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PURPOSE: The purpose is to evaluate the results of the modified direct phaco-chop technique of cataract surgery in eyes with pseudoexfoliation. METHODS: All patients with pseudoexfoliation and visually significant cataract with normal intraocular pressure (IOP) and optic nerve that underwent cataract surgery by the same surgeon using Infiniti®, OZil® Torsional handpiece (Alcon Labs), were included for this retrospective hospital-based study. Direct vertical or horizontal chop technique was used in all cases with parameters set as required for quadrant removal with high vacuum after the initial cleanup of cortex under the capsulorhexis. To allow better visualization of the hardness of the nucleus core, the sides of the lens were scooped out a central well with vacuum with maximum chopping done centrally within the rhexis as the first step to enable better assessment of the depth of burying the chopper for direct chop. Intraoperative details recorded and analyzed included ultrasound time and cumulative dissipated energy. The mean visual acuity and IOP before and after surgery were recorded at 1 day, 1 week, and 1 month. Complications during or after surgery were noted. RESULTS: A total of 138 patients with a mean age of 62 ± 6.7 years underwent phachop technique of phacoemulsification for nuclear cataract grades of nuclear sclerosis 2-4 with significant improvement in visual acuity from baseline (0.26) to 3 months (0.82), P < 0.001. The mean ultrasound torsional amplitude and cumulative dissipated energy (CDE) were greater for brown cataract of grading >3, P = 0.02. A total of 8 patients had intraoperative zonular dialysis in 1 quadrant (none in >1 quadrant), which was not associated with intraoperative vitreous prolapse in 6 eyes. CONCLUSIONS: Direct modified phaco-chop technique may be a safe technique in pseudoexfoliation due to minimal zonular stress with successful outcomes and reduced complications.
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Purpose: This study aims to evaluate efficacy and outcomes of manual small incision cataract surgery with trabeculectomy (Group 1) and phacoemulsification with trabeculectomy (Group 2) in pseudoexfoliation glaucoma (PXG). Methods: In this retrospective comparative observational case series, All patients with PXG who underwent either small incision cataract surgery or phacoemulsification with trabeculectomy from 2011-2015 were studied. Data compared included best corrected visual acuity (BCVA), intraocular pressure (IOP), total surgical time, and incidence of intra/postoperative complications. Results: A total of 82 (Group 1) and 64 (Group 2) subjects were included for the study. The baseline IOP and anti-glaucoma medications in both groups were comparable pre-operatively (group 1 = 26 ± 10.3 mmHg, group 2 = 23 ± 13.9 mmHg, P = 0.1). The IOP at final follow up between the two groups was not statistically significant (group 1 = 12 ± 3.2 mmHg, group 2 = 14 ± 1.8 mmHg, P = 0.2).The average total time of surgery (group 1 = 40 ± 21.6 min, group 2 = 34 ± 14.8 min, P = 0.4) was not statistical significant between groups. The incidence of post-operative complications were similar in both groups (P = 0.95). Conclusion: Manual small incision cataract surgery with trabeculectomy is noninferior in PXG patients with comparable surgical outcomes, when compared with phacoemulsification with trabeculectomy.
