Cyclodiode vs micropulse transscleral laser treatment.

BACKGROUND: Continuous-wave transscleral cyclophotocoagulation (CW-TSCP) is usually reserved for advanced/refractory glaucoma. Micropulse transscleral laser therapy (MPTLT) utilises short energy pulses separated by 'off'-periods. MPTLT is postulated to have fewer complications, but its relative efficacy is not known. The National Institute for Health and Care Excellence (NICE) has deemed the evidence supporting MPTLT use of inadequate quality, limiting its use to research. This study aims to evaluate MPTLT efficacy and safety compared to CW-TSCP. METHODS: This 24-month follow-up retrospective audit included 85 CW-TSCP and 173 MPTLT eyes at a London tertiary referral centre. Primary outcome was success rate at the last follow-up; defined as at least 20% intraocular pressure (IOP) reduction with the same/fewer medications, and IOP between 6 and 18 mmHg. Secondary outcomes were acetazolamide use and success rates per glaucoma type. Safety outcomes were reported as complication rates. RESULTS: By 24-months, mean IOP reduced from 34.6[±1.4]mmHg to 19.0[ ± 3.0]mmHg post-CW-TSCP (p < 0.0001); and from 26.1[±0.8]mmHg to 19.1[±2.2]mmHg post-MPTLT (p < 0.0001). Average IOP decreased by 45.1% post-CW-TSCP, and 26.8% post-MPTLT. Both interventions reduced medication requirements (p ≤ 0.05). More CW-TSCP patients discontinued acetazolamide (p = 0.047). Overall success rate was 26.6% for CW-TSCP and 30.6% for MPTLT (p = 0.83). Only primary closed-angle glaucoma saw a significantly higher success rate following CW-TSCP (p = 0.014). CW-TSCP complication rate was significantly higher than MPTLT (p = 0.0048). CONCLUSION: Both treatments significantly reduced IOP and medication load. CW-TSCP had a greater absolute/proportionate IOP-lowering effect, but it carried a significantly greater risk of sight-threatening complications. Further prospective studies are required to evaluate MPTLT compared to CW-TSCP.

Effects of COVID-19 pandemic on glaucoma appointment scheduling in a tertiary hospital in London, UK.

PURPOSE: To investigate the impact of the delay in patient appointments caused by the COVID-19 pandemic and the triage system on the glaucomatous disease of patients in a London tertiary hospital. METHODS: Observational retrospective study that randomly selected 200 glaucoma patients with more than 3 months of unintended delay for their post-COVID visit and other inclusion and exclusion criteria. Demographic information, clinical data, number of drugs, best-corrected visual acuity (BCVA), intraocular pressure (IOP), visual field (VF) mean deviation (MD), and global peripapillary retinal nerve fibre layer (pRNFL) thickness were obtained from the pre- and post-COVID visit. At the post-COVID visit, the clinical outcomes subjective clinical concern and change of treatment or need for surgery were also annotated. The variables were stratified by glaucoma severity (according to the MD into early, moderate and advanced) and by delay time (more and less than 12 months) and analysed using SPSS. RESULTS: We included 121 eyes (from 71 patients). The median patient age was 74 years (interquartile range -IQR- 15), 54% were males and 52% Caucasians. Different glaucoma types and all glaucoma severities were included. When data was stratified for glaucoma severity, at the pre-COVID visit, significant differences in BCVA, CCT and IOP were observed and there were significantly higher values in the early glaucoma group. The median follow-up delay was 11 months (IQR 8), did not differ between the glaucoma severity groups and did not correlate to the glaucoma severity. At the post-COVID visit, significant differences in BCVA, IOP, and Global pRNFL thickness were observed between the glaucoma severity groups, as lower BCVA and higher IOP and pRNFL thickness were observed in the early glaucoma group. At the post-COVID visit there was cause for concern in 40 eyes: 5 were followed more closely, 22 had a change of treatment and 13 were booked for surgery (3 for cataract and 10 for glaucoma surgery). However, the number of eyes with causes for concern were similar between the glaucoma severity groups and there was no correlation between these clinical outcomes and the delay of the post-COVID visit. The number of topical hypotensive medications increased significantly after the post-COVID visit, higher number of medications were observed in the advanced glaucoma group. When differences of IOP, MD and pRNFL thickness between the pre and post-COVID visit, only the MD difference was significantly different between the glaucoma severity groups because it was higher in the severe group. When data was stratified for delay longer or shorter than 12 months, no differences were observed between the groups except at the pre-COVID visit, when the numbers of patients with MD deviation >-6 dB had longer delay time. When differences in IOP, MD and RNFL thickness were calculated, only the pRNFL thickness showed significant differences between the delay groups, because it was higher in the longer delay group. Finally, when paired analysis of the variables at the pre- and post-COVID visits, stratified by glaucoma severity and delay were conducted, although there were no significant differences in IOP in any group, the BCVA decreased significantly in the overall group and in the longer delay groups, the number of hypotensive drugs increased significantly overall and in the moderate and advanced glaucoma, the MD of the VF worsened significantly in the overall group and in the early glaucoma and longer delay groups and the pRNFL thickness decreased significantly in all groups. CONCLUSIONS: We document that delayed care impacts negatively on the glaucomatous disease of our patients because at the post-COVID visit there were reasons for clinical concern in a third of eyes that resulted in change of treatment or surgery. However, these clinical consequences were not related to IOP, glaucoma severity or delay time and reflect that the triage methods implemented worked adequately. The most sensitive parameter to indicate progression in our sample was the pRNFL thickness.

