prospective interventional study, a total of 53 patients (53 eyes) were included. Measurements were acquired using both the Corvis-ST and ORA devices before and 3 months post- PRK. The agreement between the two devices was evaluated using limits of agreement (LoA) and Bland-Altman plots. RESULTS: The participants had a mean age of 29.6±5.21 years (range: 21 to 40), with 41 (77.4%) of them being female. Following the surgery, the average change in IOP was 0.3±1.7 mmHg for bIOP and -1.6±4.0 mmHg for IOPcc. The corresponding 95% LoA were -3.5 to 4.2 mmHg and -9.5 to 6.3 mmHg, respectively. The 95% LoA between bIOP and IOPcc after PRK was -2.3 to 8.5 mmHg. Notably, the bIOP values were higher for IOPs <20 mmHg and lower for IOPs >20 mmHg compared to IOPcc. CONCLUSIONS: The findings indicate a weak agreement between the Corvis ST-bIOP and the ORA- IOPcc both before and after PRK. These devices may not be used interchangeably for IOP measurement. bIOP exhibited less variation compared to the IOPcc, suggesting that the bIOP is a superior option for IOP reading following PRK.

Full Thickness Prophylactic Scleral Windows Decrease the Rate of Choroidal Effusion and Drainage Surgery after Ahmed Glaucoma Valve Implantation.

Purpose: To evaluate the effect of creating a full-thickness prophylactic scleral window (PSW) during Ahmed glaucoma valve (AGV) surgery on the rate of postoperative choroidal effusion and choroidal drainage surgery. Methods: In this retrospective matched case-control study, after insertion of AGV tube a PSW was created in one group. The control-matched group had AGV without a PSW. Primary outcome measures were the rate of choroidal effusion formation and choroidal drainage surgery. Results: In total, 544 patients (604 eyes) had undergone AGV implantation from 2013 to 2017. The PSW group consisted of 111 eyes of 111 patients and the control group had 111 eyes of 98 matched patients. There were no differences for systemic diseases, number of anti-glaucoma drugs, aspirin use, smoking, laterality of the operated eye, axial length, and central corneal thickness between the groups. Out of 12 eyes with choroidal effusion, only one belonged to the PSW group (P=0.02). Six eyes in the control group needed choroidal drainage surgery, but none of the eyes in the PSW group required this procedure (P=0.02). No intra- and postoperative issues were observed at the site of the scleral window in the PSW group. Conclusion: PSW creation during AGV surgery is a safe method to decrease the rate of choroidal effusion and choroidal drainage surgery.

Contemporary Approach to Narrow Angles.

Glaucoma is the leading cause of irreversible blindness worldwide. Among all glaucoma types, primary angle closure glaucoma (PACG) affects approximately 23 million people worldwide, and is responsible for 50% of glaucoma-related blindness, highlighting the devastating consequences of this disease. The main mechanism of PACG is relative pupillary block. High-risk populations are female gender, Asian ethnicity, high hyperopia, short axial length, and a thick/anteriorly positioned lens. This review discusses the clinical diagnosis, classification, and management of patients with a narrow angle with and without intraocular pressure (IOP) elevation and glaucomatous optic nerve damage, including laser peripheral iridotomy (LPI), endocycloplasty (ECPL), lens extraction, and goniosynechialysis.

Intraocular pressure profile following selective laser trabeculoplasty in pigmentary and primary open-angle glaucoma.

