Comparison of Schlemm's Canal Morphology Parameters Between Propensity Score-Matched Primary Open-Angle Glaucoma and Exfoliation Glaucoma.

Purpose: This study aimed to histologically compare the status of Schlemm's canal (SC) and Schlemm's canal endothelial (SCE) cells between trabeculectomy specimens from patients with primary open-angle glaucoma (POAG) and exfoliation glaucoma (EXG). Methods: A total of 182 eyes from 152 patients with POAG and 138 eyes from 116 patients with EXG underwent immunohistochemical staining for thrombomodulin. Equal numbers of cases were selected from both groups using propensity score matching. The following parameters were evaluated: total SC length, staining positive and negative SC length (PSC and NSC, respectively), opened and closed SC length, staining positive and opened SC length, staining positive and closed SC length, staining negative and opened SC length (NOSC), and staining negative and closed SC length. Results: After matching for age and gender, 87 cases were selected in each group. The EXG group had significantly higher preoperative IOP and medication scores. PSC was significantly longer in the POAG group, while NSC and NOSC were longer in the EXG group. Multiple regression analysis of these 174 cases revealed that PSC was significantly shorter in the EXG group. After matching for age, gender, preoperative IOP, and medication score, 64 cases were selected in each group, and NOSC was significantly longer in the EXG group. Conclusions: These findings suggest that in EXG, SCE loss occurs independently of background factors such as aging and medication use. The loss of SCE may have a more critical impact on IOP elevation in EXG compared to POAG.

Dislocation of the PreserFlo MicroShunt During a Postsurgical Needling Procedure.

We report a case of PreserFlo MicroShunt (PFM) dislocation following a postsurgical needling procedure. A 58-year-old woman underwent PFM implantation for exfoliation glaucoma in her left eye (OS). There were no intraoperative complications. Preoperatively, her best-corrected visual acuity (BCVA) was 0.6, and her intraocular pressure (IOP) was 25 mmHg with three antiglaucoma medications in the OS. On postoperative day 21, the IOP was 21 mmHg OS, and the filtration bleb had shrunk. A needling procedure was performed using a sharp 26-gauge needle to lower the IOP. On postoperative day 29, the BCVA was 0.02, and the IOP was 60 mmHg OS. Gonioscopy revealed no device tip in the anterior chamber, and peripheral anterior synechia was observed at the site of PFM insertion. Anterior segment optical coherence tomography showed a dislocated device in the subconjunctival space. On postoperative day 35, the dislocated PFM was removed, and a new device was inserted. Following the reoperation, no further complications were observed, and bleb formation was obtained. In conclusion, like other glaucoma filtering surgeries, PFM may require postsurgical needling procedures. Needling procedures may cause PFM dislocation and IOP rise, resulting in the requirement for further IOP-reducing procedures.

Factors Associated with Topical Medication Instillation Failure in Glaucoma: VRAMS-QPiG Study.

INTRODUCTION: To report eyedrop instillation techniques and factors associated with instillation failure among glaucoma subjects in the Video-Recorded Assessment of Medication Skill and Questionnaire-based evaluation of Perception in Glaucoma Study. METHODS: In this cross-sectional observational study, subjects were 60 patients with glaucoma (mean ± standard deviation age, 68.4 ± 11.3 years; 30 men) who required ocular hypotensive medication(s). Subjects completed ophthalmologic examinations and the Mini-Cog cognitive function test; their typical eyedrop instillation technique was video-recorded. Subjects rated their technique as successes/failures by questionnaire and two examiners rated the successes/failures based on video assessment. Discrepancy between self-reported and video-assessed success/failure rates of instillation was the main outcome measures. Multivariate logistic regression identified factors in instillation failure. RESULTS: Of 48/56 (86%) self-reported successes, 27/48 (56%) failed based on video assessment; as a result, 32/56 (57%) were inconsistent between subjective and objective assessments. Overall, 30/56 (54%) failed based on video assessment. In the subject-based data model, older age [odds ratio (OR) 0.93/year, P = 0.025] and lower cognitive function score (OR 2.7/score, P = 0.025) were factors in failed instillations. In the eye-based data model, less myopic objective refractive error (OR 0.77/diopter, P = 0.016) and lower visual field foveal threshold (OR 1.1/decibel, P = 0.041) were factors in failures. CONCLUSION: In addition to older age, decreased cognitive function, hyperopia, and decreased foveal sensitivity are risks for failed eyedrop instillation. Treating physicians can screen patients who require guidance by checking the risk factors of instillation failure rather than by relying on patient reports.

Randomized Multicenter Clinical Trial Comparing 0.1% Brimonidine/0.5% Timolol Versus 1% Dorzolamide/0.5% Timolol as Adjuncts to Prostaglandin Analogues: Aibeta Crossover Study.

