Is combined mechanism glaucoma a distinct entity?

PURPOSE: Primary adult glaucomas that have an occludable angle with peripheral anterior synechiae which are too few to account for the chronically raised IOP, or the glaucomatous optic neuropathy, do not fit the definition of either POAG or PACG and can be considered as combined mechanism glaucoma (CMG). We aimed to compare the clinical features and anatomical parameters of combined mechanism glaucoma with age, sex, and refraction-matched POAG and chronic PACG eyes. METHODS: Consecutive adult patients with definitive optic nerve head and perimetric changes of glaucoma were screened at a tertiary care center. All glaucomatous eyes having an IOP > 22 mmHg on at least three separate occasions and glaucomatous optic neuropathy consistent with moderate visual field loss in the eye were divided as POAG, PACG, and CMG. Eyes with occludable angles having < 90° of goniosynechiae were diagnosed as CMG. A detailed clinical examination, ocular biometry, and ASOCT were performed in the better eye of all individuals. RESULTS: A total of 93 patients with similar visual field index or pattern standard deviation on perimetry were evaluated: 32 POAG, 31 CMG, and 30 PACG. The mean anterior chamber depth was 3.47 ± 0.37 mm in POAG, 2.81 ± 0.32 mm in PACG, and 3.06 ± 0.26 mm in CMG (p < 0.0001). Mean lens thickness was 4.22 ± 0.27 mm in POAG, 4.53 ± 0.35 mm in PACG, and 4.44 ± 0.29 mm in CMG (p = 0.0004). Iridotrabecular contact on ASOCT was nil in POAG, a mean of 87.60 ± 12.802% in PACG eyes, and 15.23 ± 14.19% in CMG eyes, p < 0.0001. CMG was similar to PACG in terms of corneal diameters and lens thickness and had an axial length in between PACG and POAG. On ASOCT, all parameters had highest values in POAG eyes and the least in PACG eyes, with CMG eyes having values in between the other two groups, p value of < 0.0001 between each group for all parameters. CONCLUSION: This study has demonstrated significantly different anatomical parameters in eyes with CMG, in addition to the differences on gonioscopy and iridotrabecular contact, indicating that CMG is discernibly dissimilar to PACG and POAG.

Channel characteristics and planform dynamics in the Indian Terai, Sharda River.

The Sharda River creates and maintains the ecologically diverse remnant patches of rare Terai ecosystem in northern India. This study used repeat satellite imagery and geographic information system analysis to assess the planform dynamics along a 60 km length of the Sharda River between 1977 and 2001 to understand the altered dynamics and its plausible causes in this data-poor region. Analyses revealed that the Sharda River has undergone significant change corresponding to enhanced instability in terms of increased number of neck cut-offs and consistent occurrence of avulsions in subsequent shorter assessment periods. An increased channel area (8%), decreased sinuosity (15%), increased braiding intensity, and abrupt migrations were also documented. The river has migrated toward the east with its west bankline being more unstable. The maximum shifts were 2.85 km in 13 years (1977-1990), 2.33 km in next 9 years (1990-1999), and a substantial shift of 2.39 km in just 2 years (1999-2001). The altered dynamics is making the future of critical wildlife habitats in Kishanpur Wildlife Sanctuary and North Kheri Forest Division precarious and causing significant economic damage. Extensive deforestation and expansion of agriculture since the 1950s in the catchment area are presumed to have severely impacted the equilibrium of the river, which urgently needs a management plan including wildlife habitat conservation, control, and risk reduction. The present study provides a strong foundation for understanding channel changes in the Sharda River and the finding can serve as a valuable information base for effective management planning and ecological restoration.

Outcomes of bent ab interno needle goniectomy with phacoemulsification in moderate to severe primary open angle glaucoma.