MicroShunt versus Trabeculectomy for Surgical Management of Glaucoma: A Retrospective Analysis.

This case-control study aims to compare the efficacy, safety, and postoperative burden of MicroShunt versus trabeculectomy. The first consecutive cohort of MicroShunt procedures (n = 101) was matched to recent historical trabeculectomy procedures (n = 101) at two London hospital trusts. Primary endpoints included changes in intraocular pressure (IOP) and glaucoma medications. Secondary outcome measures included changes in retinal nerve fibre layer (RNFL) thickness, rates of complications, further theatre interventions, and the number of postoperative visits. From the baseline to Month-18, the median [interquartile range] IOP decreased from 22 [17-29] mmHg (on 4 [3-4] medications) to 15 [10-17] mmHg (on 0 [0-2] medications) and from 20 [16-28] mmHg (on 4 [3-4] medications) to 11 [10-13] mmHg (on 0 [0-0] medications) in the MicroShunt and trabeculectomy groups, respectively. IOP from Month-3 was significantly higher in the MicroShunt group (p = 0.006), with an increased number of medications from Month-12 (p = 0.024). There were greater RNFL thicknesses from Month-6 in the MicroShunt group (p = 0.005). The rates of complications were similar (p = 0.060) but with fewer interventions (p = 0.031) and postoperative visits (p = 0.001) in the MicroShunt group. Therefore, MicroShunt has inferior efficacy to trabeculectomy in lowering IOP and medications but provides a better safety profile and postoperative burden and may delay RNFL loss.

Endocyclophotocoagulation combined with phacoemulsification in surgically naive primary open-angle glaucoma: three-year results.

OBJECTIVE: To assess the safety and efficacy of endocyclophotocoagulation with phacoemulsification (phaco-ECP) in surgically naive, primary open-angle glaucoma (POAG). METHODS: A retrospective case series of patients undergoing phaco-ECP between 2007 and 2017 at a single centre in London, UK. The primary outcome was intraocular pressure (IOP). Secondary outcomes were visual acuity, visual field global indices, topical medications and surgical complications. Failure criteria were: (1) IOP > 21 mmHg or <20% reduction at two consecutive visits, (2) IOP <5 mmHg and (3) further IOP-lowering surgery. RESULTS: Eighty-three eyes from 83 patients were eligible. Pre-operatively, mean IOP (±SD) was 18.4 ± 5.2 mmHg. The mean number of topical agents (±SD) was 2.7 ± 0.9. Mean IOP (±SD) significantly reduced to 14.3 ± 4.7 at 1 year, 14.1 ± 4.0 at 2 years and 13.6 ± 3.7 at 3 years (p < 0.0001). Topical medications were significantly reduced to 1.3 ± 1.2 at 1 year, 1.7 ± 1.2 at 2 years and 1.8 ± 1.3 at 3 years (p < 0.0001). Annual IOP 'survival' was 70%, 54% and 45% at year 1, 2 and 3, respectively. Complications included uveitis (6%), macular oedema (2%), IOP spikes (1%) and corneal decompensation (1%) with no episodes of hypotony or retinal detachment. One patient underwent filtration surgery within 3 years (1%). CONCLUSION: Phaco-ECP facilitates significant IOP lowering and reduction of medication burden in surgically naive POAG requiring cataract extraction. The procedure is relatively safe and without the use of implants and their associated risks.