INTRODUCTION: This multicenter, randomized, comparative, and investigator-masked crossover clinical trial sought to compare the efficacy and tolerability of fixed combinations of 0.1% brimonidine/0.5% timolol (BTFC) versus 1% dorzolamide/0.5% timolol (DTFC) as adjunctive therapies to prostaglandin analogues. METHODS: A total of 110 patients with open-angle glaucoma or ocular hypertension previously treated with prostaglandin analogue monotherapy were randomized to receive either BTFC or DTFC as adjunctive therapy for 8 weeks. These patients were then crossed over to the alternative treatment arm for another 8 weeks. The reduction in intraocular pressure (IOP) (primary outcome), occurrence of adverse events, ocular discomfort after instillation, and patient preference (secondary outcomes) were recorded through patient interviews. RESULTS: BTFC instillation for 8 weeks reduced IOP by 3.55 mmHg, demonstrating non-inferiority to DTFC instillation (3.60 mmHg; P < 0.0001, mixed-effects model). Although adverse events were rare with both combinations, patients reported greater discomfort with DTFC than with BTFC (P < 0.0001). More patients preferred BTFC (P < 0.0001) over DTFC, as BTFC caused minimal or no eye irritation. CONCLUSION: As BTFC offered better tolerability than DTFC with comparable reduction in IOP, we recommend it as an alternative for patients who experience ocular discomfort with DTFC-prostaglandin analogue combination therapy. TRIAL REGISTRATION NUMBER: jRCTs051190125.

Patients with glaucoma who require further reduction in intraocular pressure while undergoing monotherapy with prostaglandin analogue ophthalmic solution have been prescribed two enhanced treatment options: 0.1% brimonidine/0.5% timolol fixed combination ophthalmic solution (BTFC) and 1% dorzolamide/0.5% timolol fixed combination ophthalmic solution (DTFC). The Aibeta Crossover Study Group in Japan compared the efficacy and tolerability of fixed combinations of BTFC versus DTFC when an additional fixed combination ophthalmic solution was prescribed in patients with open-angle glaucoma or ocular hypertension who had been treated with prostaglandin analogue monotherapy. We recruited 110 patients previously treated with prostaglandin analogue monotherapy at 20 clinical centers in Japan, then randomly assigned them to two alternative treatment groups: the BTFC to DTFC group or the DTFC to BTFC group, as an adjunctive therapy to prostaglandin analogues for total of 16 weeks. We compared the reduction in intraocular pressure, occurrence of side effects, eye discomfort after instillation, and patient preference between BTFC versus DTFC instillations. The intraocular pressure reduction of BTFC instillation was comparable to that of DTFC instillation, showing non-inferiority to DTFC (3.55 mmHg vs. 3.60 mmHg; P < 0.0001, mixed-effects model). Both eye drops caused few side effects; however, patients felt greater eye discomfort with DTFC than with BTFC (P < 0.0001). Because of less eye irritation, more patients preferred BTFC (P < 0.0001) over DTFC. We can recommend using BTFC for patients who feel eye discomfort with DTFC­prostaglandin analogue combination therapy.

Histological analysis of trabeculotomy - An investigation on the intraocular pressure lowering mechanism.

The primary aim of trabeculotomy (TLO) and/or minimally invasive glaucoma surgery (MIGS) is to produce a direct communication between the anterior chamber (AC) and collector channels (CC), which is believed to be the process by which intraocular pressure (IOP) is normalized. However, we previously reported our finding of the large opening of the Schlemm's canal (SC) into the AC in eyes with failed TLO (Amari et al., 2015). If the routes from the AC to the CC by TLO/MIGS are direct, IOP should be stabilized at around aqueous vein pressure if the SC and CC are undamaged. However, in eyes in which TLO/MIGS is successful, IOP usually stays at around the middle or high teens post surgery. In this current study, we retrospectively investigated the specific reason for middle- or high-teens IOP following TLO/MIGS via the histological examination of trabeculectomy (TRAB) specimens that include the area of previous TLO/MIGS in eyes with failed TLO or insufficient IOP control following TLO by specifically focusing on the behavior of the SC endothelium (SCE). Patient background, maximum IOP prior to TLO/MIGS and TRAB, the number medications administered, and elapsed time between TLO/MIGS and TRAB were reviewed. In 42 TRAB specimens of 31 120-180° TLO eyes (Group A; 27 ab-externo and 4 ab-interno eyes) and 11 360° suture TLO eyes (Group B), SC length (SCL), the site of the incision in the trabecular meshwork (TM) [i.e., the center (CEN)/anterior-tip (TIP)], and TM opening into the AC [i.e., open (OPN)/closed (CLS)] were histologically investigated. The correlation between the clinical parameters of the maximum IOP of pre-TLO/MIGS, the maximum IOP of pre-TRAB, the percentage of IOP reduction (PIR), and the histological results were statistically evaluated. Our findings revealed a significant negative correlation between the maximum IOP of pre-TRAB and SCL (P = 0.0167), and a significantly higher PIR in the eyes with OPN than those with CLS in Group A (P = 0.0045). However, no significant difference in SCL was found between the OPN and CLS eyes in both groups. In comparison to Group A, a higher percentage of OPN (82%) yet a smaller SCL (P = 0.0024) was observed in Group B. No significant correlation between clinical and histological parameters was found in Group B. In both groups, the common finding was sealing of the SC openings by SC endothelium (SCE) and no direct communication between the AC and the CC. This fact indicates that the nature by which SCE seals off the opened SC lumen into the AC created by TLO may be very important for maintaining the blood-aqueous barrier. Based on these results, we concluded that accessibility for aqueous humor to the SC and preservation of the SC may be important for lowering IOP by TLO. However, the opening of the SC into the AC (OPN type) does not guarantee an adequate IOP lowering effect if the SC is widely collapsed. Thus, TLO may be improved only by eliminating the most resistant part of the TM with minimal SCE damage.

