Wound Modulations in Glaucoma Surgery: A Systematic Review.

Excessive fibrosis and resultant poor control of intraocular pressure (IOP) reduce the efficacy of glaucoma surgeries. Historically, corticosteroids and anti-fibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5-FU), have been used to mitigate post-surgical fibrosis, but these have unpredictable outcomes. Therefore, there is a need to develop novel treatments which provide increased effectiveness and specificity. This review aims to provide insight into the pathophysiology behind wound healing in glaucoma surgery, as well as the current and promising future wound healing agents that are less toxic and may provide better IOP control.

Exploring Underrepresentation: The Role of Diversity Statements in Ophthalmology Residency Programs.

INTRODUCTION: The underrepresentation of underrepresented minorities (URMs) in the medical field, particularly in ophthalmology, poses a critical challenge to achieving diversity and equity. While URMs constitute 19% of medical school attendees, their presence is markedly lower in ophthalmology residency programs and among practicing ophthalmologists. This study seeks to investigate the prevalence of diversity statements on ophthalmology residency program websites and their role in the underrepresentation of URMs within the field. METHODS: This observational, cross-sectional study analyzed the websites of 126 ophthalmology residency programs listed on the San Francisco (SF) Match website. Diversity statements were categorized based on their inclusion of specific underrepresented groups (race or ethnicity, gender, sexual orientation, and disability) and analyzed for correlation with program characteristics. Descriptive statistics and Chi-squared tests were utilized to assess the prevalence of diversity statements and their association with program size, ranking, geographical location, and institutional nature. RESULTS: Of the 126 programs analyzed, 21 (16.7%) had diversity statements specific to the ophthalmology residency program, and 115 (91.3%) featured institutional-level diversity statements. Race or ethnicity was the most commonly addressed category in diversity statements (75.3%), followed by gender (65.9%), sexual orientation (61.1%), and disability (53.2%). Statistical analyses revealed no significant correlation between program size and the presence of diversity statements. However, higher-ranked programs were more likely to mention sexual orientation and disability. Significant differences were observed at the institutional level, with public institutions more likely to include specific diversity categories. CONCLUSION: The study highlights a significant disparity in the presence and focus of diversity statements across ophthalmology residency programs. Despite a high prevalence of institutional-level diversity statements, program-specific initiatives are lacking, particularly in addressing disability inclusion. The findings suggest a need for a more comprehensive and targeted effort to address underrepresentation in ophthalmology.

Prevalence and risk factors of retinal vein occlusion in the United States: The National Health and Nutrition Examination Survey, 2005 to 2008.

Retinal vein occlusion (RVO) is a rare, vision-threatening vascular disorder. Due to limited recovery associated with RVO, prevention is essential. There is a significant discrepancy in previously reported epidemiological studies in the United States on the prevalence and risk factors of RVO. The purpose of this retrospective, cross-sectional study was to determine the prevalence and risk factors of RVO in adults ≥40 years of age in the US using the National Health and Nutrition Examination Survey (NHANES) 2005-2008. We collected information on the demographic characteristics, medical conditions, and ocular pathology of NHANES participants. We performed weighted analysis to estimate national prevalence rates and multivariate analysis to examine associated risk factors. The main outcome measures were the prevalence of RVO and the odds ratios of associated risk factors. We included 5559 participants and found 33 cases of RVO. The overall prevalence of RVO in the US was 0.50%. Age, per 10-year increase (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.31-2.92) and elevated diastolic blood pressure, per 10 mm Hg increase (OR 1.47; 95% CI, 1.10-2.12) were significant risk factors for RVO. Race, sex, glaucoma, elevated cholesterol, and self-reported history of diabetes, stroke, and heart disease were not significant risk factors. RVO is significantly associated with older age and elevated diastolic blood pressure. Our findings should alert clinicians to identify individuals at risk for RVO.

Quantification of vascular morphology in optical coherence tomography angiography in primary open angle glaucoma.

