Feasibility of laser trabeculoplasty in angle closure glaucoma: a review of favourable histopathological findings in narrow angles.

Selective laser trabeculoplasty (SLT) has been indicated as a safe and efficient treatment for primary open-angle glaucoma; however, recent studies have also shown positive results with the use of SLT in some clinical conditions related to primary angle-closure glaucoma (PACG). Despite the potential benefits of SLT in selected cases of PACG, the mechanisms underlying the modifications in the trabecular meshwork tissue of patients with PACG are poorly understood. This narrative review approached both the current, limited knowledge about the histological changes observed in different forms of PACG and the clinical results of SLT treatment for PACG. Favourable outcomes of SLT in patients with PACG, specifically in areas of non-occluded angle, need further substantiation through large controlled clinical trials. A deeper understanding of the biomolecular changes of those areas is essential to improve both laser technical details and the clinical efficacy of SLT therapy.

Recurrent Tube Erosions with Anti-Vascular Endothelial Growth Factor Therapy in Patients with Age-Related Macular Degeneration.

PURPOSE: To determine the rates of primary and recurrent glaucoma tube shunt erosions in patients with age-related macular degeneration (AMD) receiving anti-vascular endothelial growth factor (VEGF) intravitreal injections. DESIGN: Retrospective case series. PARTICIPANTS: Patients with AMD who underwent tube revision for erosion at the Duke Eye Center from January 1, 1999, to January 1, 2019, were identified. Patients with and without anti-VEGF injections were compared. METHODS: Patient demographics, ocular diagnoses, glaucoma tube shunt types and locations, and dates of glaucoma surgeries and anti-VEGF injections were collected. Statistical analyses were performed with P < 0.05 as significant. MAIN OUTCOME MEASURES: Outcome measures included the number of tube erosions, time from anti-VEGF injection to tube erosion, and secondary complications after tube revisions. RESULTS: A total of 150 patients with AMD with anti-VEGF (309 tubes) and 262 patients with AMD without anti-VEGF (459 tubes) were identified. There was no statistically significant difference in the number of tube erosions in patients with anti-VEGF (15 tubes, 4.8%) versus without anti-VEGF (12 tubes, 2.6%) (P = 0.10). However, patients receiving anti-VEGF had on average a greater number of tube erosion events (2.1±0.7 events) compared with patients without anti-VEGF (1.3±0.7, P < 0.01). Ten patients (91%) received concurrent anti-VEGF injections at the time of tube erosion, and the average duration of prior anti-VEGF therapy was approximately 2 years. Tube erosion was noted 46.5±60.7 days from the preceding anti-VEGF injection. Secondary complications after tube revision in the anti-VEGF group included 5 explanted tubes for recurrent erosions. CONCLUSIONS: Our results suggest intravitreal anti-VEGF injections are linked to higher rates of recurrent glaucoma tube erosions in patients with AMD. The majority of patients received chronic and serial anti-VEGF injections. Thus, additional consideration should be given to glaucoma surgical planning in patients receiving anti-VEGF injections, especially in those with a primary tube erosion.

Reticular Bullous Epithelial Edema in Corneas Treated with Netarsudil: A Case Series.

PURPOSE: To describe the patient characteristics and the clinical course of an unusual reticular pattern of bullous epithelial corneal edema in a series of patients treated with netarsudil. DESIGN: Retrospective case series. METHODS: Case series at a single academic center where treatment with netarsudil produced a particular pattern of bullous epithelial corneal edema. RESULTS: Six episodes of reticular bullous epithelial corneal edema were identified in 5 eyes of 5 patients treated with netarsudil. A total of 4 of 5 patients had a history of corneal edema in the affected eye, and the fifth patient had risk factors for corneal edema including a history of anterior uveitis and an anterior chamber glaucoma drainage device. In 4 of 6 episodes, corneal edema was present, typically in the corneal stroma at the time of netarsudil initiation. In 5 of 6 cases, visual acuity worsened with onset of bullous epithelial edema, and in all cases, visual acuity stabilized or improved following discontinuation of netarsudil. In all cases, the reticular bullous epithelial edema improved or resolved after discontinuation of netarsudil. CONCLUSIONS: The patient characteristics and natural history of a particular pattern of reticular bullous epithelial edema in a series of patients treated with netarsudil once daily is reported. Most patients had a history of corneal edema or predisposing risk factors for corneal edema. All patients demonstrated improvement in bullous epithelial edema after netarsudil discontinuation. Visual acuity improved in most patients within weeks after discontinuation of netarsudil, although 2 patients also underwent surgical interventions that might have contributed to improved visual acuity.