Central serous chorioretinopathy resolution after traumatic cyclodialysis repair.

To report a rare case of central serous chorioretinopathy resolution after traumatic cyclodialysis repair. Observation: A 66-year-old Japanese woman was referred to our hospital with a visual disturbance in her right eye (OD). She had a history of blunt ocular injury when hit by a carton box 3 years previously, but the best-corrected visual acuity (BCVA) was 1.0. At the initial visit, the BCVA was 0.3 OD and 1.2 in the left eye (OS). Optical coherence tomography (OCT) showed a serous retinal detachment (SRD) in the macula; the submacular choroid was thicker OD (316 µm) than OS (246 µm). Fluorescent fundus angiography showed a subretinal macular leak. Gonioscopy and anterior-segment OCT showed angle recession and a cyclodialysis cleft at the temporal angle and cyclodialysis in the four quadrants. One month after focal photocoagulation was applied to the leakage point, the retinal detachment had not improved and the BCVA worsened to 0.2. After subsequent surgical repair of the cyclodialysis using an ab interno approach, the ciliochoroidal detachment resolved by 1 month with a simultaneous rapid decrease in the SRD and complete resolution by 2 months. At the final visit, 5 months postoperatively, the BCVA was 1.0 OD. During this period, the choroidal thickness decreased to 264 µm OD but was unchanged at 247 µm OS. Conclusion and Importance: Traumatic cyclodialysis, presumably via choroidal venous overload, can cause CSC. Since the presence of mild cyclodialysis and/or ciliochoroidal detachment may be difficult to find, post-traumatic CSC during the chronic phase of ocular trauma might be overlooked.

Comparison of outflow facility before and after the microhook ab interno trabeculotomy.

PURPOSES: To elucidate the mechanism of intraocular pressure (IOP) reduction by microhook ab interno trabeculotomy (µLOT), the aqueous humour outflow facility was compared preoperatively and post-operatively. METHODS: Fifty-one eyes (37 patients; mean age, 67.2 ± 11.8 years) were included. The IOP, number of medications and outflow facility coefficient (C) estimated by pneumatonography were compared preoperatively and post-operatively using the paired t test. Linear regression analysis was performed to identify possible correlations between the C value and IOP or number of medications. To adjust for biases from including both eyes of a patient and differences in background, the preoperative and post-operative C values were compared using a mixed effects regression model. RESULTS: The mean preoperative IOP (18.2 mmHg) and mean number of medications (2.8) decreased significantly post-operatively by 26% and 18%, respectively, to 13.5 mmHg and 2.3 (p < 0.0001, for both comparisons). The preoperative C value of 0.27 µl/min/mmHg increased significantly (p < 0.0001) by 89% to 0.51 µl/min/mmHg post-operatively. Linear regression analysis indicated that higher IOP was associated with lower C values (estimate, -0.01/mmHg, p = 0.0107); medication numbers were not associated with the C value (estimate, -0.04/medication, p = 0.1739). Mixed effects regression analysis showed that the post-operative measurement (estimate, 0.11/preoperative measurement, p < 0.0001) was associated with a higher C value, while age, sex, µLOT procedure, IOP and medication numbers were not. CONCLUSION: Outflow facility assessed by the tonographic C value increased significantly after µLOT. Increased conventional outflow by elimination of the outflow resistance at the trabecular meshwork is the main mechanism of IOP reduction after µLOT.

Comparison of Postoperative Hyphemas between Microhook Ab Interno Trabeculotomy and iStent Using a New Hyphema Scoring System.