Purpose: To quantitatively measure and compare the vascular morphology in healthy eyes and eyes with primary open-angle glaucoma (POAG) using optical coherence tomography angiography (OCTA) scans. Methods: This is a retrospective and cross-sectional study which include healthy individuals and individuals with POAG that underwent OCTA imaging at an academic center's glaucoma clinic. We analyzed OCTA scans of the macula and optic nerve head (ONH) of one eye from each subject to quantitatively measure vessel density (VD), vessel length density (VLD), and branchpoint density (BPD). We compared these 3 parameters between the healthy and POAG groups and used logistic regression classification models to determine their diagnostic value in differentiating healthy and glaucomatous eyes. Results: We included 49 healthy subjects and 49 subjects with POAG. After age-adjusted analysis, the parameters of VD, VLD, and BPD were significantly reduced in eyes with POAG (P â€‹< â€‹0.001) in all scan layers and most significantly around the ONH. The parameter with the best performances were radial peripapillary capillary (RPC) VD [AUC (areas under the curve): 0.939 (0.891, 0.987)] which had statistically higher performances (P â€‹< â€‹0.05) than parameters in the superficial or deep layers. All 3 parameters in the RPC layer had statistically similar performances. Conclusions: We found that VD, VLD, and BPD were reduced in glaucomatous eyes. The morphologic parameters of VLD and BPD had similar performances to the traditional parameter of VD in RPC layers. Our results suggest that vascular morphology parameters may provide additional value in the diagnosis and evaluation of glaucoma.

Nail-Patella Syndrome: Optical Coherence Tomography Angiography Findings.

We describe a 51-year-old Hispanic female with nail-patella syndrome (NPS), a rare genetic disease with a wide range of systemic features such as nail dysplasia and finger abnormalities, elbow webbing, iliac horn, patellar subluxation, and proteinuria. Some patients additionally have a history of glaucoma and other ocular features such as thick central corneal thickness, Lester's sign, prominent iris processes, and optic nerve cupping. Our patient had a history of glaucoma suspicion, prominent iris processes, increased cup to disc ratios, tilted optic discs, and tigroid fundi. In addition, we report optical coherence tomography angiography (OCTA) findings of focal areas of poor vessel densities in the macular and circumpapillary regions of both eyes, suggesting early compromised vascular supplies to these areas. Our OCTA findings (which include both structural and vascular details of retina and optic nerve) lend support to the use of this technology in patients with NPS.

Trends and Characteristics of Industry Payments for Ophthalmology Research From 2014 to 2020.

Importance: Characterizing industry-ophthalmology collaborations in research can highlight current areas of focus, improve transparency, and identify potential sources for conflicts of interest. Objective: To assess the trends and characteristics in research payments reported from industry to ophthalmologists from 2014 to 2020. Design, Setting, and Participants: This cross-sectional study used data from the Centers of Medicare & Medicaid Services' Open Payments database (OPD), which contains public records of payments between industry and physicians, to identify all ophthalmologists who received industry payments for research purposes between 2014 and 2020. Industry funding was compared with public research funding by the National Eye Institute. Main Outcomes and Measures: The value and distribution of payments, sponsoring manufacturers, and research products were assessed. Changes in aggregate and per individual-level funding were characterized using formal trend analysis. Results: From 2014 to 2020, 2102 ophthalmologists were reported to have received $825 417 233 in industry research payments. Industry funding increased 203% from $62 924 525 in 2014 to $190 714 508 in 2020 (P = .01). Comparatively, total National Eye Institute research funding during the same period was $5 003 407 764 and increased 6.6% from $701 313 262 in 2014 to $747 929 556 in 2020 (P = .04). The share of all medical research funding from industry directed specifically toward ophthalmology research increased from 1.2% in 2014 to 3.2% in 2020 (P = .04). The distribution of industry payments was skewed, with the top 15 of 108 manufacturers accounting for 93.9% of funding. The top 10% of ophthalmologists (210) were reported to have received 65.7% of all research dollars ($542 299 121). The highest funded research products were anti-vascular endothelial growth factor agents, glaucoma treatments, and intraocular lenses. Conclusions and Relevance: Although unequal in distribution, industry-funded research in ophthalmology is extensive and increasing in scope. Industry funding for research is less than that of public funding; however, industry funding increased faster between 2014 and 2020. Results of this study highlight the increasing importance of industry funding in ophthalmology research, but it may also present ethical challenges for clinicians collaborating with industry.

Glaucoma Diagnosis Through the Integration of Optical Coherence Tomography/Angiography and Machine Learning Diagnostic Models.