PURPOSE: To compare the intraocular pressure (IOP) profile and the incidence of IOP spikes following selective laser trabeculoplasty (SLT) between pigmentary glaucoma (PG) and primary open-angle glaucoma (POAG). MATERIALS AND METHODS: Retrospective comparative study of 65 PG eyes of 51 patients matched with 65 POAG eyes of 65 patients who received SLT. Matching was done based on age, gender, glaucoma severity, pre-laser IOP, and number of medications. Post-SLT IOP spike was defined as IOP elevation ≥5mmHg, 30-45 min after the laser. RESULTS: In PG and POAG groups, the average age was 62.33 ± 9.18 and 62.58 ± 9.19 years (p = 0.95). The glaucoma severity (p = 0.708), baseline IOP (PG = 21.61 ± 1.34mmHg vs. POAG = 21.13 ± 5.09mmHg, p = 0.943), and number of topical glaucoma medications(PG = 2.34 ± 1.34 vs. POAG = 2.1 ± 1.41, p = 0.342) were comparable. More PG patients were on oral acetazolamide (PG = 26.15% vs. POAG = 1.5%, p < 0.001). Average logMAR visual acuity was significantly higher in the POAG group (0.207 ± 0.3 vs. 0.192 ± 0.37, p = 0.012). Eyes with PG received lower laser energy (POAG = 63.65 ± 22.03 mJ vs. PG = 43.71 ± 25.68 mJ, p < 0.001). IOP spikes were recorded in 5 PG eyes (7.6%) and none in the POAG group (p = 0.058). Failure rates were similar (PG = 50.7% and POAG = 43.1%, p = 0.205). In multivariable analysis, only pre-laser IOP (coefficient = 2.154 [CI: 0.765-3.543], p = 0.003) was a significant predictor of IOP change percentage after 12 months. CONCLUSIONS: SLT was comparably effective in both PG and POAG. IOP spikes were observed only in the PG group, though the total laser energy was lower in this group compared with POAG.

Long-Term Surgical Outcomes of Glaucoma Drainage Implants in Eyes with Preoperative Intraocular Pressure Less than 19 mmHg.

Background: This retrospective review reports on patients who underwent glaucoma drainage implant (GDI) surgery and had baseline intraocular pressure (IOP) of ≤18 mmHg with at least one year of follow-up. Methods: Clinical data of 67 eyes of 67 patients were collected from patients' charts, and the outcomes of GDI were evaluated until 7 years. GDI failure was defined as IOP reduction of less than 20% from the baseline at two consecutive visits three months after surgery, decline to no light perception, or if additional glaucoma surgery was performed. Results: The average age was 65.9 ± 13.2 years. Most cases were male (52.2%), White (53.7%), and had primary open-angle glaucoma (62.7%). Forty-four eyes had prior glaucoma surgery (68.6%) and 46 (68.6%) had severe glaucoma. Though postoperative (postop) IOP changes were insignificant, the average postop number of medications dropped from 2.4 ± 1.4 to 1.9 ± 1.2 medications two years after surgery (p = 0.0451). Postop complications (23.9%) included GDI exposure (7.5%), inflammation (4.5%), shallow anterior chamber (4.5%), and strabismus (1.5%). Hypotony was observed in 4 eyes (5.9%), none of which developed hypotony maculopathy. The cumulative one-year failure rate was 56.7%, most of which were due to failure to lower IOP. Conclusion: In patients with baseline IOP ≤18 mmHg who had GDI surgery, though the change in IOP was not statistically significant, the number of medications dropped and visual field progression slowed in a subset of patients with adequate perimetric data. Due to a relatively high rate of complications and limited effectiveness in lowering IOP, GDI should be cautiously used in these eyes.

Empowering Family Glaucoma Risk Communication Using QR-Code-Mediated Online Intervention.

PURPOSE: Attempts at engaging relatives of glaucoma patients in education and screening have had limited success. This study explores the feasibility of an electronic intervention to facilitate direct yet reliable glaucoma risk communication between open-angle glaucoma patients (probands) and their first-degree relatives (FDRs). DESIGN: Prospective survey and assessment of intervention. PARTICIPANTS: Fifty adult probands, engaging 140 FDRs. METHODS: Phase I was an iterative process involving creating a customized website and Quick Response (QR)-code-based intervention designed with input from probands, FDRs of patients, community members, and researchers. In phase II, the intervention was deployed in a clinical setting; this involved recruiting probands who had a smartphone and were willing to use the QR-code to message their FDRs a standard message, including a website link about glaucoma risk in FDRs and the importance of getting examined. Follow-up interviews were conducted with probands 1 to 2 weeks after their clinic visit to assess the impact of the intervention. Demographic data, website analytics, and participant feedback were collected and analyzed. MAIN OUTCOME MEASURES: Increased awareness of glaucoma risk among FDRs and enhanced discussions. RESULTS: At the time of the first interview, probands reported that 70% of the FDRs were aware of the probands' glaucoma diagnosis, but only 26% had undergone glaucoma screening. Ninety percent of probands had no issues using the QR-codes. Website analytics recorded 73 visits from 51 distinct internet protocol addresses (IPs). After receiving the standard message, 95% of FDRs followed up with the probands, actively discussing glaucoma. Of the probands, 84% completed the follow-up interview 1 to 2 weeks after enrollment. Fifty-nine percent of the FDRs were reported to have scheduled screening appointments. The collected feedback revealed that 96% of probands found the intervention helpful, fostering glaucoma discussions with their FDRs and improving probands' comfort level in discussing health issues with FDRs from baseline (very comfortable: 88%, comfortable: 8%, neutral: 2%, and very uncomfortable: 2%) to the follow-up interview (very comfortable: 98% and comfortable: 2%). CONCLUSIONS: This innovative online method of communicating the risk of glaucoma to FDRs of probands prompted and increased the comfort level of familial discussions of glaucoma. More than half of FDRs reported making an appointment to get screened for glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Early Postoperative Aqueous Suppression Therapy and Surgical Outcomes of Ahmed Tube Shunts in Refractory Glaucoma.