We have been using our in-house scoring system of hyphemas, i.e., Shimane University RLC postoperative hyphema scoring system (SU-RLC), which we designed to classify postoperative hyphema. SU-RLC classifies the severities of hyphemas based on three factors, i.e., red blood cells (RBCs) (R) 0-3, layer formation (L) 0-3, and clot (C) 0-1, by slit-lamp observation. To test the clinical usefulness of the SU-RLC for quantifying the postoperative hyphema severity, the SU-RLC scores were compared between eyes that underwent different minimally invasive glaucoma surgery (MIGS) procedures, i.e., Tanito microhook ab interno trabeculotomy and cataract extraction (TMH-CE) (n = 64 eyes of 64 subjects; mean age ± standard deviation, 72.4 ± 8.1 years) and iStent-CE (n = 21 eyes of 21 subjects; 76.1 ± 10.6 years). Compared to the iStent-CE, higher hyphema scores with the TMH-CE were found for the R scores on postoperative days 1, 2, and 3; for the L score on postoperative day 1; and for the C score on postoperative day 2. The sums of the R, L, and C scores (RLC) on postoperative day 1 were 3.2 ± 1.1 with the TMH-CE and 1.1 ± 1.3 with the iStent-CE; the scores reached almost 0 by 2 weeks in both groups. Significant differences in the RLC scores between the surgical groups were found on postoperative days 1, 2, and 3. Multivariate analyses showed that the TMH-CE rather than iStent-CE was associated with higher R, C, and RLC scores; anticoagulant/antiplatelet use was associated with higher R score; and myopia was associated with a higher C score. In the TMH-CE group, myopia was associated with a higher C score. In the iStent-CE group, anticoagulant/antiplatelet use was associated with higher R and RLC scores; and higher postoperative 1-day intraocular pressure was associated with a higher C score. The SU-RLC successfully detected the difference in hyphema severity between different MIGS procedures; thus, we concluded that our classification system may be feasible to evaluate hyphemas after glaucoma surgery.

Transient Angle Obstruction Detected by Anterior-Segment Optical Coherence Tomography and Intraocular Pressure Elevation after Hemodialysis.

An 80-year-old Japanese man presented with decreased vision in his right eye (OD) after every hemodialysis (HD) session beginning several months previously. His local ophthalmologist prescribed antiglaucoma medications because of high intraocular pressure (IOP) (38 mm Hg) OD 4 months previously; with treatment, the IOP fluctuated between 6 and 34 mm Hg OD. When hospitalized, the IOP was measured, and the anterior chamber was observed by anterior-segment optical coherence tomography (AS-OCT) before and after HD. Before HD, the IOP levels were 7 mm Hg OD and 8 mm Hg in the left eye (OS). AS-OCT showed marked anterior iris bowing due to circumferential posterior synechia OD. The scan showed irido-trabecular contact (ITC) in the nasal angle and not the temporal angle OD. Immediately after HD, the IOP levels were 28 mm Hg OD and 12 mm Hg OS; AS-OCT showed ITC in the nasal and temporal angles OD. Since the iris bombe and HD-induced increase in the ITC were expected to have caused the IOP spike and blurred vision, posterior synechialysis and goniosynechialysis were performed OD. Postoperatively, the iris plane flattened; no IOP spike was recorded, and the blurred vision after HD resolved. At 22 months postoperatively, the IOP was 7 mm Hg in both eyes (OU). No deterioration of visual acuity and visual field was recorded during the follow-up period OU. IOP spikes can occur during and after HD because of transient anterior chamber angle obstruction in cases with narrow angles. AS-OCT is useful for detecting minor morphologic changes in the anterior chamber angle during HD.

Proposal of a simple grading system integrating cosmetic and tonometric aspects of prostaglandin-associated periorbitopathy.

