Risk Factors for Flat Anterior Chamber Requiring Intervention After Glaucoma Drainage Implant: A Retrospective Case-Controlled Study.

PURPOSE: To identify risk factors for flat anterior chamber that required additional intervention in the postoperative period (90 days) after uncomplicated Baerveldt Glaucoma Implant (BGI) surgery. DESIGN: Retrospective, matched case-control study. METHODS: A total of 42 cases (eyes) that received BGI at Anne Bates Leach Eye Hospital between February 1, 2011, and January 1, 2019, and that developed flat anterior chamber were included. For each case, we matched 2 controls (84). Variables included sex, diagnosis, diabetes, hypertension, pre- and postoperative glaucoma medications, ocular conditions, and intraocular pressure (IOP). Multivariable conditional logistic regression determined odds ratios (ORs) for independent predictors. RESULTS: Case patients were more likely to be female (69.1% case patients/41.7% controls), to have a history of taking oral carbonic anhydrase inhibitors (CAIs) at tube opening (21.4%/7.1%), to be of another race/ethnicity (11.9%/0.0%), and to have pseudoexfoliation (23.8%/6.0%), and were less likely to be using cholinergic agonists (0.0%/11.9%) at baseline and to have primary open angle glaucoma (42.9%/64.3%). Case patients had greater mean age (75.9/64.9 years), earlier tube opening time (5.6/6.2 weeks), and lower IOP after tube opening (7.2/14.4 mm Hg), but IOP before opening was higher (24.7/19.5 mm Hg). We identified 3 independent predictors: older age (10-year increase OR = 3.59, P < .0001), oral CAI use at tube opening (OR = 5.65, P = .009), and higher IOP prior to tube opening (3 mm Hg increase OR = 1.30, P = .018). CONCLUSION: Risk factors for flat anterior chamber were older age, oral CAIs at tube opening, and higher IOP before tube opening. Strategies to minimize the acute IOP reduction that preceded this complication such as discontinuing oral CAI prior to tube opening may be considered.

Slow Coagulation Transscleral Cyclophotocoagulation for Postvitrectomy Patients With Silicone Oil-induced Glaucoma.

PRECIS: Slow coagulation transscleral cyclophotocoagulation (TSCPC) is an effective and safe glaucoma surgery in patients with medically uncontrolled silicone oil (SO)-induced glaucoma. PURPOSE: The purpose of this study was to report the outcomes of slow coagulation continuous wave TSCPC in patients with medically uncontrolled secondary glaucoma following pars plana vitrectomy (PPV) and intravitreal SO injection. PATIENTS AND METHODS: This retrospective study enrolled patients with medically uncontrolled glaucoma secondary to PPV with SO injection who underwent TSCPC using slow coagulation TSCPC settings (power of 1250 mW and duration of 4 s). The primary outcome measure was surgical success at 12 months. Surgical success was defined as an intraocular pressure 6 to 21 mm Hg and reduced ≥20% from baseline, no reoperation for glaucoma, and no loss of light perception vision. Secondary outcome measures included number of glaucoma medications, visual acuity changes, and surgical complications. RESULTS: A total of 18 eyes of 18 patients were included in the study. The mean age and follow-up of the patients were 51.94±14.5 years and 16.3±3.5 months, respectively. The mean intraocular pressure decreased from 29.7±9.6 mm Hg preoperatively to 14.6±6.5 mm Hg at 12 months postoperatively (P<0.001). Glaucoma medications were reduced from 4.2±0.9 at baseline to 1.9±1.3 at 12 months after TSCPC (P<0.001). A nonsignificant change of logarithm of the minimum angle of resolution visual acuity was observed at 12 months (P=0.722). The success rate at 12 months was 72.2%. No major complications were reported during the first year of follow-up. CONCLUSION: Slow coagulation TSCPC had high efficacy and minimal complications when used as an initial glaucoma surgical procedure in patients with SO-induced glaucoma.

Treatment Outcomes of Slow Coagulation Transscleral Cyclophotocoagulation In Pseudophakic Patients with Medically Uncontrolled Glaucoma.