PURPOSE: To compare early vs. delayed use of aqueous suppressants on Ahmed glaucoma valve (AGV) outcomes. DESIGN: Single-center retrospective comparative case series. PARTICIPANTS: Patients who underwent AGV surgery at Wills Eye Hospital in the period between 2016 and 2021. METHODS: Retrospective review of AGV surgery at Wills Eye Hospital 2016 to 2021 for refractory glaucoma. Two groups were created: group 1 or those who received early aqueous suppressant therapy in the first 2 weeks postoperatively whenever the intraocular pressure (IOP) was > 10 mmHg, and group 2 or those who received delayed treatment after 2 weeks whenever the IOP exceeded the target pressure. Aqueous suppressant therapy included topical beta blockers, carbonic anhydrase inhibitors, and/or alpha agonists. MAIN OUTCOME MEASURES: The primary outcome measures were the frequency of hypertensive phase (HP) defined as IOP > 21 mmHg in first 3 months after an initial reduction to 21 mmHg or less in the first postoperative week not caused by tube obstruction or retraction, and month-12 surgical failure defined as 5 ≥ IOP > 21 mmHg on 2 consecutive visits, vision decline to no light perception (NLP), or glaucoma reoperation. Secondary outcome measures included changes in visual acuity (VA), IOP, and glaucoma medications at 12 months. Predictive factors for surgical failure were also identified. RESULTS: A total of 407 eyes of 391 patients (260 in group 1, 147 in group 2) with similar baseline characteristics were included. Hypertensive phase was more common in group 2 than 1 (41.5% vs. 18.5%; P < 0.001). At month 12 (N = 303 eyes), group 1 was less likely to fail than group 2 (21.2% vs. 36.8%, P = 0.003). Multivariate regression analysis showed that HP (odds ratio [OR] = 10.47, P < 0.001), delayed aqueous suppression use (OR = 2.17, P = 0.003), and lower baseline VA (OR = 1.56, P = 0.015) were the strongest predictors of month-12 failure. CONCLUSIONS: Early use of aqueous suppressants may lower the risk of HP and improve AGV outcomes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ahmed ClearPath vs. Baerveldt Glaucoma Implant: A Retrospective Noninferiority Comparative Study.