PURPOSE: To assess the safety and efficacy of bent ab interno needle goniectomy (BANG) in moderate to severe primary open angle glaucoma (POAG) eyes undergoing phacoemulsification (phaco). DESIGN: Single-arm, prospective, interventional study. METHODS: POAG patients with medically uncontrolled intraocular pressure (IOP), >15 mmHg for moderate and >12 mmHg for severe POAG, with visually significant cataract were recruited. All patients underwent BANG using a 26-gauge needle to excise 30° of the trabecular meshwork, along with phaco. Primary outcome was IOP. Secondary outcomes were success rate, percentage reduction in IOP/antiglaucoma medications (AGMs), and intraoperative complications. Success at 12 months was defined as: criterion A: IOP <15 mmHg for moderate glaucoma or <12 mm Hg for severe glaucoma with or without AGMs OR criterion B reduction in number of AGMs by >1. RESULTS: Thirty-two eyes of 32 patients underwent BANG + phaco. Mean age of the participants was 62.7 ± 8.4 years and there were 25 males and seven females. At 12 months, a significant decrease was noted in both IOP (from 17.6 ± 3.6 to 12 ± 1.6 mmHg, 31.8%; P < 0.001) and AGMs (from 3.7 ± 0.9 to 2.8 ± 0.8, 24.3%; P < 0.001). Twenty percent or more reduction in IOP was achieved in 62.5% (20/32) of eyes. Overall success (meeting either of the criteria A or B) at 12 months was achieved in 87.5% eyes. Mild postoperative hyphema was noted in 10 (31.2%) eyes, and two eyes (6.2%) required additional filtration surgery at 7 months. CONCLUSION: A 30-degree BANG with phaco in patients of POAG appears to be a safe, effective and affordable MIGS for developing countries.

Efficacy of Micropulse Laser Cyclophotocoagulation Therapy in Primary Angle Closure Glaucoma.

PRCIS: In primary angle closure glaucoma (PACG), micropulse cyclophotocoagulation resulted in a significant reduction in intraocular pressure (IOP), and the number of antiglaucoma medications without any sight-threatening complications. However, the IOP lowering efficacy decreased over time. PURPOSE: The purpose of this study was to evaluate the efficacy and safety of micropulse trans-scleral cyclophotocoagulation (MP-TSCPC) in PACG. PATIENTS AND METHODS: Thirty-three phakic PACG eyes with patent laser peripheral iridotomy and IOP uncontrolled on maximum tolerable antiglaucoma medications (AGMs), scheduled for trabeculectomy, were given a trial of MP-TSCPC (810 nm laser, 2000 mw power for 180 seconds, 360 degrees). The primary outcome measure was a success at 1 year with IOP ≤18 mm Hg and ≤15 mm Hg with (qualified success) or without (absolute success) AGMs after a single session of MP laser. Secondary outcome measures were changes in pupillary diameter, visual acuity, central macular thickness, and subjective pain perception. RESULTS: Thirty-two out of 33 PACG patients completed 12 months of follow-up. The mean age of patients was 54.7±8.9 years; male:female ratio was 1:1. The baseline IOP was 25.7±5.3 mm Hg, which reduced to 17.9±4.6 mm Hg at the end of 12 months (P<0.0001). Twenty eyes (62.5%) achieved qualified success, and 1 eye (3.125%) had absolute success at 12 months for IOP ≤18 mm Hg; 6 eyes (18.75%) had qualified success, and 1 eye (3.125%) had absolute success for IOP ≤15 mm Hg at 12 months follow-up. A significant reduction was also observed in the number of AGMs (4.4±0.8 at baseline to 2.9±1.1 at 12 months; P <0.0001). Five eyes (15.6%) received additional treatment-3 eyes (9.4%) requiring a subsequent filtering procedure, and 2 eyes (6.2%) requiring an additional MP-TSCPC session. No significant change in pupillary diameter (P=0.489) or central macular thickness (P=0.938) was noted at 12 months. There was a transient drop of visual acuity >2 lines in 1 patient due to cystoid macular edema, and no major postlaser complications were noted. CONCLUSIONS: MP-TSCPC can be used as an interim procedure to reduce IOP in PACG eyes and delay the need for invasive surgery. Most patients require continued use of glaucoma medications, and target IOPs achieved are in the high teens.

Effect of Mindfulness-Based Stress Reduction on Intraocular Pressure in Patients With Ocular Hypertension: A Randomized Control Trial.

