Risk Factors for Corneal Striae in Eyes After Glaucoma Surgery.

PRCIS: Eyes with corneal striae had steeper cornea, induced astigmatism, and higher corneal hysteresis (CH), which implies a relationship between striae, corneal shape, and the cornea's resistance to deformation at low intraocular pressures (IOPs). BACKGROUND: Anterior corneal striae (ACS) are associated with low IOP. However, the clinical significance of ACS is unclear. Here, we aim to evaluate differences in eyes with striae compared with eyes without striae. METHODS: Adults with ACS (cases) and without ACS (controls) ≥8 weeks after glaucoma surgery with an IOP ≤10 mm Hg were enrolled. Optical coherence tomography and optical biometry were performed. CH, defined as the difference in pressure between corneal indentation and reformation in response to an air jet, was obtained by the ocular response analyzer. Hypotony maculopathy (HM) was defined as optic disc swelling, vascular tortuosity attributed to hypotony, or clinical presence of chorioretinal folds confirmed on OCT. RESULTS: One hundred sixteen eyes (76 cases, 40 controls) were included. Cases had a lower IOP compared with controls (6.5±2.3 vs. 8.5±1, P<0.0001). A 1 mm Hg increase in CH increased ACS odds [odds ratio (OR)=1.51, P=0.01]. A 1 D increase in the flattest presurgical and postsurgical corneal power increased ACS odds by 1.83 (P=0.01) and 1.41 (P=0.02), respectively. Astigmatism increased in eyes with ACS by 1.11 D (P<0.001). ACS odds were increased with every 1 minute increase in mitomycin-C duration (OR=1.58, P=0.047) and decreased with the use of topical glaucoma medication (OR=0.62, P=0.03). Visual acuity decreased from logarithm of the minimal angle of resolution 0.22 (20/33 Snellen) presurgery to 0.28 (20/38) postsurgery (P=0.008), independent of ACS. HM occurred in 19% of cases (P=0.05). A higher postsurgical CH increased HM odds (OR=1.8, P=0.003). HM predicted a 0.41 mm decrease in axial length (P<0.0001), independent of IOP. CONCLUSION: ACS were associated with a steeper cornea, induced astigmatism, and higher CH, suggesting a relationship between striae, corneal shape, and the cornea's ability to resist deformations at lower IOP. CH, HM, and axial length shortening were associated independently of IOP.

Microinvasive Glaucoma Surgery: An Evidence-Based Review.

PURPOSE: Interest in micro-invasive glaucoma surgery (MIGS) has exploded over the last 8 years with an increase in MIGS procedures of at least 400% in the United States, according to Medicare data. MIGS is an umbrella term that can cover many different types of surgeries. This review focuses on peer-reviewed evidence for Trabectome®, iStent inject®, Kahook Dual Blade®, XEN® Gel Stent, and Hydrus®. METHODS: We present key recent studies evaluating the efficacy and safety of MIGS in various types of glaucoma patients with different stages of disease. CONCLUSION: We conclude that MIGS is generally safe and efficacious, although only some MIGS have been studied through randomized clinical trials. When comparing and contrasting the different MIGS procedures, large prospective studies are not yet the norm. High-quality large prospective studies involving MIGS will be an important next step as ophthalmologists decide how to incorporate MIGS into their surgical armamentarium.

A lot of nerve.

A 71-year-old woman with a history of acute lymphoblastic leukemia presented with unilateral optic disc edema. Laboratory evaluations for infectious, inflammatory, and neoplastic etiologies were negative. Magnetic resonance imaging of the orbits with and without contrast demonstrated enhancement and thickening of the right optic nerve with mild stranding of the intraconal fat. She underwent three large-volume lumbar punctures, all of which were negative for malignancy. An optic nerve biopsy was ultimately performed, demonstrating malignant cells on immunohistochemical staining. This case illustrates a rare case of biopsy-proven leukemic infiltration of the optic nerve head as the presenting sign of leukemic relapse despite a negative systemic workup. Leukemic infiltration should be considered in the differential diagnosis for cases of acquired disc edema, especially in patients with a past medical history of leukemia.

Impact and Implication of Fovea-Involving Intraretinal Hemorrhage after Acute Branch Retinal Vein Occlusion.