PURPOSE: Reporting treatment outcomes of slow coagulation transscleral cyclophotocoagulation (TSCPC) as an initial surgical intervention in pseudophakic patients with glaucoma. DESIGN: Retrospective case series. METHODS: This single academic center study reviewed 74 pseudophakic patients who had a diagnosis of glaucoma and no previous glaucoma surgeries (mean age 82.6 ± 12.5 years; mean follow-up 18.7 ± 9.1 months). The intervention used was slow coagulation continuous wave TSCPC (1250-mW power and 4-second duration). The primary outcome measure was surgical success defined as an intraocular pressure (IOP) of 6-21 mm Hg with a ≥20% reduction from baseline, no reoperation for glaucoma, and no loss of light-perception vision. Secondary outcome measures included glaucoma medication use, visual acuity (VA), and complications. RESULTS: IOP decreased from 27.5 ± 9.8 mm Hg preoperatively to 16.1 ± 6.3 mm Hg postoperatively (P < .001). The preoperative number of glaucoma medications was 4.1 ± 0.9 and 3.1 ± 1.3 post-TSCPC (P < .001). The cumulative probabilities of success at 1 and 2 years were 60.6 % and 58.5%, respectively. When patients were divided into 2 groups based on their baseline IOP being >21 mm Hg (high group) or ≤21 mm Hg (low group), success rates at 2 years were 64.9% and 45.5%, respectively (P = .144). The mean logarithm of the minimum angle of resolution VA changed from 0.70 ± 0.64 to 1.04 ± 0.87 at the last follow-up visit (P = .01). No serious complications were observed and most of the complications were mild and transient. CONCLUSIONS: Slow coagulation TSCPC has good efficiency, especially in patients with baseline IOP >21 mm Hg, and safety profile as an initial surgical intervention in pseudophakic patients with glaucoma.

Treatment Outcomes of Primary Transscleral Cyclophotocoagulation.

PURPOSE: To report treatment outcomes of primary transscleral cyclophotocoagulation (TSCPC) in glaucomatous eyes. DESIGN: Retrospective noncomparative study. PARTICIPANTS: Forty-eight eyes with a diagnosis of glaucoma and no previous incisional ocular surgery. METHODS: Continuous-wave TSCPC was applied to the ciliary body. MAIN OUTCOME MEASURES: The primary outcome measure was surgical success defined as an IOP ≤ 21 mmHg and reduced by 20% or more from baseline, IOP > 5 mmHg, no reoperation for glaucoma, and no loss of light perception vision. Secondary outcome measures included visual acuity (VA) and complications. RESULTS: Glaucoma eyes were stratified into 2 groups: (1) those with pretreatment IOP >21 mmHg (high group) and (2) those with pretreatment IOP ≤ 21 mmHg (low group). Mean ± standard deviation (SD) IOP at baseline was 30.6 ± 6.3 mmHg in the high group and 16.2 ± 2.8 mmHg in the low group. Mean ± SD number of glaucoma medications at baseline was 4.1 ± 0.8 in the high group and 3.6 ± 1.1 in the low group. Based on our success criteria, the cumulative probability of success during the first year of follow-up was 58.3% in the high group and 28.1% in the low group (P = 0.052). Postoperative mean IOP was significantly lower than baseline IOP in the high group at 1-, 3-, 6-, 12-, and 18-month postoperative visits (P < 0.05). No significant change was observed in IOP at follow-up visits after 1 month in the low IOP group. Throughout the first year of follow-up, both groups required fewer glaucoma medications compared with baseline at the 1-, 3-, 6-, and 12-month postoperative visits (P < 0.05). The most frequent cause of postoperative decrease in VA was cataract in 9 eyes. Decrease in vision resulting from glaucoma was observed in 3 eyes. Complications included prolonged inflammation (11 eyes), iris neovascularization (2 eyes), cystoid macular edema (4 eyes), and hyphema (1 eye). No severe or long-term complications were observed. CONCLUSIONS: Continuous-wave TSCPC was effective in lowering IOP in glaucoma patients without prior incisional ocular surgery whose disease was recalcitrant to medical therapy, particularly those with baseline IOP of more than 21 mmHg.

A Novel Surgical Approach in the Management of Peters Anomaly With Glaucoma.

Treatment options for Peters anomaly vary depending on the degree of corneal and lenticular involvement. The authors report a novel surgical approach for patients with type I Peters anomaly and glaucoma. It involves ab externo circumferential trabeculotomy, simultaneous lysis of iridocorneal adhesions at the time of trabecular cleavage, and optical iridectomy. [J Pediatr Ophthalmol Strabismus. 2020;57:e25-e29.].

Neuro-ophthalmic Disease in Pediatric Glaucoma Practice.