PURPOSE: To evaluate the effect of mindfulness-based stress reduction (MBSR) on intraocular pressure (IOP) in patients with ocular hypertension (OHT). DESIGN: Parallel arm, single masked, randomized controlled trial. METHODS: Sixty patients with ocular hypertension and IOP > 21 and < 30 mmHg were recruited at a tertiary eye care centre in India. Thirty patients (group 1) underwent six weeks of one hour daily MBSR sessions, while the other 30 patients (group 2) were waitlisted and kept on follow-up. The primary outcome was change in IOP (ΔIOP) after six weeks of MBSR. Secondary outcomes were effect on serum cortisol level, diurnal variation of IOP, vessel perfusion and vessel density on optical coherence tomography angiography (OCTA), and quality of life (QOL). RESULTS: At six weeks, a significant decrease in IOP was noted in group 1 (23.05 ± 1.17 to 19.15 ± 1.45 mmHg; P = .001) compared with group 2 (22.55 ± 0.98 mmHg to 22.37 ± 1.07 mmHg; P = .107). The ΔIOP was significantly greater in group 1 (3.93 ± 1.47) than group 2 (0.17 ± 0.58; P = .001). The diurnal fluctuation of IOP decreased in group 1 (4.87 ± 1.13 mmHg to 2.73 ± 0.98 mmHg; P = .001) as compared with group 2 (4.50 ± 0.86 mmHg to 4.30 ± 0.83 mmHg; P = .227). Significant improvement in vessel perfusion, vessel density, and flux index was noted on OCTA in group 1 compared with group 2. Group 1 showed a significant decrease (P ≤ .001) in serum cortisol level and an improved QOL (P = .001). CONCLUSION: Mindfulness-based stress reduction was associated with a significant decrease in IOP and serum cortisol, along with an improvement in optic nerve head perfusion and QOL. Mindfulness-based stress reduction can be considered as a potential treatment option in the management of OHT.

Efficacy of Trabeculectomy Combined With Limited Deep Sclerectomy Versus Trabeculectomy Alone: A Randomized-controlled Trial.

PRCIS: The addition of limited deep sclerectomy (LDS) to conventional trabeculectomy increases the success rate, especially in pseudophakic eyes. PURPOSE: This study aimed to evaluate the efficacy of LDS in enhancing the intraocular pressure (IOP)-lowering outcomes of trabeculectomy. DESIGN: This was a parallel-arm, single-masked, randomized-controlled trial. METHODS: A total of 68 patients (68 eyes) with moderate to advanced primary open-angle glaucoma or primary angle-closure glaucoma with pseudophakia were recruited at a tertiary eye care center in Northern India and randomized into 2 groups. Thirty-five eyes in group 1 were subjected to trabeculectomy alone and 33 eyes in group 2 were subjected to trabeculectomy with LDS. All cases were supplemented with low-dose subconjunctival mitomycin-C (0.1 mg/mL for 1 min) in both groups. The primary outcome measure was IOP, and success rates were calculated for IOP ≤18/15/12 and ≥5 mm Hg. The secondary outcome measures included evaluation of bleb morphology, presence of an intrascleral aqueous lake, and supraciliary flow on ultrasound biomicroscopy. RESULTS: The mean postoperative IOP at 12 months was 13.4±1.83 mm Hg in group 1 and 12.5±1.67 mm Hg in group 2 (P=0.04). For IOP cutoff ≤15 mm Hg, absolute success was noted in 11 (31.4%) and 22 eyes (66.6%) in groups 1 and 2, respectively (P=0.004). At 12 months, the intrascleral lake was detected in 2 (6%) eyes in group 1 and in 9 (29%) eyes in group 2 (P=0.02). Supraciliary flow was detected in 2 eyes (6.2%) in group 2 and none in group 1 at 12 months (P=0.02). In the Cox proportional hazard model, trabeculectomy with LDS was associated with a lower rate of failure (hazard ratio: 0.32, 95% confidence interval: 0.13-0.75, P=0.009). CONCLUSION: The addition of LDS to trabeculectomy led to lower mean IOP and higher success rates at 12 months, compared with trabeculectomy alone.

Effect of Mindfulness Meditation on Intraocular Pressure and Trabecular Meshwork Gene Expression: A Randomized Controlled Trial.