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Catarata , Glaucoma , Facoemulsificação , Trabeculectomia , Catarata/complicações , Glaucoma/complicações , Glaucoma/cirurgia , Humanos , Pressão Intraocular , Estudos Retrospectivos , Resultado do Tratamento , Acuidade VisualRESUMO
PURPOSE: To characterize anatomical dimensions of a disc notch using novel methods using spectral domain optical coherence tomography (SD-OCT). PARTICIPANTS: All age- and severity-matched glaucoma patients with disc notch (defined as complete loss of neural rim with no residual rim between disc and cup) seen from 2014 to 2015 who underwent enhanced depth imaging with SD-OCT (Cirrus HD-OCT version 6.5, Carl Zeiss, USA) were included for this retrospective observational study. METHODS: Using known dimensions of the 200 * 200 optic disc cube (6 * 6 mm), the notch width was calculated from the margins of the notch on either side using ImageJ software. The height was calculated from the lowest margin of the cup to the lowest point of the defect on the optic disc. These were compared with the quadrant retinal nerve fiber layer (qRNFT) and sectoral retinal nerve fiber layer (sRNFLT) thickness in notch and the sector 2 clock hours adjacent to the notch region (SaRNFLT). RESULTS: The height and width of the notch in 31 eyes of 27 patients were 2.6 ± 0.48 mm and 2.23 ± 0.31 mm. The RNFL thickness in the same sector as that of the notch was 41 ± 21.06 µm while the adjacent two sectors measured 62 ± 26.5 and 64 ± 26.5 µm on either sides of the sector of the notch. The difference between the sRNFLT and saRNFLT ranged from -9 to 67 and -13 to 50 µm, respectively. This difference was significantly associated with height of the notch (R2 = 20.8, p = 0.01). CONCLUSION: Automated analysis of a notch and RNFL thickness in that sector can help in precise glaucoma monitoring in the region of interest.
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Glaucoma de Ângulo Aberto/diagnóstico , Imageamento Tridimensional , Fibras Nervosas/patologia , Disco Óptico/patologia , Tomografia de Coerência Óptica/métodos , Campos Visuais , Feminino , Seguimentos , Glaucoma de Ângulo Aberto/fisiopatologia , Humanos , Pressão Intraocular , Masculino , Pessoa de Meia-Idade , Células Ganglionares da Retina/patologia , Estudos RetrospectivosRESUMO
PURPOSE: To compare the efficacy of combined manual small incision cataract and glaucoma surgery with anterior chamber maintainer (ACM) alone versus that with intraoperative viscoelastics. METHODS: Hospital electronic medical records of patients who underwent small incision cataract and trabeculectomy and intraocular lens implantation without Mitomycin-C from 2014 to 2016 were identified from the hospital operation theater database for this retrospective, hospital-based comparative study. All MSICS surgeries were performed by a single surgeon under peribulbar block. Data retrieved from all patients undergoing surgery with viscoelastic (group 2) or under AC maintainer without viscoelastic (group 1) included preoperative visual acuity, preoperative treated intraocular pressure, number of anti-glaucoma medications before surgery, total surgical time, intraoperative complications, postoperative best-corrected visual acuity and IOP at one week and one month, need for additional procedures, and corneal clarity. Differences in surgical time and postoperative course in both groups were compared. RESULTS: Of 268 manual combined cataract and glaucoma surgeries done from 2014-2016, we identified 147 eyes of 130 age-matched patients, which included 51 PACG, 50 POAG, 12 NTG, and 24 PXG eyes with a mean age of 66 ±11.2 years and 64± 10.8 years in group 2 (n=74) and group 1 (n=73), respectively; p=0.9. The surgical time was significantly lower in group 1 (16±4.8 minutes compared to 44±14.6 minutes for group 2; p<0.001) with transient edema seen <1 week after surgery in 24 eyes of group 2 and seven eyes of group 1; p=0.02. The postoperative IOP at all postoperative visits dropped to >50% in both groups with 11 eyes (PXG n=6, PACG n=5) requiring medications for rise in intraocular pressure at a median time of 1.2 months (r=0.2-3 months). The final visual acuity improved >4 snellen lines in all cases with two patients with advanced damage having 1 line improvement in Snellen acuity at final follow-up. CONCLUSION: The ACM can help completely avoid the use of viscoelastic during surgery, which can be an effective technique for MSICS with trabeculectomy in low resource stings. Training for such procedures should be incorporated into residency training programs.