ABSTRACT: The distribution of prostaglandin-associated periorbitopathy (PAP) graded using the Shimane University PAP Grading System (SU-PAP) among glaucoma/ocular hypertension subjects using a topical FP or EP2 receptor agonist was reported. A 460 consecutive 460 Japanese subjects (211 men, 249 women; mean age ±â€Šstandard deviation, 69.9 ±â€Š14.5 years) who had used either a FP agonist (0.005% latanoprost, 0.0015% tafluprost, 0.004% travoprost, 0.03% bimatoprost, or fixed combinations of these) or EP2-agonist (0.002% omidenepag isopropyl) for more than 3 months in at least 1 eye were retrospectively enrolled. Age, sex, prostaglandin, intraocular pressure (IOP) measured by Goldmann applanation tonometry (IOPGAT) and iCare rebound tonometry (IOPRBT), difference between IOPGAT and IOPRBT (IOPGAT-RBT), PAP grade, and PAP grading items were compared among groups stratified by PAP grade or prostaglandins. Of the study patients, 114 (25%) had grade 0 (no PAP), 174 (38%) grade 1 (superficial cosmetic PAP), 141 (31%) grade 2 (deep cosmetic PAP), and 31 (7%) grade 3 (tonometric PAP). The IOPGAT was significantly higher in grade 3 (17.5 ±â€Š5.4 mm Hg) than grades 0 (15.0 ±â€Š5.1 mm Hg, P = .032) and 1 (14.5 ±â€Š4.2 mm Hg, P = .008), and the IOPGAT-RBT was significantly higher in grade 3 (5.8 ±â€Š3.2 mm Hg) than the other 3 grades (1.3-1.9 mm Hg, P < .001 for all comparisons); the IOPRBT was equivalent among the 4 grades. The PAP grade was significantly higher associated with travoprost (2.0 ±â€Š0.8) and bimatoprost (2.0 ±â€Š0.7) than latanoprost (1.0 ±â€Š0.8, P < .001 for both comparisons) and tafluprost (1.0 ±â€Š0.7, P < .001 for both comparisons), but significantly lower associated with omidenepag (0.0 ±â€Š0.0, P < .001 for all comparisons) than the other 4 prostaglandins. Multivariate analyses showed older age (standard ß = 0.11), travoprost (0.53, referenced by latanoprost) and bimatoprost (0.65) were associated with higher PAP grades, while tafluprost (-0.18) and omidenepag (-0.73) were associated with lower PAP grades. The PAP graded using SU-PAP reflects the degree of overestimation of the IOPGAT and different severities of PAP among the different prostaglandins. SU-PAP, the grade system constructed based on the underlining mechanisms of PAP, is a simple grading system for PAP that is feasible for use in a real-world clinical situation.

Effects of Preoperative Intraocular Pressure Level on Surgical Results of Microhook Ab Interno Trabeculotomy.

To assess the roles of preoperative intraocular pressure (IOP) level on the IOP reducing efficacy of microhook ab interno trabeculotomy (µLOT), 126 consecutive open-angle glaucomatous eyes (90 primary open angle glaucoma, 36 exfoliation glaucoma) of 126 Japanese subjects (60 men, 66 women; mean age ± standard deviation, 70.5 ± 11.4 years) who underwent µLOT alone (25 eyes, 20%) or combined µLOT and cataract surgery (101 eyes, 80%) were retrospectively included, and subdivided into four groups based on the quartile of preoperative IOP: Q1, ≤15 mmHg; Q2, 15-18 mmHg, Q3, 18-21 mmHg, and Q4, >21 mmHg. Preoperative and 12 months postoperative IOPs and numbers of antiglaucoma medications were compared among IOP groups. Factors associated with postoperative IOP were assessed using multivariate analysis, and the success of IOP control was assessed with various definitions. Postoperatively, IOP was significantly higher in Q3 (p < 0.0146) and Q4 (p = 0.0320) groups than Q1 group, while the number of medications was not significantly different among four IOP groups (p = 0.1966). Older age was associated with lower postoperative IOP, and higher preoperative IOP was associated with higher postoperative IOP, while sex, glaucoma type, surgical procedure, lens status, extent of trabeculotomy incision, and preoperative number of medications were not associated with postoperative IOP. The success rates for IOP ≤ 18 and ≤15 mmHg were higher in lower preoperative IOP groups (i.e., Q1 and Q2) than higher preoperative IOP groups (Q3 and Q4), while the success rate for ≥20% IOP reduction was higher in higher preoperative IOP groups than in lower preoperative IOP groups; the success rate for ≥0% IOP reduction was equivalent among groups. By reviewing the previous studies in ab interno trabeculotomy/goniotomy procedures, positive correlation between preoperative and postoperative IOPs was preserved throughout the studies and surgical procedures. After the µLOT, larger %IOP reduction was achieved in higher preoperative IOP groups than in lower preoperative IOP groups, while postoperative IOP was still lower than in lower preoperative IOP groups.

Fellow-Eye Comparison between Phaco-Microhook Ab-Interno Trabeculotomy and Phaco-iStent Trabecular Micro-Bypass Stent.