Purpose: To establish optical coherence tomography (OCT)/angiography (OCTA) parameter ranges for healthy eyes (HE) and glaucomatous eyes (GE) for a North Texas based population; to develop a machine learning (ML) tool and to identify the most accurate diagnostic parameters for clinical glaucoma diagnosis. Patients and Methods: In this retrospective cross-sectional study, we included 1371 eligible eyes, 462 HE and 909 GE (377 ocular hypertension, 160 mild, 156 moderate, 216 severe), from 735 subjects. Demographic data and full OCTA parameters were collected. A Kruskal-Wallis test was used to produce the normative database. Models were trained to solve a two-class problem (HE vs GE) and four-class problem (HE vs mild vs moderate vs severe GE). A rigorous nested, stratified, group, 5×10 fold cross-validation strategy was applied to partition the data. Six ML algorithms were compared using classical and deep learning approaches. Over 2500 ML models were optimized using random search, with performance compared using mean validation accuracy. Final performance was reported on held-out test data using accuracy and F1 score. Decision trees and feature importance were produced for the final model. Results: We found differences across glaucoma severities for age, gender, hypertension, Black and Asian race, and all OCTA parameters, except foveal avascular zone area and perimeter (p<0.05). The XGBoost algorithm achieved the highest test performance for both the two-class (F1 score 83.8%; accuracy 83.9%; standard deviation 0.03%) and four-class (F1 score 62.4%; accuracy 71.3%; standard deviation 0.013%) problem. A set of interpretable decision trees provided the most important predictors of the final model; inferior temporal and inferior hemisphere vessel density and peripapillary retinal nerve fiber layer thickness were identified as key diagnostic parameters. Conclusion: This study established a normative database for our North Texas based population and created ML tools utilizing OCT/A that may aid clinicians in glaucoma management.

Risk factors for intraocular pressure elevation after descemet stripping automated endothelial keratoplasty.

PURPOSE: To identify the incidence of and risk factors for intraocular pressure (IOP) elevation after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Retrospective review was conducted of 68 consecutive DSAEK procedures alone, or in combination with phacoemulsification with intraocular lens implantation or exchange, performed by two surgeons at the University of Texas Southwestern Medical Center between 2005 and 2009. Eyes that developed IOP elevation above 21 mm Hg after DSAEK and requiring initiation or escalation of glaucoma therapy were evaluated. RESULTS: Thirty-seven (54%) eyes showed IOP elevation responsive to medical treatment by a mean follow-up of 11.38 +/- 7.81 months. Six (8.8%) eyes required glaucoma surgery. In the eyes, which developed elevated IOP, gonioscopy did not reveal any new peripheral anterior synechiae formation. Prolonged topical steroid usage, rebubbling, combined DSAEK/cataract surgery, or repeat DSAEK were not significant factors (P>0.05) for development of elevated IOP, but history of previous glaucoma or ocular hypertension (OHTN) was significant (P=0.007). CONCLUSIONS: Intraocular pressure elevation is not uncommon in eyes after DSAEK, but most cases can be controlled with conservative management. Intraocular pressure elevation post-DSAEK occurred by mechanisms other than peripheral anterior synechial angle closure. The only significant risk factor for development of elevated IOP in our series was a previous history of glaucoma or OHTN.

Acute Bilateral Uveitis, Hypotony, and Cataracts Associated with Ipilimumab and Nivolumab Therapy: Optical Coherence Tomography Angiography Findings.

Immune checkpoint inhibitors are increasingly being used for the treatment of several malignancies. In rare cases, patients develop disabling ophthalmic side effects such as dry eyes, episcleritis, keratitis, uveitis, inflammatory orbitopathy, myasthenia gravis, macular edema, and serous retinal detachment. We present a case of acute bilateral anterior uveitis, prolonged hypotony, and cataracts following the use of dual therapy ipilimumab and nivolumab. Physicians should be aware of these immune-mediated ocular adverse events and should have a management plan to deal with these side effects that range from mild to vision threatening.

Polymicrobial infection confined to Ahmed glaucoma shunt.

PURPOSE: To present a case of a unique complication of an Ahmed glaucoma shunt. The pathological and immunohistochemical findings will also be discussed. OBSERVATIONS: A 58-year-old woman with glaucoma secondary to Marfan syndrome and cataract surgery developed exposure of an Ahmed glaucoma tube, intraluminal white inflammatory material, and low-grade endophthalmitis five years after insertion. The patient was treated with topical and oral antibiotics and successfully underwent removal and replacement of the shunt. Pathologic analysis of the intraluminal contents revealed a bacterial infiltrate of mixed morphology. CONCLUSIONS AND IMPORTANCE: Concurrent tube exposure, intraluminal exudates, and endophthalmitis is a rare but potentially serious complication of glaucoma drainage device surgery. When this complication is encountered, prompt medical and surgical intervention is necessary to prevent significant vision loss. Ultimately, the glaucoma shunt may be revised, replaced, or removed altogether from the eye.

Upper eyelid extension of a filtering bleb following glaucoma shunt surgery.