Possible Undiagnosed Glaucoma Detected by MultiColor Imaging of Retinal Diseases.

PURPOSE: To evaluate for the presence of visible retinal nerve fiber layer (RNFL) defects consistent with undiagnosed glaucoma in MultiColor images (Heidelberg Engineering, Heidelberg, Germany) obtained at clinicians' discretion for the diagnosis and management of retinal diseases. DESIGN: Retrospective chart review of MultiColor images obtained as part of routine clinical care between December 25, 2013 and June 24, 2014. Images were reviewed by 2 fellowship-trained glaucoma specialists (S.H.V.T., S.G.A.) for the presence of RNFL defects in the superotemporal or inferotemporal quadrants. No attention was given to the optic nerve head when identifying candidate images. Retinal nerve fiber layer defects were not considered glaucomatous if they traced to regions of retinal atrophy. PARTICIPANTS: A total of 157 retina clinic patients aged 18 years or older who carried at least 1 retinal diagnosis; patients were subsequently excluded if medical records review revealed a history of glaucoma or glaucoma suspect diagnoses at the time of imaging. METHODS: MultiColor confocal scanning laser ophthalmoscopy images were obtained using the Heidelberg Spectralis HRA+OCT (Heidelberg Engineering, Heidelberg, Germany). MAIN OUTCOME MEASURE: The primary end point was the presence of at least 1 RNFL defect tracking toward the optic nerve. RESULTS: Among 157 reviewed charts, 134 eyes of 80 patients met inclusion criteria, of whom 13 eyes of 10 patients had visible RNFL defects consistent with possible undiagnosed glaucoma. The average age of patients with presumed glaucomatous eyes was 67 years (range, 35-88 years; standard deviation, 15.7 years). The retinal diagnoses in the glaucomatous eyes included branch retinal vein occlusion (3 eyes and 1 fellow eye), neovascular age-related macular degeneration (2 eyes), non-neovascular age-related macular degeneration (both eyes of 1 patient), proliferative diabetic retinopathy (2 eyes), nonproliferative diabetic retinopathy (both eyes of 1 patient), and epiretinal membrane (1 eye). CONCLUSIONS: Retinal nerve fiber layer defects consistent with glaucoma may be visible on MultiColor images obtained for the diagnosis and management of retinal diseases and may represent an underused opportunity to prevent additional visual dysfunction in patients already undergoing retinal disease management.

Macular and retinal nerve fiber layer analysis of normal and glaucomatous eyes in children using optical coherence tomography.

PURPOSE: To evaluate macular and nerve fiber layer (NFL) thickness in normal and glaucomatous eyes of children 3 to 17 years old using optical coherence tomography (OCT-3). DESIGN: Observational cross-sectional study. METHODS: One hundred fifty-six eyes of 79 patients were enrolled in this institutional study. Fifty-two eyes (33.3%) met criteria for glaucoma and 104 (66.7%) were normal. There were 44 female (55.6%) and 35 male (44.3%) subjects whose ages ranged from 3 to 17 years old (mean 9.5 years, standard deviation 3.5 years, median 9 years). The OCT-3 (Carl Zeiss Meditec, Dublin, California) was used to obtain a fast macular thickness map as well as a fast retinal NFL map of each eye. Data from specific locations around the macula, as well as total macular volume, was analyzed. Similarly, the retinal NFL scan reports average NFL thickness from specific locations around the optic nerve. Data from the superior temporal and inferior temporal sections was analyzed. RESULTS: There was a statistically significant difference in macular thickness and NFL thickness when normal eyes were compared against those with glaucoma, in all quadrants studied (all P values

High failure rate associated with 180 degrees selective laser trabeculoplasty.

