Comparison of New Visual Disturbances after Superior versus Nasal/Temporal Laser Peripheral Iridotomy: A Prospective Randomized Trial.

PURPOSE: To determine whether laser peripheral iridotomy (LPI) location affects postoperative dysphotopsia symptoms. DESIGN: Multicenter, randomized, prospective, single-masked trial. PARTICIPANTS: Five hundred fifty-nine South Indian patients 30 years of age or older diagnosed as primary angle-closure suspects (PACSs) or with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) in both eyes. METHODS: Patients were randomized to either bilateral superior or bilateral nasal/temporal LPI. Occurrence of new visual disturbances was evaluated before and 2 weeks after LPI using a questionnaire based on the 7-item dysphotopsia symptoms described by Spaeth et al. MAIN OUTCOME MEASURES: New-onset dysphotopsia symptoms. RESULTS: Superior LPI (n = 285) and nasal/temporal LPI (n = 274) patients were matched for age (P = 0.6), gender (P = 0.7), and distribution of PACS versus PAC or PACG (P = 0.7). Similar initial laser energy settings were used in both groups (P = 0.3), although superior LPIs required more shots (P = 0.006) and greater total energy (P < 0.001) than nasal/temporal LPIs. No significant differences in postoperative anterior chamber reaction (P = 0.7) or LPI area (P = 0.9) were noted between the 2 groups. No group differences were noted regarding the proportion of patients demonstrating 1 or more dysphotopsia symptoms before LPI (15.8% for superior vs. 13.9% for nasal/temporal; P = 0.1) or any individual dysphotopsia symptom (P > 0.2 for all). After LPI, 8.9% of all patients reported 1 or more new symptoms, the most common consisting of linear dysphotopsias, glare, and blurring in 2.7%, 4.3%, and 4.3% of patients, respectively. Patients undergoing superior LPI were not more likely to describe the new onset of 1 or more dysphotopsia symptoms as compared with patients undergoing nasal/temporal LPI (8.4% vs. 9.5%; P = 0.7), nor did the frequency of any new individual symptoms differ by group (P ≥ 0.3 for all). In multivariate logistic regression analysis, neither LPI location nor LPI area nor total laser energy predicted higher odds of new postoperative dysphotopsias (P > 0.1 for all). CONCLUSIONS: Laser peripheral iridotomy likely is safe with respect to visual dysphotopsias regardless of location, LPI size, and amount of laser energy used.

Ophthalmological examination and imaging features that better predict risk of Angle Closure in siblings.

OBJECTIVE: Characteristics of individuals with angle closure may be useful in targeted screening of family members. Here, we assess if findings gathered during examination and imaging of patients with a known angle closure diagnosis (probands) could better determine the risk of angle closure in the patients' siblings. DESIGN: Cross-sectional study of patients with known angle closure and their siblings. SUBJECTS: Participants, and Controls: South Indian patients (probands) 30 years and older with open angles, suspect primary angle closure (PACS), or primary angle closure/primary angle closure glaucoma (PAC/PACG), and a biological sibling age 30 years or older (n=292 proband/sibling pairs). METHODS: Demographic data, relevant ocular history, and a comprehensive ophthalmic examination with Anterior Segment Optical Coherence Tomography (ASOCT) were obtained. Three clinically relevant models were created to analyze the contribution of specific proband factors in predicting sibling angle closure diagnosis, using demographic (age, gender), ocular exam (gonioscopy, optic nerve exam, visual acuity, intraocular pressure [IOP]), and ASOCT features to improve prediction beyond proband diagnosis alone evaluated by log likelihood ratio testing and statistical comparison of receiver operating characteristics (ROC). MAIN OUTCOME MEASURES: Sibling angle closure diagnostic accuracy. RESULTS: Demographic and ocular exam metrics did not improve the prediction of sibling angle closure for all three outcomes (sibling diagnosis: (1) PACS/PAC/PACG vs OA, (2) PAC/PACG vs PACS/OA, and (3) PAC/PACG vs PACS), adding no model improvement when compared to diagnosis alone. Models adding ASOCT metrics to the prior model including proband diagnosis, demographics and ocular exam measures led to significantly improved prediction of 2 of the 3 angle closure outcomes. Specifically, improvement was noted via likelihood ratio testing for prediction of PAC/PACG vs PACS/OA (p=0.01), or PAC/PACG vs PACS (p=0.001). For all 3 angle closure outcomes, ROC comparisons demonstrated significant improvement in AUC between the three models predicting sibling outcomes, demonstrating an increase in AUC with each successive nested model across all 3 sibling angle closure outcomes. CONCLUSIONS: Structural features of eyes with angle closure may assist in stratifying the risk of angle closure in patients' siblings. Further studies should consider evaluating this approach to achieve more targeted screenings.

