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Background Discrepancies in the literature regarding optimal optic nerve sheath diameter (ONSD) cutoffs for intracranial pressure (ICP) necessitate alternative neuroimaging parameters to improve clinical management. Purpose To evaluate the diagnostic accuracy of the dimensions of the perineural subarachnoid space to the optic nerve sheath ratio, measured using US, in predicting increased ICP. Materials and Methods In a prospective cohort study from April 2022 to December 2023, patients with suspected increased ICP underwent optic nerve US to determine the dimensions of arachnoid bulk (DAB) ratio and ONSD before invasive ICP measurement. Correlation between the parameters and ICP, as well as diagnostic accuracy, was assessed using area under the receiver operating characteristic curve (AUC) analysis. Results A total of 30 participants were included (mean age, 39 years ± 14 [SD]; 24 female). The DAB ratio and ONSD were significantly larger in participants with increased ICP (38% [0.16 of 0.42] and 14% [0.82 of 6.04 mm], respectively; P < .001). The DAB ratio showed a stronger correlation with ICP than ONSD (rs = 0.87 [P < .001] vs rs = 0.61 [P < .001]). The DAB ratio and ONSD optimal cutoffs for increased ICP were 0.5 and 6.5 mm, respectively, and the ratio had higher sensitivity (100% vs 92%) and specificity (94% vs 83%) compared with ONSD. Moreover, the DAB ratio better predicted increased ICP than ONSD, with a higher AUC (0.98 [95% CI: 0.95, 1.00] vs 0.86 [95% CI: 0.71, 0.95], P = .047). Conclusion An imaging ratio was proposed to predict ICP based on the relative anatomy of the cerebrospinal fluid space, demonstrating more accurate diagnosis of increased ICP and a strong correlation with ICP values, suggesting its potential utility as a neuroimaging marker in clinical settings. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Shepherd in this issue.
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Aracnoide-Máter , Hipertensão Intracraniana , Pressão Intracraniana , Nervo Óptico , Humanos , Feminino , Masculino , Adulto , Estudos Prospectivos , Nervo Óptico/diagnóstico por imagem , Pressão Intracraniana/fisiologia , Hipertensão Intracraniana/diagnóstico por imagem , Hipertensão Intracraniana/fisiopatologia , Aracnoide-Máter/diagnóstico por imagem , Ultrassonografia/métodos , Pessoa de Meia-IdadeRESUMO
PRCIS: Preserflo® surgery is a safe procedure, effective in reducing intraocular pressure into the "low teens", surgical survival is greatest in cases of high baseline intraocular pressure (above 21 mmHg) and when performed as a standalone procedure. PURPOSE: To evaluate midterm surgical survival and safety profile of Preserflo® filtering surgery. METHODS: Retrospective, cohort study. Consecutive patients who underwent standardized Preserflo® implantation with mitomycin C from December 2019 to April 2021 were included. Clinical data was retrieved from patient charts. Primary outcome was surgical survival at twenty-four months in accordance with World Glaucoma Association guidelines. Survival was evaluated using Kaplan-Meier statistics. Analysis was performed at eye-level and as intention-to-treat. RESULTS: Ninety-five eyes were included in this study (18 cases combined with cataract surgery). Over half of cases (n=51) were primary open angle glaucoma, with over a fifth having a prior filtering glaucoma procedure. Intraocular pressure at twenty-four months was significantly decreased from baseline (22.4±6.28 mmHg vs 12.0±3.43 mmHg), as well as the need for IOP-lowering medication (2.88 (±0.92) vs 0.79 (±1.3), P<0.001 all comparisons. Standalone Preserflo® achieved a qualified survival (irrespective of medication) of 71% (CI 95% 62%-83%) and 44% (CI 95% 27%-75%) in the combined procedure subgroup (P<0.05 when considering absolute survival). Eyes with baseline intraocular pressure ≥21 mmHg showed a greater qualified survival when compared to eyes with baseline ≤18 mmHg (80% (CI 95% 65%-100%) vs (50% (CI 95% 32%-76%; P<0.05). Intra and early operative complications were few, self-limited, and did not require surgical management. The reoperation rate was low (18%). CONCLUSION: Preserflo ® filtering surgery is effective in reducing intraocular pressure into the "low teens" and presents an adequate surgical survival and safety profile. Surgical survival appears greatest when performed as standalone and when pre-operative intraocular pressure is high (≥21 mmHg).