PURPOSE: To compare the efficacy and safety of 2 nonvalved glaucoma drainage devices (GDDs): Ahmed ClearPath (ACP) vs. Baerveldt glaucoma implant (BGI). DESIGN: Single-center, retrospective, comparative study. PARTICIPANTS: Consecutive patients who underwent ACP or BGI surgery for glaucoma (250 mm2 or 350 mm2 models), had ≥ 6 months of follow-up, and no prior GDD implantation. METHODS: Chart review of ACP or BGI surgery in patients with glaucoma at Wills Eye Hospital (2020-2023). MAIN OUTCOME MEASURES: The primary outcome measure was surgical failure at the end of follow-up, defined as intraocular pressure (IOP) > 21 or < 6 mmHg at 2 consecutive visits, progression to no light perception (NLP) vision, glaucoma reoperation, or implant removal. Secondary outcome measures included the rate of postoperative complications and changes in best corrected visual acuity (BCVA), IOP, and glaucoma medications. RESULTS: A total of 128 eyes of 113 patients (63 ACP, 65 BGI) with similar baseline characteristics and a mean follow-up duration of 19.6 ± 10.8 (median 20.5) months were included. Surgical failure occurred in 12 eyes (9.4%) with no significant difference between ACP and BGI eyes (9.5% vs. 9.2%, respectively; P = 0.810). Reasons for failure included IOP > 21 mmHg (3/12, 25.0%), glaucoma reoperation (5/12, 41.7%), and tube removal (4/12, 33.3%). No eyes progressed to NLP vision. Kaplan-Meier survival analysis showed similar cumulative rate of surgical failure in both groups (P = 0.871). Both groups achieved significant IOP and medication reduction compared to their baseline. Final IOP, BCVA, and complication rates were similar in both groups, but medication number was significantly lower in the ACP group (P = 0.012). Both the 250 mm2 and 350 mm2 models had similar outcomes, but diplopia was significantly associated with the 350 mm2 model of either implant (P = 0.012). Univariate logistic regression analysis did not identify either tube type or plate size as predictors of surgical failure. CONCLUSIONS: This study compares the recently approved ACP vs. BGI. Both implants had similar surgical failures and complication rates. Final IOP was similar in both groups, but ACP achieved lower medication number. Diplopia was significantly associated with the use of 350 mm2 model of either implant. Neither tube type nor plate size were significant predictors of surgical failure. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Virtual versus In-Person Ophthalmology Interviews: Perceptions of U.S. Ophthalmology Fellowship Applicants in 2022-2023.

Purpose Despite easing restrictions on social distancing and travel since the beginning of coronavirus disease 2019 pandemic, virtual interviews remain a widely used format for ophthalmology fellowship interviews. This study aims to evaluate the relative benefits and drawbacks of in-person versus virtual interviews during a cycle where both formats were prevalent. Methods A prospective cross-sectional study surveyed all fellowship applicants ( N = 311) who applied to Wills Eye Hospital and Bascom Palmer Eye Institute during the 2022 to 2023 application cycle. Results A total of 59 (19%) applicants responded to the survey, with the majority being male (53.0%) and between the ages of 20 and 35 (91.3%). There was no statistically significant difference between the number of virtual and in-person interviews attended or the total number of interviews attended. The highest ranked limitations of the virtual interview process were limited exposure to details of the program structure, limited opportunity to exhibit applicants' strengths to the program, and limited exposure to the fellows. The highest ranked strengths were less pressure during interviews, greater scheduling flexibility, and ability to interview at more fellowship programs. The highest ranked limitations of the in-person interview process were more pressure during interviews, inability to interview at all desired fellowship programs, and decreased scheduling flexibility. The highest ranked strengths based on median rankings were greater exposure to details of the program structure, greater ability to exhibit an applicant's strengths to the program, and greater exposure to the geographic location/city. Conclusion While both in-person and virtual interviews have their own benefits and limitations, virtual interviews appear to be more cost-effective and time-efficient while in-person interviews provide better opportunities to assess program fit and culture. A hybrid format that combines the ideal aspects of both formats may be an optimal solution.

Evaluation of the Hypertensive Phase after Ahmed Glaucoma Valve Implantation in Neovascular Glaucoma.

Purpose: To compare Ahmed glaucoma valve (AGV) outcomes in neovascular glaucoma (NVG) eyes with and without a postoperative (PO) hypertensive (HTN) phase. Design: Retrospective study at a single tertiary care center of patients who underwent AGV implantation for NVG treatment with ≥6-month follow-up. Methods: Main outcome measures included intraocular pressure (IOP), number of glaucoma medications (GM), and failure at month 6 or at the most recent visit. Failure was defined as decline to no light perception (NLP) vision, IOP >21 mm Hg, or need for glaucoma reoperations (all with GM). Results: A total of 76 eyes of 74 patients (37 without HTN phase and 39 with HTN phase) with a mean follow-up duration of 28.9 ± 25.7 months (p = 0.602) were included. Both groups had similar demographics, visual acuity (VA), number of GM, etiology of NVG, and retina treatment perioperatively. Baseline IOP was significantly higher in the HTN phase group (p = 0.001). Compared to eyes without an HTN phase, HTN phase eyes more commonly met failure criteria at month 6 (33.3 vs 9.1%; p = 0.01), but both groups had a comparable cumulative failure for the entire follow-up period (p = 0.180). At the most recent visit, the number of GM was higher in the HTN phase group (p = 0.019), but IOP was similar in both groups. PO complications were comparable and uncommon in both groups. Conclusion: Hypertensive (HTN) phase following AGV implantation for NVG is associated with higher preoperative IOP and greater failure by PO month (POM) 6. However, eyes with and without the HTN phase had similar needs for GM and failure rates over the long term. How to cite this article: Ramesh S, Shalaby WS, Myers JS, et al. Evaluation of the Hypertensive Phase after Ahmed Glaucoma Valve Implantation in Neovascular Glaucoma. J Curr Glaucoma Pract 2023;17(2):91-97.