PURPOSE: To determine the efficacy of selective laser trabeculoplasty (SLT) in a tertiary care referral center. PATIENTS AND METHODS: In this retrospective study of selective laser trabeculoplasty performed by five physicians, 94 eyes from 94 patients were included. A majority (83/92, 90%) underwent 180 degrees selective laser trabeculoplasty. Selective laser trabeculoplasty failure was defined in two ways: (1) IOP decrease <3 mm Hg (definition one), or (2) IOP decrease <20% (definition two), on two successive visits > or =4 weeks after SLT. RESULTS: Overall failure rates were 68% (64/94) and 75% (70/94) (by definitions one and two, respectively). By survival/life-table analysis, mean time to failure was 6 months and 5.5 months, by definitions one and two, respectively. By the end of the study (14.5 months), the failure rates were 86% and 92% by definitions one and two, respectively. By each definition, in both univariable and multivariable analysis, only lower baseline IOP was a significant predictor of failure. CONCLUSIONS: Selective laser trabeculoplasty had an overall low success rate in our tertiary clinic population, with overall failure rates of 68% to 74% in those who underwent 180 degrees selective laser trabeculoplasty.

Clinical comparison of the Proview eye pressure monitor with the Goldmann applanation tonometer and the Tonopen.

OBJECTIVE: To compare intraocular pressure (IOP) values obtained by patients using the new Proview eye pressure monitor (Bausch & Lomb, Rochester, NY) with those measured with the Goldmann tonometer and the TonoPen (Mentor, Norwell, Mass). METHODS: Eighty-six patients (a total of 171 eyes) with a diagnosis of glaucoma or glaucoma suspect successfully completed the study. The IOP was measured by 3 methods in the following order: Goldmann tonometer, TonoPen, and Proview eye pressure monitor. The central corneal thickness was measured by an ultrasonic pachymeter. Separately for each eye, the differences in mean IOP values between measurement methods were assessed with paired t tests and also in multivariate models that tested the dependence of IOP difference on central corneal thickness. RESULTS: There was a significant difference (P<.001) in the mean IOPs measured by the 3 different methods (Goldmann vs Proview, Goldmann vs TonoPen, and TonoPen vs Proview) for both eyes, and the difference was independent of the central corneal thickness. The differences between IOP measured by Goldmann and Proview were similar in all categories of patient-reported ease of using the Proview. CONCLUSIONS: The IOPs obtained with the Proview eye pressure monitor are significantly lower than those measured with Goldmann tonometer and the TonoPen, and variations of the central corneal thickness do not contribute to the difference. Intraclass correlations of IOP values obtained with the Goldmann and the Proview or TonoPen and Proview are not strong. On the other hand, as expected, measurements with Goldmann and TonoPen agreed fairly well.

Three-dimensional nature of retinal nerve fiber layer defects.

OBJECTIVE: To demonstrate the 3-dimensional nature of wedge-shaped retinal nerve fiber layer (RNFL) losses. To study the impact of training glaucoma fellows in this identification technique by evaluating their rate of RNFL loss detection on stereo disc photographs. METHODS: Wedge-shaped RNFL defects were identified in stereo disc photographs of early-glaucoma patients. The 3-dimensional nature of RNFL defects and overlying retinal blood vessel contour changes were identified. Four glaucoma fellows were given stereophotographs to identify the presence or absence of RNFL defects. After training in identification of RNFL defects by noting their 3-dimensional nature and overlying blood vessel contour changes, the same set of photographs were reevaluated by the fellows. We determined whether there was a difference between the before and after assessments in the probability of a correct response for each of the fellows. RESULTS: Loss of retinal thickness in the form of grooves and the resulting 3-dimensional nature of the RNFL defects were visualized on stereoscopic examination. Overlying retinal blood vessels coursed into and out of the RNFL defects. Three case examples of such wedge-shaped RNFL defects are presented. For each fellow, the proportion of RNFL defects correctly identified after training was greater than the proportion before training (P<0.001). CONCLUSIONS: Identifying the 3-dimensional nature of wedge-shaped RNFL defects may improve rate of detection of RNFL defects during clinical examination.