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PRCIS: In reducing intraocular pressure (IOP), Paul (PGI) and Baerveldt (BGI) glaucoma implants are safe and effective in patients with glaucoma. OBJECTIVE: To compare efficacy and safety profiles of the PGI and BGI in the treatment of medically uncontrolled glaucoma at 1 year of follow-up. METHODS: Retrospective analysis of patients implanted with a PGI or BGI with a minimum of 12 months follow-up. The primary outcome was surgical success defined as IOP ≥6 and ≤18 mm Hg and at least 20% IOP reduction from baseline. Secondary outcomes included IOP measurements, number of medications, and complications. RESULTS: Twenty-three patients implanted with PGI and 27 with BGI were included. At last visit (12 mo), mean IOP had decreased from 23.7 ± 6.9 to 0.1 ± 2.9 mm Hg in the PGI group versus 26 ± 7.3 to 10.4 ± 4.9 mm Hg with the BGI ( P < 0.001 for both comparisons). Overall qualified success rates were similar between groups (PGI 91% vs BGI 89%, P = 0.784). IOP was significantly lower in the PGI at week 1 and month 1 of follow-up versus the BGI (13.6 ± 6.1 vs 20.1 ± 7.4; 14.6±3.8 vs 21.2 ± 5.8 mm Hg; P < 0.002 for both) with a lower number of medications (1.57 ± 1.47 vs 2.52 ± 1.16 at mo 1, P = 0.015). Most complications were minor and similar in both groups. CONCLUSION: Both PGI and BGI are safe and effective in reducing IOP in patients with glaucoma, with similar success rates.
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Implantes para Drenagem de Glaucoma , Glaucoma , Pressão Intraocular , Tonometria Ocular , Acuidade Visual , Humanos , Pressão Intraocular/fisiologia , Estudos Retrospectivos , Feminino , Masculino , Seguimentos , Idoso , Resultado do Tratamento , Pessoa de Meia-Idade , Acuidade Visual/fisiologia , Glaucoma/cirurgia , Glaucoma/fisiopatologia , Implantação de Prótese , Anti-Hipertensivos/uso terapêutico , Anti-Hipertensivos/administração & dosagemRESUMO
INTRODUCTION: The PRESERFLO™ MicroShunt (PMS) has been proven to significantly lower intraocular pressure (IOP) in patients with glaucoma and has been available for use since 2019. With increasing published evidence and growing experience of glaucoma surgeons, the aim of this modified Delphi panel was to build on the findings of a previous Delphi panel conducted in 2021 and provide further guidance on the role of the PMS to treat patients with glaucoma in Europe. METHODS: Thirteen European glaucoma surgeons experienced in the PMS procedure participated in a 3-round modified Delphi panel. A targeted literature review and expert steering committee guided Round 1 questionnaire development. Consensus was pre-defined at a threshold of ≥ 70% of panellists selecting 'strongly agree'/'agree' or 'strongly disagree'/'disagree' for 6-point Likert scale questions or ≥ 70% selecting the same option for multiple or single-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions. RESULTS: In total, 28% (n = 9/32), 52% (n = 16/31) and 91% (n = 10/11) of statements reached consensus in Rounds 1, 2 and 3, respectively. There was agreement that the PMS may be used in patients with pigmentary, post-trauma or post-vitrectomy glaucoma and for patients with uveitic glaucoma without active inflammation. The PMS may be more suitable for patients with contact lenses than other subconjunctival filtering surgeries, without eliminating bleb-associated risks. Consensus was reached that combining PMS implantation and phacoemulsification may be as safe as standalone PMS surgery, but further efficacy data are required. Following a late rise in IOP ≥ 4 months post-surgery, topical aqueous suppressant drops or bleb revision may be suitable management options. CONCLUSIONS: This Delphi panel builds on the considerations explored in the 2021 Delphi panel and provides further detailed guidance for glaucoma surgeons on the use of the PMS, reflecting the availability of novel evidence and surgical experience. Videos are available for this article.