The authors describe a case of a filtering bleb that extended into the eyelid of a 71-year-old man following glaucoma surgery with a shunt implant. The patient presented with a left upper eyelid mass and had ocular surface and mechanical sequelae. Computed tomography scan demonstrated a fistula between the original filtering tract and the eyelid, creating an inadvertent filtering bleb. Cytology revealed fluid consistent with aqueous humor. Intraocular pressure remained normal and symptoms improved with conservative management. The patient deferred any surgical revision. Glaucoma tube shunts may lead to ocular and rare orbital complications from inadvertent bleb extension, as seen in this case.

Intraocular surgery in kyphosis: an easier approach.

We describe a 49-year-old man with advanced kyphosis and dense cataract, who could only recline to about 40° from the vertical axis despite a maximal reverse Trendelenburg position and pillows under the head, neck, shoulders and knees. With a single corneal retraction suture at 6 o'clock, the eye could be rotated horizontally, which enabled the surgeon to perform a complex cataract surgery despite prior glaucoma shunt, posterior synechiae, a small pupil and the need to stain the capsule. As the eye can be brought into any desired position with a retraction suture, patients with kyphosis or other conditions that prevent them from assuming a supine position can still have safe intraocular procedures. This maneuver reduces the need to tilt patients to an uncomfortable position that may cause pain, increased breathing difficulty and elevated posterior vitreous pressure.

Epidemiology and characteristics of childhood glaucoma: results from the Dallas Glaucoma Registry.

PURPOSE: Few studies have provided epidemiological characteristics of childhood glaucoma in a large, multiethnic population. This information is important if we are to better screen for and characterize this specific type of glaucoma. In this study, we evaluate the characteristics of patients with childhood glaucoma, including glaucoma suspects, as identified through the Dallas Glaucoma Registry (DGR). PATIENTS AND METHODS: The DGR catalogs the characteristics of glaucoma patients seen at University of Texas Southwestern Medical Center, an academic tertiary referral center for a large, multiethnic, urban population in the United States. We analyzed these patients with respect to race, medical and surgical treatment, cup-to-disc ratio, intraocular pressure, and visual outcomes. RESULTS: The study comprised 376 eyes of 239 childhood glaucoma patients, of whom 19% had primary congenital glaucoma, 4% had primary juvenile glaucoma, 45% had secondary glaucoma, and 31% were glaucoma suspects. Trauma and postsurgical aphakia were the most common causes for secondary glaucoma. Thirty-eight percent of patients were Hispanic, 30% were Caucasian, 21% were African American, 3% were Asian, and 9% were unknown or unreported. Male sex was more common at 56%. Of all eyes with glaucoma, 65% received surgical intervention while 70% required at least one medication for intraocular pressure control. Trabeculotomy and tube-shunt surgery were the most common surgeries performed. Of patients who could have Snellen visual acuity measured, glaucoma suspect eyes had the largest proportion of eyes (96%) with good visual acuity (better than 20/40) while primary congenital glaucoma eyes had the smallest proportion (41%) with good visual acuity. Secondary glaucoma eyes had the largest proportion of eyes (30%) with poor visual acuity (worse than count fingers). CONCLUSION: The most common etiologies of childhood glaucoma were primary congenital glaucoma and secondary causes including trauma and postsurgical aphakia. A high proportion of glaucoma patients were of Hispanic background, reflecting the patient population studied. Trabeculotomy and tube-shunt surgery were the most common surgical interventions performed.

Delayed traumatic phacocele following trabeculectomy.

A 56-year-old woman with a history of trabeculectomy in both eyes sustained blunt trauma to the right eye at home. She initially presented with pain, loss of vision, total hyphema, and hypotony with no evidence of rupture or tissue prolapse. Prompt anterior chamber wash out revealed a partially subluxated crystalline lens behind the pupil, but the globe was intact. At 1 month postoperatively, subconjunctival displacement of the crystalline lens was detected. The patient gave a history of severe bouts of coughing and sneezing a few days earlier. During removal of phacocele, the trabeculectomy wound was intact with no evidence of leakage. A shallow concentric furrow was noticed across the flap approximately 3 mm from the limbus. It is believed that repeat trauma pushed the crystalline lens through the weakened trabeculectomy scleral flap. The wound later self-sealed.

Dallas Glaucoma Registry: Preliminary Results.