PRECIS: Pediatric glaucoma referral to neuro-ophthalmology has a high yield for diagnosing neurological disease and neuroimaging in this cohort often uncovers intracranial abnormalities. PURPOSE: Multiple studies have examined the utility of neuro-ophthalmology referrals in an adult glaucoma patient population. No similar studies in the pediatric glaucoma population have been completed. An analysis of pediatric referral patterns and clinical characteristics can serve to guide future physician referrals and improve patient outcomes. MATERIALS AND METHODS: A retrospective review of medical records was conducted to identify pediatric patients evaluated by both glaucoma and neuro-ophthalmology services at Bascom Palmer Eye Institute from January 2013 to August 2018. Records were reviewed for clinical examination findings, demographics, ophthalmic imaging, neuroimaging, and ultimate diagnosis. RESULTS: A total of 59 patients, average age 10 years old, were included for analysis. The majority of patients were referred from pediatric glaucoma to neuro-ophthalmology (n=52, 88.1%). The most common reasons for referral included suspected nonglaucomatous optic neuropathy (n=14), optic disc swelling (n=7), color vision deficiency (n=6), and nonglaucomatous visual field defect (n=4). Referral to neuro-ophthalmology resulted in neuro-imaging in 22 patients (22/52, 42.3%), with 7 patients (7/52, 13.7%) having pathology on the scan. Ultimately, 38 patients (73.1%) referred to neuro-ophthalmology had an ultimate diagnosis unrelated to glaucoma. Color vision abnormality, optic nerve pallor, and/or retinal nerve fiber layer <70 µm in at least 1 eye were associated with a diagnosis unrelated to glaucoma. Of the 7 patients referred from neuro-ophthalmology to pediatric glaucoma, none were diagnosed with glaucoma or started on intraocular pressure lowering therapy. CONCLUSIONS: Patients referred from pediatric glaucoma to neuro-ophthalmology often have nonglaucomatous disease requiring subspecialty evaluation and neuroimaging. Neuroimaging in this cohort is high yield for uncovering intracranial pathology.

Which Patients Would Most Likely to Benefit: MIGS or MEGS, Which One Is It?

The availability of ab interno minimally invasive glaucoma surgery (MIGS) has promoted an international interest in this procedure. Our purpose is to define the role of MIGS in the constant evolving glaucoma treatment algorithm. Current MIGS approaches to lowering intraocular pressure (IOP) include increasing trabecular outflow (iStent trabecular microbypass stent, iStent inject, Hydrus Microstent, Kahook Dual Blade goniotomy, Trabectome ab interno trabeculectomy, Excimer laser trabeculotomy, and goniotomy-assisted transluminal trabeculotomy), increasing uveoscleral outflow with suprachoroidal shunts (Cypass microstent), and developing subconjunctival filtration (XEN gel stent and InnFocus microshunt). The efficacy of each depends on the achievement of desired target IOP reduction in a specific patient. The determination of whether a procedure is either a MIGS or minimally effective glaucoma surgery (MEGS) procedure is based on their efficacy and complications. Aqueous humor angiography suggests that success of trabecular bypass MIGS may not be patient-dependent only, but it may be affected by the location and flow of aqueous through collector channels. The future use of aqueous angiography may permit customized treatment of trabecular meshwork dependent MIGS procedures.

Extensive circumferential partial-thickness sclerectomy in eyes with extreme nanophthalmos and spontaneous uveal effusion.

AIM: To describe an extensive scleral excision technique to treat uveal effusion in nanophthalmic eyes. METHODS: This prospective, interventional series of eight eyes of five consecutive patients with nanophthalmos underwent scleral window surgeries. Ninety per cent of the scleral thickness, extending from immediately behind the extraocular muscle insertions to the vortex veins for 3 and 1/4 quadrants, was removed. The main outcome measure was resolution of the uveal effusions. RESULTS: Eight eyes of five patients (one female and four male) with a mean age of 46 years were studied. The mean (range) axial length was 16.1 mm (14.6-17.6 mm), and the mean refractive error was +13.6 dioptres (+10.75 to +16.00 dioptres). Following scleral excision surgery, all uveal effusions resolved within an average (±SD) of 13.9 (±8.7) days. The uveal effusion recurred in only one eye that had a vasoproliferative retinal tumour. The mean best corrected visual acuity improved from 0.69 logarithm of the minimum angle of resolution (logMAR) (Snellen equivalent: 20/97) at baseline to 0.51 logMAR (Snellen equivalent: 20/64; Wilcoxon paired t-test: p=0.016) after a mean follow-up of 35.6 months. CONCLUSION: The circumferential scleral window technique produces rapid resolution of uveal effusion in nanophthalmic eyes. No adverse effects were noted after surgery and the clinical effect was durable through 1 year. TRIAL REGISTRATION NUMBER: NCT03748732.