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Extração de Catarata/métodos , Catarata/complicações , Glaucoma , Pressão Intraocular/fisiologia , Microcirurgia/métodos , Trabeculectomia/métodos , Acuidade Visual , Glaucoma/complicações , Glaucoma/fisiopatologia , Glaucoma/cirurgia , HumanosRESUMO
PURPOSE: To report anterior segment features in unclassified anterior segment dysgenesis with overlapping features of Axenfeld-Rieger syndrome and other developmental anomalies. METHODS: This retrospective study included those with atypical or overlapping features in one or both eyes, which were identified as unclassified ASD. Typical ARS was defined as the presence of posterior embryotoxon with or without iris changes like stromal hypoplasia, corectopia, polycoria, or ectropion uvea with or without systemic features. Cases of ARS with overlapping features with other ASD, like aniridia (complete or incomplete absence of iris), iridocorneal endothelial (ICE) syndrome (beaten metal appearance of corneal endothelium), Peters anomaly, isolated trabeculodysgenesis (evidenced by Haab's striae, buphthalmos, and epiphora) in one or both eyes with other typical ARS features in the same or other eye were included and screened. RESULTS: Of 56 cases of ARS seen over 10 years, a total of 17 eyes of 11 cases (M:F=9:2, unilateral n=3) with unclassified ASD were identified with a median age of patients of 28.45±17.75 years (range 6-30 years). All cases of unclassified ASD had the presence of focal atypical strands of non-progressive anterior synechiae extending from the iris mid-periphery to the cornea with no attachments to the Schwalbe's line in any case. Adjacent keratic precipitates or pigment were present in three eyes with focal beaten metal appearance in one eye. Three patients developed repeated episodes of anterior uveitis in one eye with stromal involvement seen in all cases, which responded to antiviral therapy. CONCLUSIONS: Atypical features like focal strands with differential corneal involvement and onset of viral uveitis in unclassified ARS suggest a possible viral etiology during different periods of eye development.
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Segmento Anterior do Olho/anormalidades , Segmento Anterior do Olho/patologia , Anormalidades do Olho/patologia , Glaucoma/patologia , Adolescente , Adulto , Criança , Doenças da Córnea/patologia , Anormalidades do Olho/classificação , Oftalmopatias Hereditárias , Feminino , Humanos , Doenças da Íris/patologia , Masculino , Estudos Retrospectivos , Adulto JovemRESUMO
PURPOSE: To evaluate the conjunctival signs in different forms of pseudoexfoliation (PXF) syndrome to identify signs predicting early forms of the disease. METHODS: This observational study included patients with newly diagnosed PXF screened in the outpatient department of glaucoma services. Slit lamp photographs were captured in low and high magnification after full dilatation, and details like melanotic pigmentation, vascularity and tortuosity of vessels, scarring if any, presence of pterygium and actinic changes along with basal Schirmer's test were analysed. Variables in each subtype of PXF previously described by us, namely radial pigmentary (group A), combined pigmentary and classical (group B) and classical PXF (group C), were analysed and compared to age-matched controls. The differences between manifest (group B + C) and unmanifest or early form (group A) were also compared. RESULTS: A total of 89 eyes from 55 patients (M/F = 38:17, 21 unilateral, 34 bilateral, 48 group A, 10 group B and 31 group C) were compared with 40 controls. The Schirmer's test was statically lower in patients with manifest PXF (10 ± 1.4 mm) and unmanifest PXF (14 ± 0.6 mm), p < 0.001. The most frequent conjunctival finding (n = 88) in this cohort was lightly pigmented melanotic pigmentation present close to limbus without evidence of any feeder vessels or actinic changes and associated with pupillary ruff atrophy in the same quadrant. Analysing different PXF forms, there was conjunctival melanosis in one or all quadrants in all forms of PXF which was more prominent in manifest PXF, present in a mean 2 ± 1.7 quadrants in unmanifest and manifest PXF, p = 0.01. CONCLUSION: Conjunctival melanosis with associated pupillary ruff atrophy in the same quadrant may be the earliest signs of early pseudoexfoliation.