Effect of Phacoemulsification on Intraocular Pressure in Eyes with Functioning Tube Shunts.

Purpose: To evaluate the effect of phacoemulsification on intraocular pressure (IOP) in eyes with functioning tube shunts. Methods: This was a retrospective chart review of primary open-angle glaucoma (POAG) patients with a functioning tube who underwent phacoemulsification and had ≥24 months of follow-up. The primary end point was defined as surgical failure (IOP > 21 mmHg) at month 24, progression to no light perception (NLP) vision, glaucoma reoperation, or implant removal. Surgical failure defined as IOP >18 and >15 mmHg, changes in visual acuity (VA), IOP, and number of medications were assessed. Results: Twenty-seven eyes of 27 patients with moderate or severe POAG were included. The mean age of the patients was 64.2 ± 10.8 years. The interval between the tube shunt and phacoemulsification was 28.8 ± 25.0 months. At the end of the study, four (14.8%) eyes met the failure criteria; the average time to failure was 9.3 ± 3.8 months. The causes of failure were high IOP in two (50.0%) and glaucoma reoperation in two (50.0%) eyes; however, no eyes progressed to NLP vision. Surgical failure defined as IOP >18 and >15 mmHg showed an increasing failure rate (18.5% and 48.5%, respectively).Themean IOP and medications number remained stable at month 24 compared to baseline (P = 0.131 and P = 0.302, respectively). Initially, VA showed improvement, with the greatest improvement at 6 months (P = 0.001), but at 24 months the improvement was no longer significant (P = 0.430). Conclusion: Phacoemulsification in patients with functioning tubes did not change the mean IOP in most of the patients (86.2%); the number of medications also did not increase.

Hemorrhagic Complications Following Trabecular Bypass Microstent Surgery in the Setting of Antithrombotic Therapy.

PRCIS: In this retrospective study, the use of chronic antithrombotic therapy (ATT) did not increase the risk of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification. Stent type and female sex were associated with hyphema. PURPOSE: To report the incidence of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification with and without (ATT). METHODS: Retrospective case series on glaucoma patients on chronic ATT who underwent trabecular bypass microstent surgery (iStent, iStent inject, and Hydrus) combined with phacoemulsification between 2013 and 2019 with ≥3-month follow-up. The primary outcome measure was the incidence of hemorrhagic complications within a 3-month postoperative period. Generalized estimating equations were created to account for inter-eye correlation and logistic regression analysis was performed to identify factors predictive of hemorrhagic complications. RESULTS: Of 333 patients (435 eyes), 161 patients (211 eyes) were on ATT and 172 patients (224 eyes) were not on ATT; both groups were similar in age and baseline ocular characteristics. The only hemorrhagic complication was hyphema, which occurred in 84 (19.3%) eyes (41 ATT, 43 non-ATT eyes; P = 1.00). Onset was at postoperative day 1 in 98.8% of eyes, with a duration of 1 week in 73.8% of eyes, without difference between ATT and non-ATT groups. Hyphema was most common with Hydrus microstent (36.4%) versus iStent (19.9%) and iStent inject (8.5%) ( P = 0.003). In the multivariate model, the female sex was a predictor of hyphema [hazard ratio (HR) = 2.062; P = 0.009], iStent inject was protective against hyphema (HR = 0.379; P = 0.033), whereas Hydrus did not reach statistical significance (HR = 2.007; P = 0.081). Age, systemic comorbidities, ATT use, and baseline ocular characteristics were not significant predictors. CONCLUSIONS: Hemorrhagic complications after trabecular bypass microstent surgery were limited to transient hyphema and were not associated with chronic ATT use. Stent type and female sex were associated with hyphema.