The aim of this study is to compare the surgical efficacy and safety between microhook ab-interno trabeculotomy (µLOT) and iStent trabecular micro-bypass stent implantation when both were combined with cataract surgery in both eyes of patients. Sixty-four glaucomatous eyes (32 participants; mean age, 75.9 ± 7.6 years; 15 men, 17 women) were included retrospectively. Intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), anterior chamber flare (ACF) and corneal endothelial cell density (CECD) were evaluated preoperatively, as well as 2, 3, 6, and 12 months postoperatively. Surgical complications and interventions were compared between the procedures. The preoperative IOP and medications with µLOT (18.8 ± 5.7 mmHg and 3.0 ± 1.2, respectively) were higher than with the iStent (15.5 ± 3.4 mmHg and 2.7 ± 1.2, respectively) (p = 0.0001 and p = 0.0437, respectively). At 12 months, the µLOT values (12.6 ± 2.3 mmHg and 2.3 ± 0.9, respectively) were identical to iStent (12.8 ± 2.5 mmHg and 2.3 ± 0.9, respectively) (p = 0.0934 and p = 0.3251, respectively). At 12 months, the IOP decreased more with µLOT (6.2 mmHg, 29.5%) than iStent (2.7 mmHg, 15.6%) (p = 0.0003). The decrease in medications was greater with µLOT (0.7) than iStent (0.4) (p = 0.0437). Survival rate of IOP control ≤15 mmHg and IOP reduction ≥20% was significantly higher after µLOT (40.6% at 12 months) than iStent (18.8%) (p = 0.0277). The frequency of layered hyphema was significantly greater with µLOT (8 eyes, 25%) than iStent (0 eyes, 0%) (p = 0.0048). The increase in the ACF at 2 weeks postoperatively was significantly greater with µLOT than iStent (p = 0.0156), while changes in the BCVA and CECD were identical between groups. The fellow-eye comparison showed that the IOP reduction was greater with µLOT than iStent when combined with cataract surgery.

Refractive Status in Eyes Implanted with Toric and Nontoric Intraocular Lenses during Combined Cataract Surgery and Microhook Ab Interno Trabeculotomy.

PURPOSE: To compare the refractive status between eyes implanted with toric and nontoric intraocular lenses (IOLs) during combined cataract surgery and microhook ab interno trabeculotomy (µLOT), a minimally invasive glaucoma surgery (MIGS). METHODS: Twenty eyes of 20 patients who had open-angle glaucoma, cataract, and preexisting regular corneal astigmatism exceeding 1.5 diopters (D) and underwent combined µLOT and phacoemulsification were recruited retrospectively. Ten eyes were implanted with a toric IOL and 10 eyes with a nontoric IOL. The primary outcomes were the uncorrected visual acuity (UCVA) and refractive cylinder at 3 months postoperatively. RESULTS: The mean UCVA of the toric IOL group (logarithm of the minimum angle of resolution (logMAR), 0.23 ± 0.25) was significantly better than that of the nontoric IOL group (logMAR, 0.45 ± 0.26) at 3 months postoperatively (p < 0.05). The mean absolute residual refractive cylinder of the nontoric IOL group (2.25 ± 0.62 D) was significantly greater than that of the toric IOL group (1.30 ± 0.68 D) (p < 0.05). Postoperatively, 60% of eyes in the toric IOL group and 10% in the nontoric IOL group had an absolute refractive astigmatism level of 1.5 D or less. Surgically induced astigmatism (0.77 ± 0.43 D for toric group and 0.60 ± 0.32 D for nontoric group) and IOP reduction (33.9 ± 15.6% for toric group and 29.4 ± 11.7% for nontoric group) were not different between groups. CONCLUSIONS: Use of toric IOL during combined cataract surgery and µLOT is possible and better than not, but physician should prevent their patient of persisting residual astigmatism. The study was registered at https://www.umin.ac.jp/, and the clinical trial accession number is https://clinicaltrials.gov/ct2/show/UMIN000043141.

A case of chronic retinal necrosis after tube shunt surgery for secondary glaucoma associated with cytomegalovirus corneal endotheliitis.

BACKGROUND: We report a case of chronic retinal necrosis (CRN) combined with cytomegalovirus (CMV) corneal endotheliitis. CASE PRESENTATION: An 80-year old man was diagnosed with CRN that developed after tube shunt surgery with vitrectomy for secondary glaucoma associated with CMV corneal endotheliitis. After the use of oral valganciclovir and panretinal photocoagulation, the retinal lesion resolved rapidly and he has maintained visual acuity better than before the onset of CRN. CONCLUSIONS: Use of oral valganciclovir, prophylactic panretinal photocoagulation for the non- perfusion area and vitrectomy were effective in maintaining the visual acuity for the patient with CRN.

Surgical Results of Ahmed Glaucoma Valve Implantation in One-chamber Eyes.