BACKGROUND: Although glaucoma is a leading cause of blindness worldwide, yet there are no large databases where risk factors, current management options and outcomes may be evaluated. With this concept in mind, Dallas Glaucoma Registry was established to focus on an ethnically mixed North Texas population. METHODS: This is a retrospective, chart review of 2,484 patients (4,839 eyes) with glaucoma from three clinics. Data collected included: age, race, gender, intraocular pressure, visual acuity, central corneal thickness, cup-to-disk ratio, extent of visual field damage, glaucoma diagnoses, medical and surgical therapies. RESULTS: The most prevalent glaucoma was primary open angle glaucoma accounting for 44.4% of patients, followed by glaucoma suspect (39.5%), secondary glaucoma (7.2%), angle closure glaucoma (6.8%), normal tension glaucoma (1.7%), and childhood glaucoma (0.5%). The mean (SD) age was 68.7 (13.8) and 41.3% were non Hispanic white, 37.0% were black, 10.4% were Hispanic and 11.3% were of other ethnic origin. Hispanic representation in glaucoma did not match their numbers in general population of North Texas. CONCLUSION: Large numbers of patients in the ongoing Dallas Glaucoma Registry do provide adequate data to better understand risk factors, early detection, improved screening targets, treatment options, outcomes and future studies.

Intraocular pressure reduction in the untreated fellow eye after selective laser trabeculoplasty.

OBJECTIVE: To investigate the effect of selective laser trabeculoplasty (SLT) on the intraocular pressure (IOP) of untreated fellow eyes in patients with open-angle glaucoma. STUDY DESIGN: Retrospective chart review. PATIENTS AND METHODS: Charts of all patients who underwent SLT at the University of Texas Southwestern Medical Center at Dallas between September 2003 and May 2006 were reviewed. Each patient had IOP measurements by Goldmann applanation tonometry in both eyes preoperatively, and at 1 hour, 2 weeks, 3 months, and 6 months postoperatively. Patient age, gender, diagnosis, central corneal thickness (CCT), previous intraocular surgeries, and degrees of laser treatment were tabulated for each patient. Patients with a history of previous glaucoma surgery in either eye were excluded as were those who underwent any change in glaucoma medications or further laser or surgical intervention in either eye within 6 months of SLT. Data were analyzed using a paired two-tailed t-test, an unpaired two-tailed t-test, ANOVA, and linear regression. RESULTS: A total of 43 patients were included through 6 months of follow-up. Mean reduction in IOP in the treated eye was 3.9 +/- 0.6 mmHg or 18.8% (p < 0.001) at final exam. Mean IOP reduction in the fellow untreated eye was 2.1 +/- 0.5 mmHg or 11.2% (p < 0.01). Patients with higher preoperative IOPs had a greater reduction in IOP in both eyes (p < 0.001 for treated eyes, and p = 0.02 for untreated eyes). Patients who were on a larger number of glaucoma medications preoperatively had a greater response in both eyes (treated eye p = 0.002, untreated eye p = 0.008). There was no significant difference in IOP response in either eye based on age, gender, CCT, degrees of treatment, or phakic status. CONCLUSIONS: SLT produces a sustained and statistically significant IOP reduction in the fellow untreated eyes of patients with open-angle glaucoma. The results of our study support a biological mechanism of action for SLT. Limitations of this study include its retrospective design, relatively small sample size, a possible effect of increased compliance with medical therapy following SLT, and an inherent bias of excluding patients who underwent a change in medications or further laser or surgical therapy during the period under review.

Risk factors for progression to blindness in high tension primary open angle glaucoma: Comparison of blind and nonblind subjects.

AIMS: To determine which risk factors for blindness were most critical in patients diagnosed with high tension primary open angle glaucoma (POAG) in a large ethnically diverse population managed with a uniform treatment strategy. METHODS: A longitudinal observational study was designed to follow 487 patients (974 eyes) with POAG for an average of 5.5 +/- 3.6 years. Detailed ocular and systemic information was collected on each patient and updated every six months. For this study, blindness was defined as visual acuity of 20/200 or worse and/or visual field less than 20 degrees in either eye. Known risk factors were compared between patients with blindness in at least one eye versus nonblind patients. RESULTS: The patients with blindness had on average: higher intraocular pressure (IOP, mmHg): (24.2 +/- 11.2 vs. 22.1 +/- 7.7, p = 0.03), wide variation of IOP in the follow-up period (5.9 vs. 4.1 mmHg, p = 0.031), late detection (p = 0.006), poor control of IOP (p < 0.0001), and noncompliance (p < 0.0003). Other known risk factors such as race, age, myopia, family history of glaucoma, history of ocular trauma, hypertension, diabetes, vascular disease, smoking, alcohol abuse, dysthyoidism, and steroid use were not significant. CONCLUSIONS: The most critical factors associated with the development of blindness among out patients were: elevated initial IOP, wide variations and poor control of IOP, late detection of glaucoma, and noncompliance with therapy.