PURPOSE: To evaluate the effect of mindfulness meditation (MM) on intraocular pressure (IOP) and trabecular meshwork (TM) gene expression in patients with medically uncontrolled primary open angle glaucoma (POAG). DESIGN: Parallel arm, single-masked, randomized controlled trial. METHODS: Sixty POAG patients with IOP ≥21 mm Hg taking maximal topical medication and scheduled for trabeculectomy were included in this study at a tertiary eye care center in India. Thirty patients (Group 1) underwent 3 weeks of 45-minute daily MM sessions in addition to medical therapy while Group 2 continued medical therapy only. Primary outcome was change in IOP (ΔIOP) after 3 weeks of MM. Secondary outcomes were probability of success, percentage of reduction in IOP, effect on diurnal variations of IOP, changes in quality of life (QoL), and changes in gene expression patterns in TM. RESULTS: At 3 weeks, a significant decrease in IOP was seen in Group 1 (20.16 ± 3.3 to 15.05 ± 2.4mm Hg; P = .001), compared to Group 2 (21.2 ± 5.6 to 20.0 ± 5.8mm Hg; P = .38). ΔIOP was significantly higher in Group 1 than in Group 2 (5.0 ± 1.80 vs. 0.20 ± 3.03mm Hg; P = .001). Analysis of gene expression revealed significant upregulation of nitric oxide synthetase (NOS1 and NOS3) and neuroprotective genes with downregulation of proinflammatory genes in Group 1 in comparison to Group 2 (P = .001). CONCLUSIONS: MM was associated with significant decrease in IOP and changes in TM gene expression, indicating its direct impact on ocular tissues.

Efficacy of Needling Revision After XEN Gel Stent Implantation: A Prospective Study.

INTRODUCTION: The XEN gel stent is currently the only minimally invasive glaucoma surgical device that targets the subconjunctival outflow pathway through an ab interno placement. It has demonstrated a significant intraocular pressure (IOP)-lowering potential and a favorable safety profile compared with traditional filtering surgery. However, despite a less invasive approach, the presence of a filtering bleb inevitably implies some risk of complications. The most commonly reported bleb-related complication, with rates as high as 45%, is bleb fibrosis associated with raised IOP. To restore filtration in those failing blebs, needling revision is considered the procedure of choice. In this study, we present the results of mitomycin C-augmented needling after XEN implantation. METHODS: This was a prospective, interventional study, conducted at a single tertiary glaucoma center. Fifty-one eyes of 51 patients with raised IOP associated with either a fibrotic or shallow bleb or increased vascularity following XEN gel stent implantation at the investigation site between January 2015 and June 2016 were enrolled in this study. Patients with other identified causes of filtration failure (stent malposition, internal ostium obstruction, retained viscoelastic) were excluded. Included patients who underwent mitomycin C-augmented needling revision, and follow-up examinations were conducted at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. The primary outcome was the magnitude of IOP reduction following needling revision at the last follow-up visit. Secondary outcome measures were the number of needling procedures carried out in all patients, the rate of patients requiring further filtering surgery following needling revision, and the rate of intraoperative and postoperative complications associated with needling revisions. RESULTS: The average age was 74.4±9.6 years; 66.7% (n=34) were female individuals. Primary open-angle glaucoma was the most common diagnosis (n=21, 41.2%). A total of 78 needling procedures were performed over the 24-month follow-up. Overall 20 of 51 eyes (39.2%) required >1 needling revision, and 14 eyes (24.5%) eventually required reoperation to maintain IOP within their desired target range. Before XEN implantation, mean preoperative IOP was 22.3±8.2 mm Hg and decreased to 14.1±8.0 mm Hg at day 1 postoperatively (-36.8%). The last measured IOP before the first needling revision was on average 23.6±8.9 mm Hg, which reduced to a mean 12.1±4.2 mm Hg at the first postrevision appointment (-48.7%). At the last follow-up appointment, on average 17.0±7.0 months after the first needling, the mean IOP was 14.3±4.1 mm Hg (-35.9% and -39.4% from preoperative and prerevision baselines, respectively). Complications associated with needling revisions were partial amputation of the XEN implant during needling (n=2, 3.9%), hypotony with choroidal detachment (n=1, 2%), and failure to achieve target IOP requiring subsequent surgery (n=14, 27.5%). No association was found between any of the recorded characteristics and the number of needling revisions performed or their outcomes. DISCUSSION: The present study shows that needling revision following XEN gel stent implantation is a relatively safe and efficient intervention to restore filtration in failing blebs, with a significant and durable IOP-reduction potential.

Relationship Between Contact Lens Sensor Output Parameters and Visual Field Progression in Open-angle Glaucoma: Assessment of a Practical Tool to Guide Clinical Risk-assessment.