PRECIS: Ahmed glaucoma valve (AGV) implantation in eyes with damaged iris-lens diaphragms ("1-chamber" eyes) resulted in mean intraocular pressure (IOP) and antiglaucoma medications decreases of 66% and 59% (P<0.0001 for both), respectively, at the mean 23-month follow-up. PURPOSE: The purpose of this study was to report the results of AGV implantation with pars plana tube insertion to control IOP in glaucomatous eyes with damaged iris-lens diaphragms ("1-chamber" eyes). METHODS: The medical records of 52 consecutive glaucomatous 1-chamber eyes (48 Japanese patients, mean age±SD, 76.0±11.2 y) were retrospectively reviewed. Other than aphakic eyes, eyes were defined as having 1 chamber if intraocular lenses (IOLs) were sclerally or intrasclerally fixated, IOLs were fixed on-the-bag due to posterior capsular defects, vitreous collapse into the anterior chamber resulted from Zinn zonular dialysis, and phacodonesis or IOL-donesis required lens/IOL explantation during AGV implantation. The data collected were preoperative/postoperative IOPs, numbers of antiglaucoma medications, visual acuity, anterior chamber flare, visual field mean deviation, corneal endothelial cell density, and surgical complications/interventions. RESULTS: The preoperative IOP (28.5±9.4 mm Hg) and a number of antiglaucoma medications (3.2±1.2) decreased significantly (P<0.0001 for both) to 9.8±3.3 mm Hg and 1.3±1.3, respectively, at the final visit (mean follow-up, 23 mo). The success rates of IOP control (6 to 21 mm Hg and >20% reduction irrespective of medication use) were 82.5% and 79.0%, respectively, at postoperative years 1 and 2. The most common postoperative complications were macular edema (n=9, 17%), choroidal detachment (n=8, 15%), vitreous hemorrhage (n=7, 13%), and hyphema (n=7, 13%). The most common postoperative intervention was tubal repositioning/reopening (n=6, 12%). Compared with preoperative values, the visual acuity, anterior chamber flare, mean deviation, corneal endothelial cell density remained unchanged postoperatively. CONCLUSION: Choice of pars plana AGV tube insertion with simultaneous vitrectomy is reasonable to achieve IOP reduction and minimize vision-threatening complication in glaucomatous eyes with a damaged iris-lens diaphragm.

Midterm Results of Microhook ab Interno Trabeculotomy in Initial 560 Eyes with Glaucoma.

All the 560 glaucomatous eyes of 375 Japanese subjects (181 men, 194 women; mean age ± standard deviation, 76.0 ± 13.2 years) who underwent microhook ab interno trabeculotomy (µLOT) alone (159 eyes, 28%) or combined µLOT and cataract surgery (401 eyes, 72%) performed by one surgeon at Matsue Red Cross Hospital between May 2015 and March 2018 to control intraocular pressure (IOP) were retrospectively assessed. Preoperative and postoperative IOPs, numbers of antiglaucoma medications, the logarithm of the minimum angle of resolution visual acuity (logMAR VA), anterior chamber (AC) flare, visual field mean deviation (MD), and corneal endothelial cell density (CECD) were compared up to 36 months. Surgical complications and required interventions were described. The duration of the follow-up was 405 ± 327 (range, 2-1326) days. The mean preoperative IOP (20.2 ± 7.0 mmHg) and number of antiglaucoma medications (2.8 ± 1.1) decreased to 13.9 ± 4.5 mmHg (31% reduction, p < 0.0001) and 2.5 ± 1.0 (11% reduction, p < 0.0001), respectively, at the final visit. After combined surgery, compared with preoperatively, the final VA improved 0.11 logMAR (p < 0.0001), AC flare increased 4.5 photon counts/msec (p = 0.0011), MD improved 0.6 decibel (p < 0.0001), and the CECD decreased 6% (p < 0.0001). Layered hyphema (172 eyes, 31%) and hyphema washout (26 eyes, 5%) were the most common postoperative complication and intervention, respectively. At the final visit, 379 (69%) eyes achieved successful IOP control of ≤18 mmHg and ≥20% IOP reduction, and 349 (64%) eyes achieved successful IOP control of ≤15 mmHg and ≥20% IOP reduction. Older age, steroid-induced glaucoma, developmental glaucoma, and the absence of postoperative complications were associated with lower final IOP; exfoliation glaucoma, other types of glaucoma, and higher preoperative IOP were associated with higher final IOP. µLOT has a significant IOP-lowering potential in patients with glaucoma, and improves visual function when combined with cataract surgery.

Effects of French maritime pine bark/bilberry fruit extracts on intraocular pressure for primary open-angle glaucoma.

We tested oral French maritime pine bark (40 mg)/bilberry fruit extract (90 mg) supplements for intraocular pressure-lowering effects in Japanese subjects with primary open-angle glaucoma. Eighteen subjects (29 eyes) were recruited with intraocular pressure of ≥15 mmHg who used one to three bottles of antiglaucoma medications. After a 2-week observation (period 1), subjects ingested a tablet/day of Sante® Glagenox for 4 weeks (period 2). The mean intraocular pressure (17.2 ± 2.3 mmHg) decreased significantly to 15.7 ± 1.9 mmHg (8.7% reduction) at week 4 (p = 0.0046). The mean morning intraocular pressure (14.1 ± 3.1 mmHg) self-measured using the iCare HOME tonometer during period 1 decreased significantly to 13.3 ± 2.9 mmHg (5.7% reduction) during period 2 (p = 0.0291). Blood redox parameters, diacron reactive oxygen metabolites, biologic antioxidant potential, and sulfhydryl tests were unchanged after 4-week supplementation. Intra-subject comparisons, compared to period 1, showed pooled, self-measured, period-2 intraocular pressures was significantly lower in nine subjects (50%), unchanged in six subjects (33%), and elevated in three subjects (17%), suggesting some non-responders. Four-week supplementation with French maritime pine bark/bilberry fruit extracts can further reduce intraocular pressure even in Japanese patients with controlled primary open-angle glaucoma. Further study should confirm the intraocular pressure-lowering effects and mechanisms of this supplement in glaucoma management. The study was registered in UMIN (ID: UMIN000033200).

