Glaucoma screening skills among general ophthalmologists - How general should it be?

Purpose: To compare the glaucoma assessment skills among general ophthalmologists in their referral patients over 5 years. Methods: This was a retrospective auditing of the electronic medical record database. Details of consecutive new glaucoma patients seen in the glaucoma services of a tertiary eye care institute in 2013 and 2018 were collected. Details of each patient included the clinical presentation, baseline intra-ocular pressure (IOP), type and severity of glaucoma, referral details, gonioscopy, HVF (Humphrey visual field) data, and the number of medications. Statistical tests used were the Chi-square test and T test using SPSS version 22. Results: Of 28,886 medical records screened, 211 and 568 new glaucoma patients were retrieved in 2013 and 2018, respectively. The patients presenting in 2018 were younger (58.1 ± 15.4 years) at presentation than in 2013 (65.6 ± 15.2 years), P < 0.01, and also had higher baseline IOP (IOP ≥40 mm Hg was found in 9.5% in 2018 versus 2.4% in 2013; P < 0.01). The percentage of eyes with presenting visual acuity worse than 20/400 or 20/600 was higher in the patients presenting in 2018 (22.2% vs. 15.1%; P = 0.03). Although primary glaucoma predominated in both periods, the number of eyes referred to as disc suspects showed an increase in 2018 (4.7% to 14.4%; P < 0.01). Among 195 and 517 referrals in 2013 and 2018, respectively, the documentation of clinical findings were dismally poor in both the groups in terms of absent gonioscopy (99% vs. 98.2%, P = 0.4), absent disc details (89.6% vs. 91%, P = 0.5), or absent visual field analysis (79.1% vs. 74.8%, P = 0.2). However, the missing IOP values were significantly better in the latter year (77.3% vs. 57.2%; P < 0.01). Conclusion: The increase in the number of new glaucoma patients and referrals did not show a corresponding improvement in documentation of findings except for IOP recording among general ophthalmologists. Hence, we need to re-emphasize the training of general ophthalmologists on basic glaucoma evaluation to improve their referral ability.

Changes in corneal thickness after vitrectomy-Implications for glaucoma practice.

PURPOSE: To evaluate changes in central corneal thickness (CCT) following vitrectomy. METHODS: All consecutive old and new patients referred to glaucoma services for possible secondary glaucoma after vitrectomy and who had undergone corneal pachymetry between July 2013 to June 2020, were included. The eye that developed elevated intraocular pressure (IOP) and was diagnosed clinically as glaucoma after vitrectomy, was labelled as the "affected" eye. The contralateral eye of the patient with normal IOP and no history of vitrectomy was labelled as the "control" eye. The difference in CCT in the affected eye and the contralateral control eye (ΔCCT) and CCT were compared between different age groups. Correlation of CCT in the affected eye with age, diagnosis, type of surgery done, lens status and pre-existing glaucoma was done using multivariate regression analysis. RESULTS: Of 127 eyes of 120 patients (M:F = 85:35), the average CCT in the affected eye was significantly higher than the unaffected contralateral control eye (p<0.0001). The ΔCCT in eyes presenting at an age <25 years was higher (median 582, 497-840) than those that presented later (median 518, 384-755), p <0.0001, with maximum ΔCCT seen in eyes that had undergone vitrectomy at age<12 years. The CCT in the affected eye was significantly higher in aphakic eyes (588±81.6 microns) than in pseudophakic eyes (552±79.03 microns), p = 0.03. On multivariate analysis, age<25 years remained as a significant influencer of CCT in the affected eye (ß = -1.7, p<0.001, R2 = 28.3%). CONCLUSIONS: Young age group<25 years are more prone to corneal remodelling and CCT changes after vitrectomy.

Atypical associations of viral anterior uveitis with glaucoma-a series of challenging scenarios with review of literature.