Comparison between ocular biometry parameters in patients with unilateral congenital glaucoma.

Purpose: To compare the axial length (AL) and corneal diameter between glaucomatous eye (GE) and fellow normal eye (NE) in patients with unilateral congenital glaucoma and to obtain a normative database for ocular growth among Indian children below 3 years of age. Methods: Retrospective longitudinal study. Patients who had a follow-up of 3 years from diagnosis with ocular biometry parameters being recorded at least thrice (once a year) and fellow eye being normal were included. Data collected were age, gender, intraocular pressure (IOP), AL, corneal diameter, optic disc findings, diagnosis, and surgery details. Results: Eleven patients were analyzed. All GE underwent combined trabeculotomy with trabeculectomy. Mean (SD) baseline IOP, AL, and corneal diameter were 17.1 (6.7) mmHg, 18.9 (1.1) mm and 12 (0.91) mm in GE, and 11.1 (3.8) mmHg, 17.8 (0.44) mm, and 10.5 (0.58) mm in NE, respectively. Increase in AL was 3.1 mm in the first year followed by 0.6 mm in second year and 0.4 mm in third year in GE compared to 2.6, 0.6, and 0.5 mm in NE, respectively. Corneal diameter increased by 1.1 mm in GE in the first year and remained stable thereafter compared to 0.7 mm in first year followed by 0.3 mm in second year and stable thereafter in NE. The percentage of success was 73% at 3 years. Conclusion: Axial length and corneal diameter were higher in GE than NE at all-time points. With prompt intervention, the growth curve of the GE was made parallel to that of NE.

Smartphone Gonioscopy With a Magnifying Intraocular Lens: A Cost-effective Angle Imaging Device.

Gonioscopy is an important part of glaucoma diagnosis and management. Imaging and documentation of the anterior chamber angle has been previously performed using slit-lamp-assisted photography or using smartphones with or without an attached macro lens. Smartphones have transformed ophthalmic imaging by virtue of their availability, easy use, and portability. In this report, the authors aim to demonstrate gonio-imaging using a smartphone attached with an intraocular lens which behaves like a macro lens. With the patient in a sitting position or in the supine position, a goniolens is placed on the patient's cornea. A smartphone with a 10 D intraocular lens attachment over its camera is used to take images or videos of the anterior chamber angle with high magnification. This imaging modality is cost-effective and can be used for screening and photographic documentation of the angle, and can be of immense benefit, especially in primary health care centers.

The Heritability of Primary Angle Closure Anatomic Traits and Predictors of Angle Closure in South Indian Siblings.

PURPOSE: To estimate the heritability of ocular biometric and anterior chamber morphologic parameters and to determine predictors of angle closure concordance in South Indian probands with angle closure and their siblings DESIGN: Prospective observational cohort study METHODS: Subjects received a standardized ophthalmic examination, A-scan ultrasonography, pachymetry, and anterior segment optical coherence tomography (ASOCT) imaging. Heritability was calculated using residual correlation coefficients adjusted for age, sex, and home setting. Concordant sibling pairs were defined as both proband and sibling with angle closure. Predictors of angle closure concordance among siblings were calculated using multivariable logistic regression models. RESULTS: A total of 345 sibling pairs participated. All anterior chamber parameters were highly heritable (P < .001 for all). Similarly, all iris parameters, axial length, lens thickness (LT), central corneal thickness, anterior lens curvature, lens vault (LV), spherical equivalent, and intraocular pressure were moderately to highly heritable (P < .004 for all). LV and LT were more heritable among concordant siblings (P < .05 for both). In contrast, ASOCT angle parameters had statistically insignificant heritability estimates. In multivariable analyses, siblings older than their probands were more likely to be concordant for angle closure (OR 1.05, 95% CI 1.01, 1.09; P = .02) and siblings with deeper anterior chamber depths (ACDs) compared to their proband were less likely to be concordant for angle closure (OR 0.74, 95% CI 0.64, 0.86; P < .001). CONCLUSIONS: Iris, anterior chamber, and lens parameters may be heritable whereas angle parameters were not. LT and LV may play important roles in the pathogenesis of angle closure. Siblings who are older or have a shallower ACD may need more careful disease monitoring.