Histologic Findings of Trabecular Meshwork and Schlemm's Canal After Microhook Ab Interno Trabeculotomy.

INTRODUCTION: Trabeculotomy (LOT) and related goniotomy surgeries are classified based on excision or incision of the trabecular meshwork (TM); however, histologic evidence of the incision/excision pattern is insufficient. CASE PRESENTATIONS: Two cases of glaucomatous eyes in which trabeculectomy specimens previously "incised" during LOT were assessed histologically. A 39-year-old man with juvenile open-angle glaucoma (case 1) and a 70-year-old man with exfoliation glaucoma (case 2) underwent trabeculectomy for insufficient intraocular pressure reduction or visual field progression after initial microhook ab interno trabeculotomy (µLOT). In case 1, Schlemm's canal (SC) opened into the anterior chamber due to extensive absence of the inner wall of SC and TM. In case 2, SC endothelium (SCE)-marker CD34 staining showed the slit-like entry site of a previous LOT, the SC lumen was sealed partially by scleral tissue, and CD34-positive and CD34-negative areas in the SC wall suggested SCE dropout and partial conversion of SC into ghost vessels. Active aqueous outflow-marker podoplanin (D2-40) staining showed intense immunolabeling in the sclera between the entry site and collector channels, indicating aqueous outflow. DISCUSSION: The µLOT cleft can appear as both incisional and excisional patterns. In addition to incremental conventional outflow with reduced TM resistance, another unconventional outflow may be a mechanism of IOP reduction after LOT procedures.

Effect of Toric Intraocular Lens Implantation on Visual Acuity and Astigmatism Status in Eyes Treated With Microhook Ab Interno Trabeculotomy.

PRCIS: Use of toric intraocular lenses is a reasonable option for better visual outcomes when a combined minimally invasive glaucoma surgery (MIGS) and cataract surgery is performed in eyes with corneal astigmatism. PURPOSE: To assess the efficacy of toric intraocular lenses (IOLs) in combined cataract and MIGS, visual and refractive outcomes were compared between eyes implanted with nontoric and toric IOLs during microhook ab interno trabeculotomy triple procedures. METHODS: Glaucomatous eyes with preexisting corneal astigmatism exceeding -1.5 D implanted with nontoric (n=10) or toric (n=10) IOLs were evaluated retrospectively. The uncorrected visual acuity (UCVA) and refractive astigmatism preoperatively and 3 months postoperatively were compared. RESULTS: Preoperatively, the groups had similar logarithm of the minimum angle of resolution (logMAR) UCVAs and refractive astigmatism. Postoperatively, the logMAR UCVA (toric, 0.07±0.07; nontoric, 0.33±0.30; P=0.0020) was significantly better and the refractive astigmatism (toric, -0.63±0.56 D; nontoric, -1.53±0.74 D; P=0.0110) significantly less in the toric group. The toric group had postoperative improvements in the logMAR UCVA (-0.58, P=0.0039) and refractive astigmatism (+1.45 D, P=0.0195). Vector analyses showed the postoperative centroid magnitude of refractive astigmatism was less in the toric group (0.23 D at 83 degrees) than the nontoric group (1.03 D at 178 degrees). Postoperatively, 70% of eyes in the toric group had 1.0 D or less refractive astigmatism compared with 10% in the nontoric group. Surgically induced astigmatism (nontoric group, 0.62 D at 10 degrees; toric group, 0.50 D at 113 degrees) and intraocular pressure reduction (22% in both groups) did not differ between groups. CONCLUSIONS: Better visual outcomes may be achieved with toric IOLs when a combined MIGS/cataract surgery is performed in eyes with corneal astigmatism.

A Case of Pediatric Cyanoacrylate Adhesive Injury to the Eye.

A 5-year-old Japanese boy presented to the emergency room of our hospital because his right eye had been glued shut for 2 h following instillation of cyanoacrylate adhesive. The clinical examination showed redness of the right upper and lower lid skin; the right eyelid margins adhered to each other because of matting of the eyelashes, and crystallized glue was found within the matted eyelashes. The "hook" technique, which separates the eyelids using a blunt-tip device, was performed to separate the lids. The technique seems to be simple and safe for physicians such as ophthalmology residents to use to treat cyanoacrylate-induced adhesion of the eyelids of patients who often first present to their local emergency room as in our case.