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BACKGROUND/AIMS: The goal of health research is to improve patients care and outcomes. Thus, it is essential that research addresses questions that are important to patients and clinicians. The aim of this study was to develop a list of priorities for glaucoma research involving stakeholders from different countries in Europe. METHODS: We used a three-phase method, including a two-round electronic Delphi survey and a workshop. The clinician and patient electronic surveys were conducted in parallel and independently. For phase I, the survey was distributed to patients from 27 European countries in 6 different languages, and to European Glaucoma Society members, ophthalmologists with expertise in glaucoma care, asking to name up to five research priorities. During phase II, participants were asked to rank the questions identified in phase I using a Likert scale. Phase III was a 1 day workshop with patients and clinicians. The purpose was to make decisions about the 10 most important research priorities using the top 20 priorities identified by patients and clinicians. RESULTS: In phase I, 308 patients and 150 clinicians were involved. In phase II, the highest-ranking priority for both patients and clinicians was 'treatments to restore vision'. In phase III, eight patients and four clinicians were involved. The top three priorities were 'treatments to stop sight loss', 'treatments to restore vision' and 'improved detection of worsening glaucoma'. CONCLUSION: We have developed a list of priorities for glaucoma research involving clinicians and patients from different European countries that will help guide research efforts and investment.
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PURPOSE OF REVIEW: To address the current role of artificial intelligence (AI) in the field of glaucoma. RECENT FINDINGS: Current deep learning (DL) models concerning glaucoma diagnosis have shown consistently improving diagnostic capabilities, primarily based on color fundus photography and optical coherence tomography, but also with multimodal strategies. Recent models have also suggested that AI may be helpful in detecting and estimating visual field progression from different input data. Moreover, with the emergence of newer DL architectures and synthetic data, challenges such as model generalizability and explainability have begun to be tackled. SUMMARY: While some challenges remain before AI is routinely employed in clinical practice, new research has expanded the range in which it can be used in the context of glaucoma management and underlined the relevance of this research avenue.
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Aprendizado Profundo , Glaucoma , Humanos , Inteligência Artificial , Glaucoma/diagnóstico , Técnicas de Diagnóstico Oftalmológico , Campos VisuaisRESUMO
PROLOGUE: Glaucoma surgery has been, for many decades now, dominated by the universal gold standard which is trabeculectomy augmented with antimetabolites. Tubes also came into the scene to complement what we use to call conventional or traditional glaucoma surgery. More recently we experienced a changing glaucoma surgery environment with the "advent" of what we have become used to calling Minimally Invasive Glaucoma Surgery (MIGS). What is the unmet need, what is the gap that these newcomers aim to fill? Hippocrates taught us "bring benefit, not harm" and new glaucoma techniques and devices aim to provide safer surgery compared to conventional surgery. For the patient, but also for the clinician, safety is important. Is more safety achieved with new glaucoma surgery and, if so, is it associated with better, equivalent, or worse efficacy? Is new glaucoma surgery intended to replace conventional surgery or to complement it as an 'add-on' to what clinicians already have in their hands to manage glaucoma? Which surgery should be chosen for which patient? What are the options? Are they equivalent? These are too many questions for the clinician! What are the answers to the questions? What is the evidence to support answers? Do we need more evidence and how can we produce high-quality evidence? This EGS Guide explores the changing and challenging glaucoma surgery environment aiming to provide answers to these questions. The EGS uses four words to highlight a continuum: Innovation, Education, Communication, and Implementation. Translating innovation to successful implementation is crucially important and requires high-quality evidence to ensure steps forward to a positive impact on health care when it comes to implementation. The vision of EGS is to provide the best possible well-being and minimal glaucomainduced visual disability in individuals with glaucoma within an affordable healthcare system. In this regard, assessing the changes in glaucoma surgery is a pivotal contribution to better care. As mentioned, this Guide aims to provide answers to the crucial questions above. However, every clinician is aware that answers may differ for every person: an individualised approach is needed. Therefore, there will be no uniform answer for all situations and all patients. Clinicians would need, through the clinical method and possibly some algorithm, to reach answers and decisions at the individual level. In this regard, evidence is needed to support clinicians to make decisions. Of key importance in this Guide is to provide an overview of existing evidence on glaucoma surgery and specifically on recent innovations and novel devices, but