Glaucoma Surgical Outcomes in Patients with a History of Scleritis.

PURPOSE: To assess the outcomes of glaucoma surgery in patients with a history of scleritis at a tertiary medical center. METHODS: The retrospective case series included patients with a history of scleritis who required glaucoma surgery between 4/2006 and 8/2021. RESULTS: Two hundred and eighty-one eyes of 259 patients had glaucoma and scleritis with 28 eyes (10%) of 25 patients requiring glaucoma surgery. Post-operatively, one eye (4%) had infectious scleritis. Eleven (39%) surgeries failed: 5 tube shunts, 5 cyclophotocoagulation, and 1 gonioscopy-assisted transluminal trabeculotomy. Five (18%) eyes required tube revisions due to tube exposures without infection (3), iris blocking the tube (1), or to shorten tube length (1). CONCLUSIONS: Patients with a history of scleritis have a low risk of scleritis recurrence or scleral perforation after glaucoma surgery but should be counseled appropriately on the higher risk of reoperation.

Agreement of ocular response analyzer cornea compensated IOP with corvis ST biomechanical IOP following Femtosecond Laser-assisted LASIK.

OBJECTIVES: To compare intraocular pressure (IOP) measurement by ORA-IOPcc and Corvis-bIOP after femtosecond laser-assisted LASIK (FS-LASIK). METHODS: In this prospective cohort study, 56 eyes from 56 consecutive patients scheduled for FS-LASIK were enrolled. All patients had IOP measurement with ORA and Corvis ST by two blinded independent expert examiners. IOP examinations were conducted between 8 and 11 A.M. Data were collected at baseline and 3 months after FS-LASIK. RESULTS: The mean age of the participants was 29.1 ± 6.3 years, and 42 (75%) were female. The average of central corneal thickness (CCT) decreased from 537 ± 23 µm at baseline to 458 ± 31 µm after FS-LASIK. The mean postoperative change of IOP was 0.0 ± 2.1 for bIOP and -2.5 ± 3.2 mmHg for IOPcc. The corresponding 95% limits of agreement (LoA) was -4.1 to 4.1 mmHg and -3.8 to 8.8 mmHg, respectively. Both methods showed no significant correlation between ∆IOP and ∆CCT. The 95% LoA between bIOP and IOPcc after FS-LASIK was -4.8 to 9.1 mmHg. CONCLUSIONS: Compared to the ORA-IOPcc, the Corvis-bIOP showed less variation after FS-LASIK and might be a more appropriate choice for measuring IOP in this condition. The agreement of bIOP vs. IOPcc after FS-LASIK is below the clinically acceptable level, and the two methods could not be regarded as interchangeable.

Chronic angle closure glaucoma with an atypical iris-pupillary membrane.

PURPOSE: To report the presentation and management of a 65-year-old female who presented with chronic angle closure glaucoma and an atypical iris membrane. CASE REPORT: A 65-year-old healthy female with no significant past medical history presented to the emergency room with a 2-day history of headache, blurry vision, and right ocular pain. She denied any such prior episodes, any prior ocular history including ocular trauma, or a family history of glaucoma. She was diagnosed with bilateral, severe chronic angle closure glaucoma with an atypical, pigmented iris-pupillary membrane in the right eye. Given the appearance of the membrane, ocular oncology consultation and anterior segment imaging were unremarkable. Surgical management included complex cataract extraction, limited pars plana anterior vitrectomy, iris membrane removal, and placement of a sulcus tube shunt. CONCLUSIONS: This complex case of chronic angle closure glaucoma with an atypical pupillary membrane highlights the importance of maintaining a broad differential and ruling out secondary pathologies such as iris melanoma. Additionally, it highlights the complexities of cataract extraction with a shallow anterior chamber.

The effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% at a tertiary glaucoma center.