PURPOSE: In recent years, new technologies have emerged to better analyze and interpret intraocular pressure (IOP) fluctuations. Among them is the progression report (PR), an algorithm based on continuous contact lens sensor (CLS) readings to estimate the likelihood of fast visual field (VF) glaucomatous progression. The objective of this study is to validate the PR. METHODS: In this retrospective study, 30 open-angle glaucoma patients were enrolled. Twenty-four hours IOP-related variations were recorded using a CLS. Recordings were used to generate PR. The likelihood of fast VF progression (<-1 dB/y mean deviation) was estimated by 2 masked assessors based on clinical parameters. At least 3 VF were performed over the 2 years following the initial assessment, to determine actual progression. RESULTS: Mean age was 65.9±10.45 years, with a mean baseline mean deviation of -5.4±5.1. After a mean follow-up of 29.5±12.9 months, 26.7% of eyes were assessed as fast progressors (-2.9±1.9 dBs/y). The average risk-score attributed by the PR was 42% [41% (slow) vs. 44% (fast); P=0.035]. Correlations between the 2 assessors were good (r=0.59), and identical to that between PR and the averaged assessors' gradings. Correlations between mean deviation progression rates and PR, Assessor 1 and Assessor 2's gradings were, r=0.57, 0.31, and 0.43, respectively. CONCLUSIONS: PR provided comparable predictions of the risk of fast VF progression as did physician estimates based on all available clinical data. With their relationship to the eye's biomechanical properties and the ocular tissues' response to pressure variations, CLS recordings may offer new information that complements conventional examinations.

Assessing impact of industrialization in terms of LULC in a dry tropical region (Chhattisgarh), India using remote sensing data and GIS over a period of 30 years.

The main focus of the paper is to assess the land use/ land cover (LULC) change in northern Chhattisgarh due to industrialization using remote sensing and Geographical Information System (GIS). The impact was assessed using an information extraction method applied to temporal satellite data (LANDSAT and IRS scenes) in GIS domain. For assessing the impact on natural resources, the classification scheme was restricted to (1) Forest patches ((a) completely cleared, (b) partially cleared, (c) least affected), (2) Non-Forest ((d) completely changed, (e) least changed), (3) Industrial/Mining area, and (4) River. Over the three decades 22.22% of forests have been completely cleared and converted to industrial setup. Another 25% is completely cleared and 10% is degraded. Around 4% of agricultural area is totally affected due to industrial activity. Random assessment of plant distribution (Trees, Shrubs and Herbs) indicates significant changes in the herb distribution directly related to distance gradient form the industrial/mining setup. Visual recording, socio-economic survey and satellite data also helped in delineation of extent of environmental pollution in forest and non-forest areas. The paper presents methodology for the environmental impact assessment.

Evaluation of Vision-related Quality of Life in Patients with Glaucoma: A Hospital-based Study.

INTRODUCTION: Quality of life (QoL) is a broad concept that is affected in a complex way by many factors. Healthcare interventions are targeted now days to improve quality of life of affected individuals. Glaucoma is a major cause of irreversible blindness throughout the world and affects patient's quality of life in several ways. In present study, we aim to evaluate and quantify vision related quality of life in glaucoma patients in a tertiary care hospital setting. MATERIALS AND METHODS: Vision related quality of life was evaluated in glaucoma patients using GQL-15 questionnaire, which compares the subjective performance of various vision related tasks in these patients. Fifty diagnosed cases of glaucoma and fifty healthy volunteers were included in the study. In both these groups, standard tests for visual function were done and both were assigned to complete the questionnaire. GQL-15 questionnaire includes 15 items divided between 4 factors pertaining to visual disability: central and near vision, peripheral vision, dark adaptation and glare, and outdoor mobility. Higher scores indicate greater difficulty in performing vision-related activities and poorer QoL. RESULTS: A total of 100 cases were enrolled out of which 50 were diagnosed glaucoma cases and 50 were controls. Almost three fourth of glaucoma patients, i.e., 72% were diagnosed as chronic open angle glaucoma where 24% were angle closure patients and rest 4% were normal tension glaucoma patients. The mean GQL score of glaucoma cases was 26.00 ± 10.84 and for controls it was 15.02 ± 0.14 (p value < 0.05). All subscale scores also showed a uniform rise in their value as we move from mild to severe cases thereby concluding that all visual parameters worsen with increase in severity pattern of disease. CONCLUSIONS: As glaucoma patients have reduced vision related quality of life, so every effort should be made to preserve visual functions in these patients. Many activities that define independence and productivity in society require good vision and hence one of most devastating consequences of advancing visual impairment in glaucoma is progressive loss of independence thereby affecting patients quality of life. HOW TO CITE THIS ARTICLE: Dhawan M, Hans T, et al. Evaluation of Vision-related Quality of Life in Patients with Glaucoma: A Hospital-based Study. J Curr Glaucoma Pract 2019;13(1):9-15.