Assessment of glaucoma referral letter for quality and accuracy among patients referred to a tertiary eye care center.

Purpose: To assess the quality and accuracy of glaucoma referrals from ophthalmologist. Methods: Retrospective review of patients chart with referral letter to a tertiary glaucoma center between January and December 2017. Patients aged <16 years, lens-induced glaucoma, uveitic glaucoma, and glaucoma following retinal and corneal surgery were excluded. Results: A total of 184 patients referred by 55 ophthalmologists were included. Mean patient age (SD) was 57.8 ± 14 years. Intraocular pressure was not documented in the referral letter in 113 (61%) patients, gonioscopy in 174 (95%) patients, disc findings in 149 (81%) patients, and visual fields in 175 (95%) patients. Thirteen (37%) of the 35 patients referred as open angle glaucoma were found to have angle closure glaucoma. Pseudoexfoliation glaucoma was diagnosed in 29 (16%) patients, of which 18 were missed by the referring ophthalmologist. Conclusion: In our study >90% of referral letter did not have the essential parameters. A standard template for glaucoma referral is suggested, which will help the patient to get better transfer of care.

Mefenamic acid-induced bilateral transient myopia, secondary angle closure glaucoma and choroidal detachment.

Drug-induced secondary angle closure is quite common and in the majority of cases simply stopping the medication leads to rapid reversal of the condition and resolution of glaucoma. We describe here a patient who presented with secondary angle closure glaucoma and myopia following mefenamic acid ingestion which was managed successfully by stopping the medication, symptomatic treatment and reassurance.

Intermediate-term outcome of Aurolab aqueous drainage implant.

PURPOSE: To report the intermediate-term safety and efficacy of Aurolab aqueous drainage implant (AADI) in patients with glaucoma. METHODS: Retrospective review of patients who underwent AADI between January 2013 and December 2016. Patients aged >16 years and with a minimum follow-up of 6 months were included. Success was defined as complete when the intraocular pressure was ≥6 and ≤21 mmHg without antiglaucoma medication and as qualified if those requiring additional antiglaucoma medications were included. RESULTS: The study included 55 patients (55 eyes) with a mean age ± standard deviation (SD) of 47.3 ± 18.1 years with a mean follow-up of 16.7 ± 11.4 months. Mean intraocular pressure reduced from 30.8 ± 11.1 mmHg to 13.1 ± 4.7, 14.1 ± 4.8, 15.7 ± 2.5 (P < 0.001) mmHg at 6 months, 1 year, and 2 years, respectively. The mean number of antiglaucoma medications reduced from 3.4 ± 1 to 0.8 ± 1.2, 0.7 ± 1.1, 0.8 ± 1 (P < 0.001) at 6 months, 1 year, and 2 years, respectively. The cumulative probability of complete and qualified success was 62% and 100% at 6 months, 54% and 92% at 1 year, and 43% and 88% at 2 years, respectively. Four patients failed during the follow-up period. Postoperative complication occurred in 28 eyes (51%), of which 17 eyes (31%) required intervention. CONCLUSION: AADI is a safe and effective treatment for the control of intraocular pressure in patients with glaucoma.

Effect of Mannitol on Intraocular Pressure in Vitrectomized and Nonvitrectomized Eyes: A Prospective Comparative Study.

PURPOSE: To compare the effect of mannitol in reducing intraocular pressure (IOP) in vitrectomized and nonvitrectomized eyes. MATERIALS AND METHODS: Prospective comparative case study. Eyes with IOP≥40 mm Hg were included. Eyes which are vitrectomized and silicon oil filled were classified as group 1, and nonvitrectomized open-angle eyes were classified as group 2. Mannitol (20%, 1 g/kg) was administered intravenously over 30 minutes, and IOP was recorded at 30 minutes interval till 2 hours and at the third and fourth hour from the start of mannitol. RESULTS: Thirty eyes (patients) were recruited in each group. Mean (SD) IOP reduced from 48.5±5.2 to 43.7±8 at 30 minutes, 40.7±8.4 at 60 minutes, 37.3±9.6 at 90 minutes, 35.6±10.4 at 2 hours, 34±10.7 at 3 hours, and 33±11.2 mm Hg at 4 hours in group 1, and from 48.9±6.5 to 43.2±8.6 at 30 minutes, 40.2±7.8 at 60 minutes, 36.7±7.3 at 90 minutes, 35.1±7.7 at 2 hours, 34.2±8.8 at 3 hours, and 35.7±9.4 mm Hg at 4 hours in group 2. There was a significant reduction in IOP at each time point compared with baseline in both the groups (P<0.001). There was no significant difference in IOP between the 2 groups at each time point. CONCLUSION: Mannitol reduces IOP significantly in both vitrectomized and nonvitrectomized eyes.