PURPOSE: To report unusual associations, atypical clinical presentations, and outcomes of tailored treatment of viral uveitis and glaucoma. METHODS: Patients diagnosed with viral uveitis with associated glaucoma, seen at a tertiary eye care center between 2013 and 2020, were screened. Twenty-four patients with unclassified or atypical clinical presentations of viral uveitis, atypical clinical course, or with diagnostic challenges and associated glaucoma, were included. Patients with classical features of viral anterior or posterior uveitis, other forms of autoimmune/infectious/traumatic uveitis, were excluded. RESULTS: Viral re-activation causing recurrent choroidals after glaucoma filtering surgery responsive to systemic antiviral therapy, massive pigment dusting/plume as a presenting feature, multiple progressive focal anterior synechiae similar to iridocorneoendothelial (ICE) syndrome, were seen in this cohort of unusual viral uveitis in glaucoma. A high index of suspicion helped diagnose a viral etiology in cases with high intraocular pressure (IOP) after uneventful Ahmed glaucoma valve surgery (AGV) or post-YAG capsulotomy laser, presumed Posner-Schlossman syndrome with multiple recurrences or presumed steroid glaucoma. All patients responded well with anti-viral and tailored concomitant steroids, anti-glaucoma therapy with loss of visual acuity seen in one eye developing optic atrophy. CONCLUSIONS: Uncommon clinical presentations or associations of viral uveitis in glaucoma should be kept in mind. A high index of suspicion and tailored prompt treatment may ensure good outcomes preventing further visual morbidity in glaucoma.

Eye: the door to undiagnosed chronic myeloid leukaemia.

Chronic myeloid leukaemia (CML) is a myeloproliferative neoplasm that can present in varied ways from incidental finding on haemogram to symptomatic presentation such as splenomegaly. We report an interesting case of a 22-year-old man who presented with loss of vision in right eye for 1 month. There were no pre-existing ocular or systemic diseases. On detailed ocular examination, a diagnosis of right eye rubeosis iridis, hyphaema, cataract and vitreous haemorrhage with left eye suspected leukaemic retinopathy was made. Routine haemogram revealed high leucocytosis. Systemic evaluation with investigations confirmed the diagnosis of CML and the patient was started on appropriate therapy.

Retained iron intraocular foreign body with late onset siderotic glaucoma: a clinical challenge.

Siderotic glaucoma is a rare and challenging clinical scenario caused by a retained iron intraocular foreign body (IOFB), which results in irreversible vision loss. Presented here is a case of secondary open-angle glaucoma in a 36-year-old man that was refractory to maximal medical therapy. A meticulous history and careful clinical examination revealed that he had a penetrating trauma 15 years ago, a self-sealed corneal entry wound, open angles, a retained encapsulated metallic IOFB and siderosis bulbi. Removal of the foreign body not only controlled intraocular pressure, but also improved vision.

Clinical profile and outcomes of neovascular glaucoma in the era of anti-vascular endothelial growth factor.

PURPOSE: To report the clinical profile and visual impairment in various stages of neovascular glaucoma (NVG) at a tertiary eye center in East India. METHODS: The electronic medical records of the hospital database of patients with neovascular glaucoma seen between 2013 and 2020 were reviewed. Gonioscopic details were used to stratify patients into nonspecified NVG (Group 1), open-angle NVG (Group 2), and closed-angle NVG (Group 3). The clinical profile, angle features, cause of NVG, systemic associations, visual impairment, and blindness (defined as logarithm of the minimum angle of resolution, LogMar >1.3 at baseline and at final follow-up), and outcomes of medical/surgical interventions were compared between the three groups. RESULTS: Of 846 eyes of 810 patients with NVG (Group 1, n = 564 eyes, Group 2, n = 61 eyes, and Group 3, n = 220 eyes), at baseline, the blindness rates in Groups 3 and 2 were 90 and 75%, respectively. The time from a previous intervention to the onset of NVG ranged from 3 to 5 months, while the median duration of NVG was about 4-4.5 months (0.03-120 months). Multivariate regression identified a longer duration of NVG as the only variable associated with poor final visual acuity. CONCLUSION: Visual morbidity by NVG remains as high as 75-90% in developing countries, even with the availability of anti-VEGFs and after improved management/investigative at all stages.