PURPOSE: To assess real-world effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% (FCNL) in management of glaucoma patients in a tertiary eye care center. METHODS: This retrospective cohort study included glaucoma patients initiated on FCNL from January 2018 to July 2021 with at least 1-month follow-up. Demographic and clinical data were collected at baseline and at follow-up visits through 12 months. Patient-solicited side effects were recorded at each visit. Maximum glaucoma pharmacotherapy was defined as surgery/laser being the next treatment option following an intensive pharmacotherapy regimen, or when pharmacotherapy could not be increased due to allergy/intolerance or all pharmacologic mechanisms already being in use. RESULTS: Seventy-nine eyes of 47 patients were included. Mean age was 67.7 ± 14.7 years. Baseline IOP was 18.7 ± 4.9 mmHg; mean change in IOP (∆IOP) each study visit compared to baseline ranged from - 1.6 ± 3.5 to - 4.4 ± 4.1 mmHg (all p < 0.05). The eyes on maximum glaucoma pharmacotherapy (73.4%) had similar ∆IOP compared to those on non-maximal therapy at each visit (p > 0.2 for all). Forty-three (54.4%) eyes were switched from a prostaglandin analog alone, producing a 1-month IOP reduction of - 4.7 ± 3.9 mmHg at 1 month which remained significant at each visit for the 12-month study period (all p < 0.05). Across all study visits, conjunctival hyperemia was documented in 26 (32.9%) eyes. Subjective blurry vision was reported in 22 (27.8%) eyes without significant worsening of visual acuity at any visit (all p > 0.05). Six (7.6%) and 7 (8.9%) eyes required further medical or surgical/laser intervention, respectively. Kaplan-Meier analysis revealed no significant difference in the need for subsequent medical or surgical intervention between those on maximum and non-maximal pharmacotherapy (p > 0.4). CONCLUSION: FCNL was well-tolerated and demonstrated a significant and sustained reduction in IOP, even as last-line therapy before incisional or laser surgery in those on maximum glaucoma pharmacotherapy. FCNL is a viable treatment option for glaucomatous eyes before consideration of surgical intervention.

Variance in the macular sublayers' volume as a diagnostic tool for primary open-angle glaucoma.

PURPOSE: To assess the variance of macular sublayers' volume in glaucoma patients compared with normal individuals. METHODS: This case-control observational study included 63 cases of primary open-angle glaucoma and 57 healthy controls. Macular volumetric scans were captured at the 6 mm ETDRS circle for each retinal sublayer using Spectralis OCT2. The studied macular sublayers included the retinal nerve fiber layer, ganglion cell layer, inner plexiform layer, inner nuclear layer, outer plexiform layer, outer nuclear layer, and outer retinal layers (external limiting membrane to the retinal pigment epithelium). Standard deviation (SD) and coefficient of variation (CoV) of macular sublayers' volume were calculated. An unpaired Student t test (or its nonparametric equivalent) was used to compare each variable between groups. The receiver operating characteristic curve (ROC) was used to investigate the discriminative ability of each parameter. RESULTS: There was no significant difference for age or sex between the groups. The SD (of all sublayers' volume) was greater in the glaucomatous eyes compared with controls (0.620 ± 0.073vs.0.524 ± 0.056  mm3, respectively; P < 0.001). The same pattern was observed for CoV (7.890 ± 0.979vs.6.128 ± 0.583; P < 0.001). The area under curves (AUCs) for SD and CoV were 0.855and0.930, respectively (P = 0.05). The best cutoff value for the CoV was 6.712. The CoV and ganglion cell layer (GCL) volume revealed similar sensitivity (80.75) at 95% specificity for diagnosing glaucoma. The CoV detected 5 patients with glaucoma who had normal GCC volume. CONCLUSION: This study showed that the macular sublayers' volume variance parameters could be viable OCT biomarkers for detecting glaucomatous changes.

Deadbolt cataract due to misplanted minishunt.