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Túnica Conjuntiva/patologia , Síndrome de Exfoliação/patologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Túnica Conjuntiva/anormalidades , Síndrome de Exfoliação/fisiopatologia , Feminino , Humanos , Pressão Intraocular/fisiologia , Masculino , Pessoa de Meia-Idade , Pterígio/patologiaRESUMO
PURPOSE: To investigate and compare the visual field performance following three different types of visual field instruction strategies. METHOD: Ninety consecutive visual field-naïve glaucoma patients who can perform the test and understand instructions were imparted three forms of instructions prior to the visual field test. Patients with visual acuity <20/200, central corneal opacities, or anterior segment pathology and patients unable to understand general instructions/uncooperative were excluded. All forms of instructions were given by a trained optometrist in the patients' own language as an instruction leaflet read out in 5 min for a verbal group (group1) and by a 5 min video created in house (group 2). Group 3 patients were shown the video first, followed by verbal instructions. We evaluated the reliability parameters in each group after visual field testing by an independent optometrist blinded to the form of instruction given. RESULTS: Among the three groups, group 3 patients had the least number of repeat tests. Eyes with MD<-12Db had better reliability than that of the other groups. Mixed-model linear regression analysis shows that the duration of the test was significantly influenced by the severity of glaucoma in group 1, which is further predisposed by false negatives (FN; ß = 0.06, p < 0.0001, R2 61.7%). CONCLUSION: The video with verbal instruction can minimize the number of repeated tests compared with only verbal or only video instruction medium. The video as well as the combined video/verbal instructions have a practical influence of obtaining more reliable fields compared with only verbal instruction.
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Glaucoma/diagnóstico , Guias de Prática Clínica como Assunto , Acuidade Visual , Testes de Campo Visual/normas , Campos Visuais , Estudos Transversais , Feminino , Glaucoma/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
BACKGROUND: The aim of this study was to evaluate responses on multifocal electroretinogram (mfERG) with ganglion cell-inner plexiform layer (GCIPL) thickness on cirrus spectral-domain optical coherence tomography (SD-OCT) in glaucoma. METHODS: All diagnosed glaucoma patients attending glaucoma services at our institute from November 2012 to April 2013 were screened for this observational hospital-based study. Controls included patients attending our outpatient services for general eye checkup. Structural parameters on SD-OCT including GCIPL and retinal nerve fiber layer (RNFL) thickness were compared with functional parameters on mfERG in early (mean deviation <-6 dB), moderate (-6 to - 12 dB), and controls. RESULTS: A total of 54 cases and 33 controls fulfilling inclusion criteria were recruited for the study. The average and minimum GCIPL thickness did not vary significantly between early and control eyes while moderate glaucoma eyes had marginally lower GCIPL thickness than early glaucoma eyes. The GCIPL minimum thickness on univariate regression was found to be influenced by N2 amplitudes (ß = -0.5, P = 0.012) and global N2P1amplitudes (ß =0.6, P = 0.01) in moderate glaucoma. In early glaucoma, these were influenced only by RNFL parameters with no association with functional mfERG responses. Multivariate logistic regression identified global N2P1 amplitude to be significantly influencing GCIPL average and minimum thickness (P = 0.01 and 0.02, R2 = 47.8% and 52.3%, respectively) in moderate glaucoma. Maximum area under the curve was found for GCIPL minimum (95% confidence interval [CI] 0.53-0.81) and N2P1 amplitude (95% CI 0.55-0.80). CONCLUSIONS: The second order responses N2P1 and N2 amplitude on mfERG predict function that correlated with structural GCIPL thickness in moderate glaucoma. Early glaucoma may be best predicted by RNFL thickness rather than on mfERG responses.