Selective laser trabeculoplasty reduces mean IOP and IOP variation in normal tension glaucoma patients.

PURPOSE: To evaluate the effect of selective laser trabeculoplasty (SLT) in normal tension glaucoma (NTG) patients. PATIENTS AND METHODS: A retrospective review was performed of NTG patients who had undergone SLT at the Duke University Eye Center between 12/2002 and 7/2005. For each eye of each patient at pre-laser and post-laser time points, the IOP measurements were summarized by mean, standard deviation, and range. Then for each of these descriptive statistics, the differences between pre-laser and post-laser values were obtained. Statistical analysis was performed using a random effects model. MAIN OUTCOME MEASURES: difference in mean IOP, standard deviation of IOP, and range of IOP. RESULTS: Thirty-one eyes of 18 patients were included for analysis. The average of the mean pre-operative IOP measurements was 14.3 +/- 2.6 mmHg compared to 12.2 +/- 1.7 mmHg (P < 0.001) post-operatively. The mean pre-operative standard deviation was 1.9 +/- 0.9 mmHg compared to 1.0 +/- 0.6 mmHg (P = 0.002) post-operatively while the mean IOP range prior to treatment was 4.5 +/- 2.5 mmHg compared to 2.5 +/- 1.9 mmHg (P = 0.017) after treatment. CONCLUSION: In this pilot study, SLT was found to lower mean IOP and intervisit IOP variation in NTG patients. Given the importance of IOP variation and its association with glaucoma progression, measurement of IOP variation following treatment with SLT may be considered.

Optical coherence tomography in the eyes of normal children.

OBJECTIVE: To collect a normative database of macular thickness, retinal nerve fiber layer (RNFL) thicknesses, and optic nerve topography in the healthy eyes of children aged 3 to 17 years using optical coherence tomography (OCT) measurements. METHODS: Scans were obtained for 286 healthy children (black, 114; white, 154; other, 18). Each child had a dilated eye examination, an axial length measurement using the IOL Master (Carl Zeiss Meditec, Dublin, California), and OCT measurements using the fast macular map, fast RNFL thickness, and fast optic disc protocols of the Stratus OCT (OCT-3; Carl Zeiss Meditec). RESULTS: Black children had smaller macular volume and foveal thickness, larger RNFL thickness, and larger cup-disc area ratios compared with white children. Macular volume and average outer macular thickness correlated negatively with axial length in white children. Foveal thickness correlated positively with age in black children only. Average RNFL correlated negatively with axial length in white children only (P < .05 for all). Normative data for all variables were recorded and compared with reported adult values. CONCLUSIONS: Stratus OCT-3 measurements of macular and RNFL thickness and optic nerve topography vary with race, axial length, and age in healthy children. Normative pediatric OCT data should facilitate the use of OCT in assessing childhood glaucoma and other diseases.

New ways to measure intraocular pressure.

PURPOSE OF REVIEW: In the last 10 years, several new means to measure intraocular pressure have emerged. This review covers recent findings concerning four new technologies: the ocular response analyzer, dynamic contour tonometry, rebound tonometry and the Proview phosphene tonometer. RECENT FINDINGS: The ocular response analyzer provides measurements of corneal biomechanics, including corneal hysteresis. Intraocular pressure readings from the ocular response analyzer have correlated well with Goldmann applanation tonometry and seem to be independent of corneal thickness in nonglaucoma patients; however, further studies are needed to determine whether this is true in glaucoma patients. Dynamic contour tonometry also appears to give pressure readings that are independent of corneal thickness. Rebound tonometry is convenient, can be used without topical anesthesia and appears to correlate well with Goldmann tonometry; however, pressure readings from rebound tonometry are not independent of corneal properties. Use of the Proview phosphene tonometer appears to decrease patient anxiety regarding their glaucoma; however, studies have not been supportive of its accuracy. SUMMARY: Dynamic contour tonometry provides intraocular pressure readings that are less dependent on corneal properties than Goldmann applanation tonometry. Rebound tonometry appears to correlate well with Goldmann tonometry and can be used without topical anesthesia.