Guidelines and Recommendations for Tonometry Use during the COVID-19 Era.

The novel coronavirus disease COVID-19 caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has resulted in a substantial change in eye care and clinical practice. There has been conflicting information and weak evidence on the virus's transmission through tears. Yet, virus detection on cornea and conjunctiva surface as a gateway for infection is not well-studied. Moreover, there have been no reported cases of SARS-CoV-2 transmission through tonometry to date. Thus, this uncertainty has urged this review on evidence-based guidelines and recommendations on tonometer use in the COVID-19 era. The aim of this article is to provide ophthalmologists with recommendations for tonometry practice based on current evidence and best practice guidelines.

A CNN-aided method to predict glaucoma progression using DARC (Detection of Apoptosing Retinal Cells).

BACKGROUND: A key objective in glaucoma is to identify those at risk of rapid progression and blindness. Recently, a novel first-in-man method for visualising apoptotic retinal cells called DARC (Detection-of-Apoptosing-Retinal-Cells) was reported. The aim was to develop an automatic CNN-aided method of DARC spot detection to enable prediction of glaucoma progression. METHODS: Anonymised DARC images were acquired from healthy control (n=40) and glaucoma (n=20) Phase 2 clinical trial subjects (ISRCTN10751859) from which 5 observers manually counted spots. The CNN-aided algorithm was trained and validated using manual counts from control subjects, and then tested on glaucoma eyes. RESULTS: The algorithm had 97.0% accuracy, 91.1% sensitivity and 97.1% specificity to spot detection when compared to manual grading of 50% controls.  It was next tested on glaucoma patient eyes defined as progressing or stable based on a significant (p<0.05) rate of progression using OCT-retinal nerve fibre layer measurements at 18 months. It demonstrated 85.7% sensitivity, 91.7% specificity with AUC of 0.89, and a significantly (p=0.0044) greater DARC count in those patients who later progressed. CONCLUSION: This CNN-enabled algorithm provides an automated and objective measure of DARC, promoting its use as an AI-aided biomarker for predicting glaucoma progression and testing new drugs.

Micropulse transscleral cyclophotocoagulation: initial results using a reduced energy protocol in refractory glaucoma.

PURPOSE: This study evaluates the 6-month safety and efficacy of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in cases of uncontrolled glaucoma/ocular hypertension using a reduced energy protocol. METHODS: Retrospective analysis of patients undergoing MP-TSCPC from January-April 2018 was carried out. Patients received up to 90 s of laser with settings of 2000 mW/Cm2 and a duty cycle of 31.3%. RESULTS: A total of 29 patients were included, with a mean age of 64.7 ± 15.1 years. The most common diagnosis was primary open angle glaucoma (41.4%) with a mean Logmar visual acuity of 1.5 ± 1.2. All subjects had either undergone intraocular surgery (58.6% filtration surgery) or continuous wave diode laser prior to micropulse treatment. Mean pre-laser IOP was 26.2 ± 11.1 mmHg. There was a significant reduction (p < 0.05) in IOP at 1 month to 15.8 ± 5.4 mmHg (39.7% reduction), at 3 months to 15.04 ± 5.25 mmHg (42.6% reduction) and at 6 months to 18.19 ± 7.47 mmHg (30.6% reduction). There was also a corresponding reduction (p < 0.05) in the number of topical agents required to control pressure from a baseline of 3.31 ± 0.97, to 2.72 ± 0.88 at 1 month, 2.76 ± 0.91 at 3 months and 2.90 ± 1.08 at 6 months. Requirements for oral acetazolamide reduced from 41.3% (1/29) at baseline to 3.4% (1/29) at 6 months. Success rates were 75.9% at 1 month, 79.3% at 3 months and 58.6% at 6 months. There was no drop in the visual acuity, no change in central retinal thickness and no cases of intraocular inflammation. CONCLUSIONS: MP-TSCPC at a decreased duration is effective at reducing intraocular pressure in ethnically diverse glaucoma patients refractory to previous glaucoma laser or surgeries at 6 months follow-up, with no significant complications. Further work is needed to confirm efficacy in the long term and to determine optimal settings.