Caregiver Burden in Primary Congenital Glaucoma.

PURPOSE: To evaluate the demographic, clinical, and socioeconomic factors associated with variation in the quality of life (QOL) in caregivers of children with primary congenital glaucoma (PCG) in south India. DESIGN: Cross-sectional survey. METHODS: Caregivers of children younger than 18 with diagnosed PCG were prospectively enrolled at Aravind Eye Hospital in Madurai and Coimbatore, India. Participants completed 2 questionnaires, the PHQ-9 (9-item Patient Health Questionnaire) and the CarCGQoL (Caregivers Congenital Glaucoma QOL Questionnaire). Clinical, demographic, and socioeconomic data were obtained for each child-caregiver dyad. Rasch-calibrated scores were calculated for patient-reported outcome measures. Spearman correlation and linear regression were used to analyze data to determine associations with caregiver QOL. RESULTS: There were 70 caregivers (mean age 32.1, 77.1% female) of 70 children with PCG (mean age 7.7, 37.1% female) included in the study. In univariate and multivariable analyses, child's age (ß = -0.04; 95% confidence interval, -0.08 to -0.01) and duration of disease (ß = - 0.03; 95% confidence interval, -0.07 to -0.01) were the only factors associated with CarCGQoL. Survey items related to anger, self-confidence, irritability, appetite, and interest in leisure activities had the lowest scores. There was a negative correlation between CarCGQoL and PHQ-9 scores (r = -0.66, P < .01), indicating that worse caregiver QOL was significantly correlated with more depressive symptoms. CONCLUSION: This study identified traits associated with QOL decline, as well as the QOL issues most likely to affect caregivers of children with PCG in south India. Findings from this study may be important for designing interventions to improve caregivers' QOL, thereby maximizing their ability to care for children with PCG.

Bilateral idiopathic spontaneous filtering bleb with ectopia lentis: A case report and review of literature.

A 26-year-old male presented with superior filtering bleb with scleral thinning, dislocated lens, and hypotony in both the eyes. His cornea was normal without any sign of ectasia, and there was no history of recurrent redness, trauma, or surgery in either eye. Anterior segment optical coherence tomography did not reveal communicating fistula between the anterior chamber and subconjunctival space. Physical examination and blood investigations did not reveal any systemic association. He was diagnosed to have spontaneous filtering bleb, which is a rare condition observed with ocular or systemic abnormalities.

Suprachoroidal hemorrhage following removal of releasable suture after combined phacoemulsification-trabeculectomy.

We report a case of suprachoroidal hemorrhage following removal of a releasable suture after combined phacoemulsification-trabeculectomy.

Automated Detection of Glaucoma From Topographic Features of the Optic Nerve Head in Color Fundus Photographs.

OBJECTIVE: To describe and evaluate the performance of an automated CAD system for detection of glaucoma from color fundus photographs. DESIGN AND SETTING: Color fundus photographs of 2252 eyes from 1126 subjects were collected from 2 centers: Aravind Eye Hospital, Madurai and Coimbatore, India. The images of 1926 eyes (963 subjects) were used to train an automated image analysis-based system, which was developed to provide a decision on a given fundus image. A total of 163 subjects were clinically examined by 2 ophthalmologists independently and their diagnostic decisions were recorded. The consensus decision was defined to be the clinical reference (gold standard). Fundus images of eyes with disagreement in diagnosis were excluded from the study. The fundus images of the remaining 314 eyes (157 subjects) were presented to 4 graders and their diagnostic decisions on the same were collected. The performance of the system was evaluated on the 314 images, using the reference standard. The sensitivity and specificity of the system and 4 independent graders were determined against the clinical reference standard. RESULTS: The system achieved an area under receiver operating characteristic curve of 0.792 with a sensitivity of 0.716 and specificity of 0.717 at a selected threshold for the detection of glaucoma. The agreement with the clinical reference standard as determined by Cohen κ is 0.45 for the proposed system. This is comparable to that of the image-based decisions of 4 ophthalmologists. CONCLUSIONS AND RELEVANCE: An automated system was presented for glaucoma detection from color fundus photographs. The overall evaluation results indicated that the presented system was comparable in performance to glaucoma classification by a manual grader solely based on fundus image examination.