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PURPOSE: To evaluate different clinical variants of pseudoexfoliation syndrome and their risk of developing ocular hypertension (OHT) or glaucoma (PXG). DESIGN: Cross sectional hospital based study. SETTING: All patients seen at glaucoma services of a tertiary eye care center in east India. METHODS: Electronic medical records search of hospital database including consecutive new and old cases seen during April 2013 to March 2015 was done to retrieve case sensitive words including pseudoexfoliation, PXF, PEX, PXG and pseudoexfoliative glaucoma over any part of the clinical electronic sheet of the patient. All demographic and clinical details including laterality, the pattern of deposits, need for medicines and disc damage at presentation was compared in eyes with radial pigmentary, classical or combined forms of PXF phenotypes. RESULTS: Of 110313 PXF patients seen during the period of 2013-2015, a total of 2297 eyes of 1150 PXF patients were identified including 525 unilateral PXF (meaning a total of 1775 PXF eyes with 625 patients having bilateral disease, n = 1250 eyes, other clinically normal eye, n = 522) at presentation. Of 525 unilateral PXF eyes, 105 had OHT and 131 had glaucoma while bilateral cases had more >50% (675 eyes of 1250 eyes) with glaucoma. Glaucoma with significant changes in IOP with or without disc damage was seen in 32% of pigmentary and 39% of classical PXF forms with eyes with combined forms of PXF having around 50% with glaucoma at presentation compared to other forms, p<0.001. CONCLUSION: Different phenotypic variants of PXF in this Indian cohort was associated with 30-50% risk of OHT or glaucoma respectively. Adequate care is required while examining the pattern of PXF in each case to prognosticate each patient/eye.
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Registros Eletrônicos de Saúde , Síndrome de Exfoliação/patologia , Auditoria Médica , Idoso , Feminino , Humanos , MasculinoRESUMO
Purpose: To evaluate the differential expression of tear matrix metalloproteinases (MMP) 2 and 9 in of patients with various forms of glaucoma. Methods: Tear samples were collected with a Schirmer's strip from 148 eyes of 113 patients (medically naïve patients with primary open-angle [POAG] or angle closure glaucoma [PACG] and those with pseudoexfoliation syndrome [PXF] or glaucoma [PXG]). These were compared to patients undergoing cataract surgery (controls) for this cross-sectional study. Functional activities of tear MMP-9 and MMP-2 were analyzed by gelatin zymography. Tenon's capsules (n = 15) were harvested from the inferior quadrant in those undergoing cataract surgery and protein expression of MMP-9 was analyzed by immunohistochemistry (IHC). Hydrogen peroxide (H2O2) stress-induced effects on in vitro activities of MMP-9 in human trabecular meshwork (HTM) cells were analyzed. Results: The MMP-9 activity in tears was increased significantly in POAG, (n = 27), PACG (n = 24), and PXF (n = 40) eyes compared to controls (n = 35), and was increased significantly in eyes with glaucoma compared to moderate/severe glaucoma (P < 0.001). The MMP-9 expression was significantly lower in PXG (n = 22) eyes. Immunohistochemistry of Tenon's capsule revealed increased expression of MMP-9 in primary glaucoma eyes. Increased MMP-9 activity was seen in in vitro by gelatin zymography and was confirmed by Western and immunofluorescent assay on HTM upon 800 and 1000 µM H2O2-induced stress for 2 to 3 hours with approximately 80% cell death. Conclusions: Increased tear MMP-9 activity in early glaucoma and pseudoexfoliation syndrome suggesting activation of extracellular matrix (ECM) degradation can be used as a tear-based predictive biomarker. Decreased expression in advanced stages suggests exhaustion of the degradation response.