BLIND-SIDED BY COSMETIC VEIN SCLEROTHERAPY: A CASE OF OPHTHALMIC ARTERIAL OCCLUSION.

PURPOSE: Cosmetic vein sclerotherapy is increasingly used to treat varicose veins because of its effectiveness and adherence with British Pharmacopoeia specifications. We present the first documented case of ophthalmic artery occlusion resulting in panocular ischemia secondary to intravascular injection of sodium tetradecyl sulfate sclerosant in a young healthy women seeking treatment for prominent facial veins in her forehead. METHODS: The patient presented with unilateral sudden loss of vision. Funduscopy demonstrated a pale retina, cherry-red spot, and sclerosant visualized directly at the macula. She underwent emergency treatment for central retinal artery occlusion followed by fundal photographs, fluorescein angiography, and optical coherence tomography. RESULTS: Despite intervention, the vision remained no perception to light. Magnetic resonance imaging, echocardiography, and Doppler ultrasound were unremarkable. The patient later developed neovascular sequelae requiring laser pan-retinal photocoagulation. CONCLUSION: Widely regarded as safe, and approved by the U.S. Food and Drug Administration, the only published ocular side effects of foam sclerotherapy are transient visual disturbances or temporary scotomas. This case demonstrates irreversible loss of vision as a previously unreported complication. While undoubtedly rare, we believe physicians and surgeons using sclerosant in the orbital adnexa, face, nose, and sinuses should be aware of this sight-threatening complication of injection and counsel potential patients accordingly.

Severe Corticosteroid-Induced Ocular Hypertension Requiring Bilateral Trabeculectomies in a Patient with Takayasu's Arteritis.

We present a rare case of severe corticosteroid-induced ocular hypertension (OHT) after prolonged systemic corticosteroid use in a young woman with Takayasu's arteritis. As she did not sufficiently respond to ocular antihypertensive therapies, bilateral enhanced trabeculectomies were required to normalize her intraocular pressures. The systemic side effects of corticosteroids are well known, yet steroid-induced OHT and glaucoma remain silent causes of ocular morbidity. This case highlights the importance of IOP-monitoring in visually asymptomatic patients on systemic corticosteroids. It further emphasizes the need to raise awareness of the potential ocular side effects of steroids amongst physicians, in particular those looking after patients with autoimmune and inflammatory diseases.

Complications secondary to cosmetic artificial iris anterior chamber implants: a case report.

BACKGROUND: Artificial iris anterior chamber implants were originally developed for therapeutic purposes but have been used recently for the cosmetic alteration of eye colour. There is a growing body of evidence surrounding their associated risks. We report a case presenting with complications secondary to bilateral NewColorIris® implants, including the first report of pressure-induced stromal keratopathy in this context. CASE PRESENTATION: A thirty-eight year old South American man presented as an emergency in the UK with best corrected visual acuities of 1/60 OD and 6/18 OS, bilateral corneal decompensation, lens opacities and raised intraocular pressures 4 years following bilateral NewColorIris® implantation in Panama. Anterior segment optical coherence tomography demonstrated the direct apposition of the implant with the iris and iridocorneal angle, together with pressure-induced stromal keratopathy with a fluid interface between the corneal stroma and previous laser-assisted in situ keratomileusis flaps. We describe the successful combined medical and surgical management in this case to yield a final visual acuity 6/12 in both eyes. CONCLUSION: Artificial iris anterior chamber implants are associated with sight-threatening complications that can present years after their implantation. We caution against their use for the cosmetic alteration of eye colour.