Identifying the predictors of needling after XEN gel implant.

PURPOSE: To identify factors associated with probability of needling after XEN implant. METHODS: Analysis of data from prospective case series of patients with standalone XEN implant or combined XEN + cataract. Primary outcome was to determine whether postoperative day 1 and week 1 intraocular pressure (IOP), type of glaucoma, and glaucoma severity affected probability and number of needling interventions required. RESULTS: A total of 149 eyes of 113 patients were included in the analysis. In the XEN alone group, mean IOP at day 1 and week 1 was 9.70 ± 5.43 and 10.33 ± 4.41 mmHg, respectively. Eyes with lower IOP on day 1 were less likely to require needling (Odds ratio; OR, 1.14; 95% CI, 1.02-1.28; p = 0.02). A similar association (OR, 1.15; 95% CI, 1.06-1.26; p = 0.001) was observed between day 1 IOP in and number of needling interventions. In the XEN + cataract group, mean IOPs at day 1 and week 1 were 13.75 ± 7.52 and 11.81 ± 5.36 mmHg, respectively. No significant association was noted between early postoperative IOP and probability or number of needling in this group. With IOP > 20 mmHg the probability of needling was ~ 80%. This number decreased to 35% if day 1 IOP was < 10 mmHg. CONCLUSION: Postoperative day 1 IOP is a predictor for needling in patients undergoing standalone XEN implantation. These results suggest that surgeons should not wait too long to intervene via needling if IOP in the early postoperative period is in the high teens or above. Type or severity of glaucoma did not influence the probability of needling or number of needling interventions required.

'Van Herick Plus': a modified grading scheme for the assessment of peripheral anterior chamber depth and angle.

AIM: To evaluate the accuracy of a new, modified grading scheme involving a short vertical slit beam, at the inferior angle for peripheral anterior chamber depth (PAC) and angle estimation and its correlation with anterior segment optical coherence tomography (ASOCT). METHODS: A cross-sectional study of consecutive phakic patients, above 40 years of age, was performed. Using a short, vertical slit beam not reaching the pupil, the inferior angle at the sclerolimbal junction was evaluated, photographed and assessed by a ratio of peripheral anterior chamber depth to peripheral corneal thickness (PAC:PCT) and iridocorneal angle (ICA) on ImageJ software. The inferior angle at the same meridian was also recorded on ASOCT. RESULTS: Based on the PAC:PCT ratio, the subjects were divided into four groups: I (<1/4), II (1/4-1/2), III (>1/2-1) and IV (>1). The clinically assessed angle by short vertical slit beam correlated well with ASOCT values, trabecular-iris angle (TIA) (r=0.918; p<0.001) and scleral spur angle (r=0.903, p<0.001). The mean difference between ICA and TIA on ASOCT was 0.7970; 95% limits of agreement:-5.7670 to 7.3610 (±1.96 SD). For angles graded narrow on ASOCT (TIA <200), using a cut-off of peripheral PAC:PCT <1/4, the area under the curve was 0.918 with a sensitivity of 85.2% and a specificity of 88.2%. There was good agreement between ImageJ parameters with those assessed subjectively on photograph of the slit beam examination by a glaucoma fellow (weighted kappa=0.74) as compared with a general ophthalmologist, where there was moderate agreement (weighted kappa=0.57). CONCLUSION: A short, vertical slit lamp beam evaluation at the inferior angle is an easy and relatively accurate method for both peripheral anterior chamber depth and angle assessment. It correlated well with ASOCT and can be used as a more reliable screening tool to identify eyes with possibly occludable angles.

Pattern Scanning Laser (PASCAL) for Peripheral Iridoplasty in Eyes With Plateau Iris Syndrome: A Novel Application.