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Glaucoma/enzimologia , Metaloproteinase 2 da Matriz/metabolismo , Metaloproteinase 9 da Matriz/metabolismo , Lágrimas/enzimologia , Idoso , Análise de Variância , Western Blotting , Estudos de Casos e Controles , Estudos Transversais , Síndrome de Exfoliação/enzimologia , Feminino , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Cápsula de Tenon/enzimologia , Malha Trabecular/enzimologiaRESUMO
OBJECTIVE: To compare the variability of central field index (CFI) versus visual field index (VFI) in stable glaucoma with central fixation involvement. MATERIALS AND METHODS: For this retrospective study, we identified multiple visual fields (VFs) of patients with repeatable central fixation involvement on Humphrey VFs (24-2 and 10-2 program) which were stable (clinically and on VFs) over a very short period of 2 to 3 months. The VFI and CFI were calculated as described in earlier reports. We graded the fields as early [mean deviation (MD)>-6 dB], moderate (-6.1 to -12 dB), and severe glaucoma (<-12 dB) based on MD on 24-2 program. The variability of CFI and VFI between visits and across different severity of glaucoma was compared. Relation of the divergence to field indices and clinical parameters were assessed. RESULTS: The intervisit difference for VFI was greater than CFI ranging from -4% to 9% versus -1% to 8% in early (P=0.9), -13% to 18% versus -6% to 17% (P=0.056) in moderate, and -21% to 19% versus -9% to 9% (P<0.001) in severe glaucoma. The CFI within each group had narrower range than VFI with maximum range in severe glaucoma (33% to 95%). The divergence of CFI from VFI started at MD 24-2 beyond (worse) -10 dB. This difference between CFI and VFI was associated significantly with number of points with P<1% on 24-2 (R=80.3%). CONCLUSIONS: CFI is less variable than VFI in stable eyes with fixation involvement especially in severe glaucoma indicating need for incorporating CFI calculation for monitoring advanced disease in eyes with central defects.
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Glaucoma/fisiopatologia , Pressão Intraocular/fisiologia , Campos Visuais/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Glaucoma/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Testes de Campo Visual , Adulto JovemRESUMO
PURPOSE: To review the old and existing classification systems for primary angle closure disease. METHODS: Literature review and new proposed classification system. RESULTS: Existing classification systems have several shortcomings which cannot be applied in a clinical setting. This can be addressed by a proposed scoring system. CONCLUSION: A scoring system would be most appropriate for any clinical setting as well as for prognosticating primary angle closure disease.
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Câmara Anterior/diagnóstico por imagem , Glaucoma de Ângulo Fechado/classificação , Glaucoma de Ângulo Fechado/diagnóstico , Gonioscopia , Humanos , Imagem de Banda Estreita/métodosRESUMO
PURPOSE: To evaluate the angle closure scoring system (ACSS) for stratifying primary angle course disease. METHODS: This observational cross sectional institutional study included patients with primary open angle glaucoma suspects (n = 21) and primary angle closure disease (primary angle closure, PAC, n = 63 and primary angle course glaucoma, PACG, n = 58 (defined by International society of Geographical and Epidemiological Ophthalmology, ISGEO). Two independent examiners blinded to clinical details, graded good quality pre-laser goniophotographs of the patients incorporating quadrants of peripheral anterior synechieae (PAS), non-visibility of posterior trabecular meshwork (PTM) and blotchy pigments (ranging from 1-4 quadrants), iris configuration, angle recess (sum of above depicting ACSSg) and lens thickness/axial length ratio (LT/AL), cup disc ratio and baseline intraocular pressure (IOP) to give total score (ACSSt). RESULT: There were significant differences in ACSSg scores within the same ISGEO stage of PAC and PACG between eyes that required nil or >1medicines after laser iridotomy, p<0.001. The ACSSg was associated with need for >1 medicines in both PAC and PACG eyes, p<0.001. An ACSSg score>12 and 14 in PAC (odds ratio = 2.7(95% CI-1.7-5.9) and PACG (Odds ratio = 1.6(95%CI-1.19-2.2) predicted need for single medicines while ACSSg scores >14 and 19 predicted need for ≥2 medicines in PAC and PACG eyes, respectively. The LT/Al ratio, IOP score or cup disc score did not influence the need for medical treatment independently. CONCLUSION: The ACSS can be a useful clinical adjunct to the ISGEO system to predict need for medicines and prognosticate each stage more accurately.