Comparison between Nonmydriatic Spectral Domain Optical Coherence Tomography and Conventional Ophthalmologic Examination in Detecting Adult Macular Pathology.

OBJECTIVE: To compare nonmydriatic spectral domain optical coherence tomography (NMOCT) to comprehensive ophthalmologic evaluation (COE) in detecting adult macular abnormalities. METHODS: This is a single-reader observational pilot study of adults older than 50 years with no known ophthalmologic problems to assess the correlation between NMOCT and COE in detecting macular abnormalities classified as epiretinal, intraretinal, subretinal, or a combination thereof. Subjects underwent NMOCT of the macula followed by COE which included a dilated fundus examination and ancillary tests as needed. RESULTS: A total of 771 eyes of 406 patients were included. Cohen's kappa coefficient of agreement between NMOCT and COE for detecting any abnormality was high (0.90, p < 0.0001), with NMOCT having an overall sensitivity of 82.65% and specificity of 98.97%. Sensitivities and specificities of NMOCT in detecting each category of macular abnormalities were as follows: epiretinal (86.36%, 99.73%), intraretinal (80.00%, 99.58%), and subretinal (88.89%, 99.73%), respectively. CONCLUSION: NMOCT is a promising tool for detecting adult macular abnormalities.

INTRAVITREAL DEXAMETHASONE IMPLANT IN RETINITIS PIGMENTOSA-RELATED CYSTOID MACULAR EDEMA.

PURPOSE: To report the clinical outcome after intravitreal dexamethasone implant in patients with retinitis pigmentosa and cystoid macular edema. METHODS: Multicenter retrospective case series of eyes with retinitis pigmentosa and cystoid macular edema that underwent intravitreal dexamethasone implant. Primary outcome measures were best-corrected visual acuity in LogMAR and central macular thickness. Statistical analyses used two-tailed comparison with Wilcoxon signed-rank test. RESULTS: There were a total of 45 eyes from 34 patients with a mean age of 32.7 years (range 16-57) and mean follow-up of 15.5 ± 13.0 months. At Month 3 after the first injection, mean initial best-corrected visual acuity improved from 0.61 ± 0.38 (20/81) to 0.37 ± 0.16 (20/47) (P = 0.012), whereas mean central macular thickness (µm) decreased from 506 ± 288 µm to 311.7 ± 71.6 µm (P < 0.001) and mean intraocular pressure increased from 15.7 ± 2.3 mmHg to 19.8 ± 11.0 mmHg (P = 0.01). Fourteen eyes had multiple injections (1-7 reinjections) at a mean interval of 6 months. Treatment effect was durable with multiple injections, but with seven eyes developing visually significant cataracts. CONCLUSION: Best-corrected visual acuity improved up to 4 months in around half of the eyes. Eyes that benefited the most were pseudophakic, steroid nonresponsive, with large initial central macular thickness, and profuse fluorescein dye leakage.

Intraocular Inflammation in Diabetic Populations.

PURPOSE OF REVIEW: The purpose of this review is to determine the prevalence of uveitis in the diabetic population, the clinical features of the uveitis and diabetes when coexisting and pathophysiology of a possible correlation. We also aim to review the cases of diabetes and uveitis in the literature. RECENT FINDINGS: The basis of an association between uveitis and diabetes mellitus (DM) is the common pathophysiology of inflammation. There are several reports on a DM-related uveitis, defined as idiopathic anterior uveitis in the presence of poorly controlled DM, but causation has not been established. There are conflicting results in the literature regarding an association between uveitis and DM. More studies are needed to determine if an association truly exists.

Nontuberculous Mycobacterial Ocular Infections: A Systematic Review of the Literature.

Nontuberculous or atypical mycobacterial ocular infections have been increasing in prevalence over the past few decades. They are known to cause periocular, adnexal, ocular surface and intraocular infections and are often recalcitrant to medical therapy. These infections can potentially cause detrimental outcomes, in part due to a delay in diagnosis. We review 174 case reports and series on nontuberculous mycobacterial (NTM) ocular infections and discuss etiology, microbiology, risk factors, diagnosis, clinical presentation, and treatment of these infections. History of interventions, trauma, foreign bodies, implants, contact lenses, and steroids are linked to NTM ocular infections. Steroid use may prolong the duration of the infection and cause poorer visual outcomes. Early diagnosis and initiation of treatment with multiple antibiotics are necessary to achieve the best visual outcome.