A 62-year-old woman with stable unilateral glaucoma in the left eye presented for a cataract consultation. In 2010, laser peripheral iridotomies (LPI) were performed on both eyes by a different provider. Her postoperative course was complicated by a recalcitrant steroid response with a highest intraocular pressure (IOP) of 65 mm Hg in the left eye. A trabeculectomy with a glaucoma minishunt (EX-PRESS, Alcon) was then performed by that provider (Supplemental Figure 1, http://links.lww.com/JRS/A603). Thereafter, IOP control of the left eye was normalized and maintained without topical antiglaucoma medications. Historically, her right eye has been always her better eye. Recently, she noticed metamorphopsia in her left eye. Her ocular history was also notable for high refractive errors requiring continuous spectacles wear, possible mild refractive amblyopia of the left eye, history of submacular choroidal nevus with drusen in the right eye, and an epiretinal membrane (ERM) with macular pucker in the left eye. Her husband is an optician. Both inquire about refractive cataract surgery options to correct astigmatism and presbyopia; both have reservations regarding cost and visual quality associated with diffractive optic intraocular lenses (IOLs). Her deteriorating visual acuity in both eyes affects her ability to work. Her corrected distance visual acuity was 20/40 in both eyes (pinhole, no help) while wearing spectacles according to a prescription of -8.50 diopters (D) +1.50 D × 106 for the right eye and -13.00 D +3.25 D × 057 for the left eye. Her corrected near visual acuity was 14/14 in both eyes with the abovementioned prescription and a +3.00 D add. Central corneal thickness was 618 µm in the right eye and 631 µm in the left eye. IOP was 20 mm Hg in the right eye and 10 mm Hg in the left eye on no antiglaucoma medications. Pertinent findings on slitlamp examination included bilateral dermatochalasis, a shallow diffuse thick bleb superiorly in the left eye only, patent LPI superiorly in both eyes, nuclear sclerotic and cortical cataracts in both eyes (with prominent focal spoke superiorly left eye only) (Figure 1, A-C). Fundus photos show posterior vitreous detachment in both eyes, ERM with macular pucker in the left eye, and submacular choroidal nevus (2.5 × 3.0 disc diameter size) with overlying drusen in the right eye (Supplemental Figure 2, A, http://links.lww.com/JRS/A604). Gonioscopy revealed open angles in both eyes, albeit with focal narrowing without synechiae superiorly in the left eye only (Figure 1, D-FJOURNAL/jcrs/04.03/02158034-202207000-00020/figure1/v/2022-06-24T130746Z/r/image-tiff). Most importantly, however, the distal tip of the minishunt was not positioned as expected in the anterior chamber; rather, it was noted to pierce the peripheral iris near the iris root superiorly. Most of the minishunt shaft and spur were positioned in the posterior chamber with the distal tip penetrating into the superior aspect of the capsular bag and cataract in the left eye-like a deadbolt. Visual field testing showed a full field in the right eye and an inferior nasal step in the left eye (Supplemental Figure 2, B, http://links.lww.com/JRS/A604). In addition to slitlamp, gonioscopic, and fundus photos, we also obtained optical coherence tomography of the macula and nerve (Supplemental Figure 2, C, http://links.lww.com/JRS/A604), optical biometry, ultrasound biomicroscopy, endothelial cell counts, and corneal topography (Supplemental Figure 3, http://links.lww.com/JRS/A605). How would you counsel this patient regarding her glaucoma condition, the misplanted minishunt, and her cataract surgery and IOL options? How would you manage the misplanted minishunt? What surgical approaches or specific techniques would you consider for cataract removal and visual rehabilitation?

Can trainees perform Ahmed glaucoma valve surgery as effectively as attendings?

OBJECTIVE: To compare the surgical outcomes and early postoperative complications of Ahmed glaucoma valve (AGV) implantation performed by residents with those performed by attending physicians. METHODS: This is a retrospective, case-control study. Data were gathered from chart reviews of consecutive cases of AGV model FP7 implantation between January 2014 and July 2017. Postoperative 1-year results of patients who had at least 3 months follow-up were evaluated. RESULTS: One hundred and forty-four eyes of 144 patients were included in this study: 72 patients in the resident group, and 72 age- and sex-matched patients in the attending group. Hyphema and shallow anterior chamber were significantly more common in the resident group vs. attending group (25% vs. 2.8% and 19.4% vs. 7.0%; P = 0.001 and P = 0.04, respectively). Neovascular glaucoma (NVG) was more common in resident vs. attending group (30.6% vs. 1.4%; P < 0.001). No significant difference in mean intraocular pressure (IOP) was found at any postoperative follow-up visits between the surgery groups (P > 0.05, for all). The number of postoperative visits within 3 months was similar between the groups (P = 0.84). CONCLUSION: Resident-performed AGV surgery lowered IOP, similar to attending-performed surgery. More frequent complications were observed in the resident group, which might be due to the predominance of NVG in this group.