PURPOSE: To compare clinical outcomes in patients with branch retinal vein occlusion (BRVO) with (group A) or without (group B) fovea-involving intraretinal hemorrhage (IRH). DESIGN: Retrospective cohort study. PARTICIPANTS: All patients diagnosed with acute, treatment-naive BRVO seen by the Duke Eye Center Retina Service from January 1, 2009, through June 30, 2017 who had treatment-naive BRVO with disease onset <3 months before presentation, macular involvement, spectral-domain OCT and color fundus photographs at presentation, and >12 months offollow-up. METHODS: Retrospective study using a database of patients diagnosed with BRVO over an 8-year period. The presence of fovea-involving IRH was determined from baseline fundus photographs by human graders and confirmed with multimodal imaging. Presenting features, treatment patterns, and clinical outcomes were compared. MAIN OUTCOME MEASURES: Visual acuity (VA), cystoid macular edema (CME), central subfield thickness (CST), and number of anti-vascular endothelial growth factor (VEGF) injections. RESULTS: Of 172 patients with BRVO, 33 (19.2%) presented with fovea-involving IRH. At presentation, group A had worse VA (0.54±0.06 logMAR [Snellen equivalent, 20/69] vs. 0.34±0.03 logMAR [Snellen equivalent, 20/44]; P = 0.001), greater CST (523.8±32 µm vs. 345.9±11.8 µm; P < 0.001), were more likely to have CME (93.9% vs. 48.2%; P < 0.001), and received more anti-VEGF injections in the first year (4.50±3.43 vs. 1.89±3.26; P < 0.001) than group B. Final VA was worse in group A (0.57±0.12 logMAR [Snellen equivalent, 20/74] vs. 0.35±0.05 logMAR [Snellen equivalent, 20/45]; P = 0.05). More patients in group A had loss of >2 lines of VA (36.4% vs. 18.7%; P = 0.04) or >3 lines (27.3% vs. 10.8%; P = 0.05) at final follow-up. Group A was more likely to have CME (63.6% vs. 27.3%; P < 0.001) at final follow-up with greater treatment burden, yet experienced a greater decrease in CST (-197.8±45.3 µm vs. -51.7±14.7 µm; P = 0.005). CONCLUSIONS: Acute BRVO presenting with fovea-involving IRH is associated with worse presenting features, greater treatment burden, and worse clinical outcomes despite current therapeutic interventions.

Gender and Ethnicity of Enrolled Participants in U.S. Food and Drug Administration (FDA) Clinical Trials for Approved Ophthalmological New Molecular Entities.

PURPOSE: The purpose of this review is to describe the demographics (age, gender, race and iris color) of subjects enrolled in clinical trials supportive of approved New Molecular Entities (NMEs) in ophthalmology over the last 10 years (2006-2016). METHODS: Publicly available data on Drugs@FDA were reviewed for all 9 approved NMEs, including biologics, from 2006 to 2016. RESULTS: All NMEs have publicly available data on the race, gender and age of clinical trial participants. Women and white subjects comprise a majority of clinical trial participants (68% and 92%, respectively). FDA analyses on all 9 NMEs did not find any differences across age, gender, race, or iris color subgroups.

Acquired Corneal Neuropathy and Photoallodynia Associated With Malposition of an Ex-PRESS Shunt.

PURPOSE: Corneal neuropathy is a recently described disease process that is not well understood and is likely underdiagnosed as a result. This is the first reported case of an acquired corneal neuropathy associated with malposition of an Ex-PRESS shunt. METHODS: A single case report. RESULTS: We report the case of a 50-year-old man with a history of multiple procedures for glaucoma who subsequently developed photoallodynia and corneal neuropathy in association with malposition of an Ex-PRESS shunt in the peripheral cornea. Laser confocal microscopy (HRT3/RCM) of the cornea showed the presence of neuromas, decreased nerve density, and a significant increase of dendritiform immune cells consistent with our diagnosis. Initial treatment with steroid pulse therapy did not result in decreased inflammation or symptomatic improvement leading to surgical explantation of the shunt. One month after surgery, there was noticeable improvement in the patient's pain and photoallodynia (approximately 40%) as well as the abnormalities seen on confocal microscopy. CONCLUSIONS: We hypothesize that poor Ex-PRESS shunt positioning can act as a nidus for corneal inflammation, resulting in corneal neuropathy and lowering of the nociception threshold.

Increased Prevalence of Optic Disc Drusen after Papilloedema from Idiopathic Intracranial Hypertension: On the Possible Formation of Optic Disc Drusen.

This is a 25-year observational retrospective review of 372 consecutive participants with optic disc drusen or resolved papilloedema from idiopathic intracranial hypertension. The prevalence of optic disc drusen at 19% among eyes with resolved papilloedema was approximately 10 times higher and significantly increased (p < 0.001) as compared with the occurrence in the general population. Eyes with both resolved papilloedema and optic disc drusen had similar visual acuity and visual field outcome as compared with resolved papilloedema alone. Eyes with exposed drusen had significantly worse visual acuity and visual field outcome (p < 0.001) than buried drusen. The high prevalence of optic disc drusen after papilloedema has resolved suggests a non-coincidental relationship. Optic disc drusen formation can be a sequela of papilloedema.

THE ROLE OF EARLY VITRECTOMY IN THE TREATMENT OF FUNGAL ENDOGENOUS ENDOPHTHALMITIS.

PURPOSE: To review the therapeutic role of vitrectomy in fungal endogenous endophthalmitis. METHODS: Six cases were identified as fungal endogenous endophthalmitis through positive cultures or clinical presentation. RESULTS: All six cases had fungal endogenous endophthalmitis risk factors; average diagnostic delay was 7.5 days; all cases were managed with vitrectomy, intravitreal antifungals, and systemic antifungals within 24 hours of fungal endogenous endophthalmitis diagnosis. Visual acuity of 20/200 or better was achieved by 5 of 6 eyes, with 4 of those eyes achieving 20/40 or better. CONCLUSION: An early vitrectomy in high-risk patients may improve visual outcomes and aid in diagnosis.