PURPOSE: The purpose of this study was to evaluate safety and efficacy of pattern scanning laser (PASCAL) for peripheral iridoplasty in eyes with plateau iris syndrome. MATERIALS AND METHODS: This study was a retrospective review of cases that underwent PASCAL laser peripheral iridoplasty. Eyes with plateau iris syndrome confirmed on gonioscopy and ultrasound biomicroscopy were included in the study. Primary and secondary outcome measures were angle widening on gonioscopy and magnitude of intraocular pressure (IOP) reduction, respectively. RESULTS: Twelve eyes of 8 patients that completed 1-year follow-up were analyzed. Angle widening was noted in 46% of treated quadrants by at least 1 grade (Shaffer classification) at 1-month follow-up. A statistically significant IOP reduction was noted at 1 year from 20.6±4.8 to 17.8±3.8 mm Hg (P=0.01). At 1 month, 8 of 12 eyes (66.6%) achieved gonioscopic success (widening of the angle by at least 1 grade in 2 of 4 quadrants). At 1 year, 6 of 12 eyes (50%) achieved tonometric success (20% reduction or 3 mm Hg IOP reduction from the baseline without addition of new antiglaucoma medications). No adverse effects associated with PASCAL laser peripheral iridoplasty were observed. CONCLUSIONS: PASCAL laser iridoplasty can be a safe and effective alternative to argon laser peripheral iridoplasty in the management of eyes with plateau iris syndrome. Our findings need to be further validated on larger sample size and in different ethnicities.

Unilateral Congenital Cataract: Clinical Profile and Presentation.

PURPOSE: To study the clinical profile and presentation of children with unilateral cataract. METHODS: In this hospital-based, observational, cross-sectional study, patients 15 years of age or younger who presented with unilateral cataract were recruited. Cases of cataract secondary to causes such as trauma or uveitis were excluded. Age at detection and presentation, distance from the treatment center, presenting complaints, cataract morphology, and biometry were noted for each case. RESULTS: A total of 76 patients were recruited. Most patients presented with complaints of leukocoria. Persistent fetal vasculature accounted for 27.6% of cases and was the most common identifiable cause of cataract in this study. Subsequently, patients were divided into two groups: no persistent fetal vasculature (control) and persistent fetal vasculature. A male predominance was noted in both groups. The mean age at detection was 27.58 ± 37.02 and 6.17 ± 8.42 months and the mean age at presentation was 55.613 ± 45.21 and 14.83 ± 17.75 months in the control and persistent fetal vasculature groups, respectively. In the persistent fetal vasculature group, a significant difference was noted in the axial length, keratometry, and corneal diameter between the affected and normal eyes (P = .027, .00176, and .0114, respectively). In the control group, this difference was observed only in keratometry readings (P = .0464). The mean distance traveled by patients to reach the treatment center was 211 km. CONCLUSIONS: Persistent fetal vasculature is an important and less identified cause of unilateral cataract. A significant delay is noted in the detection and presentation of unilateral cataract. [J Pediatr Ophthalmol Strabismus. 2018;55(2):107-112.].

Prospective Randomized Trial Comparing Mitomycin C Combined with Ologen Implant versus Mitomycin C Alone as Adjuvants in Trabeculectomy.

PURPOSE: Comparative evaluation of trabeculectomy with mitomycin C (MMC) versus trabeculectomy with MMC plus Ologen (Aeon Astron Europe, Leiden, The Netherlands). DESIGN: Prospective, randomized, comparative study. PARTICIPANTS: Fifty eyes of 50 patients with primary open-angle glaucoma or pseudophakic primary angle-closure glaucoma were recruited. METHODS: Twenty-five eyes underwent trabeculectomy with low-dose MMC alone (0.1 mg/ml for 1 minute; MMC group) and 25 eyes underwent trabeculectomy with low-dose MMC plus Ologen (Ologen group) at a tertiary eye care center. Only patients with minimum follow-up of 12 months were included in the study. MAIN OUTCOME MEASURES: Percentage reduction in intraocular pressure (IOP). Secondary outcome measures included percentage of patients achieving absolute and qualified success for IOP of less than 15 mmHg and less than 18 mmHg, bleb morphological features, need for antiglaucoma medications, and rate of complications. RESULTS: The mean preoperative IOP was 25.96±4.82 mmHg and 26.32±4.27 mmHg in the MMC and Ologen groups, respectively (P = 0.81). Mean postoperative IOP at 12 months was 11.33±3.18 mmHg in the MMC group and 14.35±3.34 mmHg in the Ologen group (P < 0.001 at all visits in both the groups). Significantly higher IOP reduction was noted in the MMC group at both 6 months (56.9% vs. 47.1%; P = 0.035) and 12 months (55% vs. 44.2%; P = 0.019). Cumulative success (absolute plus qualified success) was achieved in 86.3% of eyes in the MMC group compared with 73.9% of eyes in the Ologen group (P = 0.46) when IOP of 15 mmHg or less was considered as the definition of success. CONCLUSIONS: The addition of a biodegradable collagen implant (Ologen) does not improve efficacy of MMC-augmented trabeculectomy in primary adult glaucomas.

Systemic Associations of Childhood Glaucoma: A Review.

PURPOSE: To review systemic associations of childhood glaucoma. METHODS: Patients younger than 15 years and diagnosed as having glaucoma were divided into four groups: isolated primary congenital glaucoma, glaucoma with other congenital ocular anomalies, congenital glaucoma with known systemic diseases, and secondary glaucoma. Prevalence and type of systemic associations in each group were studied. RESULTS: A retrospective analysis of 371 patients diagnosed as having glaucoma was done. In the primary congenital glaucoma group, 13 of 218 (5.9%) patients had an associated systemic illness: congenital heart disease and global developmental delay were the most common systemic manifestations. In the congenital ocular anomalies group, 10 of 63 (15.8%) patients had an associated systemic illness. Axenfeld-Reiger syndrome, aniridia, and Peters' anomaly frequently had systemic comorbidities with congenital heart disease. In the known systemic diseases group, all 18 (100%) patients had systemic manifestations of an associated syndrome: Sturge-Weber and Down syndrome were the most frequent. In the secondary glaucoma group, 9 of 72 (12.5%) patients had systemic involvement, which was often seen as the most common cause after congenital cataract surgery. These children had congenital heart disease and global developmental delay as a consequence of congenital rubella and congenital cytomegalovirus infection. CONCLUSIONS: The study found that 12.9% of patients with childhood glaucoma had an associated systemic abnormality. Patients with congenital glaucoma and other ocular anomalies have a three times higher risk of an underlying systemic anomaly than patients with isolated primary congenital glaucoma. A team comprising an ophthalmologist, pediatrician, and anesthesiologist is recommended to treat these cases. [J Pediatr Ophthalmol Strabismus. 2018;55(6):397-402.].

Innovations in glaucoma surgery from Dr. Rajendra Prasad Centre for Ophthalmic Sciences.

Trabeculectomy surgery is the current standard of care in glaucoma for achieving a low target intraocular pressure if medical therapy is not adequate. Augmentation of trabeculectomy with antimetabolites brought a revolutionary change in the long-term success rates of trabeculectomy, but along with it came a plethora of complications. There still is a big window for therapeutic innovations on this subject. The foremost target for these innovations is to modulate the wound healing response after glaucoma drainage surgery. Achieving the desired balance between long-term success of filtering blebs versus early failure due to scarring of blebs and hypotony due to dysfunctional filtering blebs poses a unique challenge to the ophthalmologists. Alternatives to trabeculectomy such as glaucoma drainage devices and minimally invasive glaucoma surgeries cannot solve the problem of glaucoma blindness in our country, mainly due to their unpredictable results and unfavorable cost-benefit ratio. In this article, we present a summary of our innovations in glaucoma surgery to advance patient care by making it more effective, safer, and economical.

Evaluating role of bone marrow-derived stem cells in dry age-related macular degeneration using multifocal electroretinogram and fundus autofluorescence imaging.

AIM: To evaluate the role of bone marrow-derived stem cells in the treatment of advanced dry age-related macular degeneration (AMD) using multifocal electroretinogram (mf-ERG) and fundus autofluorescence imaging. METHODS: Thirty patients (60 eyes) with bilateral central geographic atrophy (GA) were recruited. Worse eye of each patient received autologous bone marrow-derived hematopoietic stem cells (BM-HSCs) (group 1) and the fellow eye with better visual acuity served as control (group 2). The effect of stem cell therapy was determined in terms of visual acuity, amplitude and implicit time in mf-ERG and size of GA on fundus autofluorescence imaging. These tests were performed at presentation and first, third and sixth month follow up. Adverse events (if any) were also monitored. RESULTS: At 6mo follow-up there was no statistically significant improvement in median logMAR best corrected visual acuity (BCVA) in either group. Mf-ERG revealed significant improvement in amplitude and implicit time in the intervention group. A significant decrease was also noted in greatest linear dimension (GLD) of GA in the eyes receiving stem cells [6.78±2.60 mm at baseline to 6.56±2.59 mm at 6mo (P=0.021)]. However, no such improvement was noted in the control group. CONCLUSION: Electrophysiological and anatomical improvement in the intervention group sheds light on the therapeutic role of BM-HSCs. Further studies are required to determine the stage of disease at which the maximal benefit can be achieved and to standardize the dose and frequency of stem cell injection.