also to set standards in surgical design and reporting for future studies on glaucoma surgical innovation. Designing studies in surgery is particularly challenging because of many subtle variations inherent to surgery and hence multiple factors involved in the outcome, but even more because one needs to define carefully outcomes relevant to the research question but also to the future translation into clinical practice. In addition this Guide aims to provide clinical recommendations on novel procedures already in use when insufficient evidence exists. EGS has a long tradition to provide guidance to the ophthalmic community in Europe and worldwide through the EGS Guidelines (now in their 5th Edition). The EGS leadership recognized that the changing environment in glaucoma surgery currently represents a major challenge for the clinician, needing specific guidance. Therefore, the decision was made to issue this Guide on Glaucoma Surgery in order to help clinicians to make appropriate decisions for their patients and also to provide the framework and guidance for researchers to improve the quality of evidence in future studies. Ultimately this Guide will support better Glaucoma Care in accordance with EGS's Vision and Mission. Fotis Topouzis EGS President
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Glaucoma , Humanos , Europa (Continente) , França , Glaucoma/cirurgia , Grécia , LondresRESUMO
OBJECTIVES: To review the optimal diagnostic cut-off of ultrasonographic optic nerve sheath diameter (ONSD) in the diagnosis of increased intracranial pressure (IICP). METHODS: A systematic search was conducted of available studies assessing the use of ONSD ultrasonography in patients with suspected IICP. Meta-analysis of diagnostic accuracy of ultrasonographic ONSD was performed using a bivariate model of random effects to summarize pooled sensitivity and specificity. A summary receiver operating characteristics (SROC) curve was plotted. Accuracy measures associated with ONSD cut-off and predefined covariates were investigated with meta-regression. RESULTS: We included 38 studies, comprising a total of 2824 patients. A total of 21 studies used invasive techniques as a reference standard estimation of IICP and meta-analysis revealed a pooled sensitivity of 0.90 (95% CI 0.85-0.93) and specificity of 0.87 (95% CI 0.80-0.91). Optimal ONSD cut-off values ranged between 4.1 mm and 7.2 mm. Meta-regression analysis showed that ONSD cut-off values of 5.6 to 6.3 mm were associated with higher pooled specificity compared to cut-off values of 4.9 to 5.5 mm (0.93, 95% CI 0.85-0.97 vs. 0.78, 95% CI 0.65-0.87; p = 0.036). CONCLUSIONS: Ultrasonography of ONSD shows a high diagnostic accuracy for IICP, with high pooled sensitivity and specificity. Additionally, larger cut-off values seem to significantly increase specificity without compromising sensitivity, which support their use as optimal ONSD cut-off. The overall high sensitivity of ultrasonographic ONSD suggests its usefulness as a screening tool for IIC, which may provide an estimate of when invasive methods are warranted. CLINICAL RELEVANCE: ONSD ultrasonography is a fast and cost-effective method with a high diagnostic accuracy to detect IICP. The optimum ONSD cut-off hasn't been established before, but we suggest the 5.6 to 6.3 mm range as the best for the diagnosis of IICP.
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Hipertensão Intracraniana , Pressão Intracraniana , Humanos , Pressão Intracraniana/fisiologia , Nervo Óptico/diagnóstico por imagem , Hipertensão Intracraniana/diagnóstico por imagem , Sensibilidade e Especificidade , Ultrassonografia/métodosRESUMO
PURPOSE: To evaluate bleb morphology features of different glaucoma drainage devices (GDD) using magnetic resonance imaging (MRI). MATERIALS AND METHODS: Prospective cohort study of GDD and bleb morphology in consecutive glaucoma patients implanted with Ahmed Glaucoma Valve (AGV), Paul Glaucoma Implant (PGI), Baerveldt Glaucoma Implant (BGI) and Ahmed ClearPath (ACP) devices. Thirty-six eyes from 30 consecutive patients underwent standardized GDD implantation followed by MRI at least 1 month after surgery. Main outcomes included bleb volume and endplate position relative to the optic nerve. Secondary outcomes included intraocular pressure (IOP), medication and surgical complications during a 12-month follow-up. RESULTS: Seven eyes were implanted with the AGV (19%), 5 with BGI (14%), 16 with PGI (44%) and 8 with ACP (22%). MRI scans were obtained 85 ± 66 days after surgery. Mean total bleb volume was 563 ± 390 mm3 . This bleb volume was inversely correlated with early post-operative IOP (day 7; rs = -0.3326, p = 0.0475) but positively correlated with IOP at 12 months (rs = 0.3592, p = 0.0341). No significant difference in total bleb volume was found between GDD types (p = 0.1223). A double-layered bleb was observed in 34 eyes (94%). The inferior bleb volume was significantly larger in PGI devices versus other GDD types (380 ± 205 vs. 193 ± 161 mm3 ; p = 0.0043). Distance from the endplate to the optic nerve was 9.5 ± 4.0 mm, similar across GDDs (p = 0.2519). CONCLUSIONS: Double-layered blebs are a common finding with GDDs. Bleb volume showed different correlations with IOP at distinct timepoints and the PGI device formed larger blebs. A standardized GDD implantation technique ensures a safe distance from the GDD endplate to the optic nerve.
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Implantes para Drenagem de Glaucoma , Glaucoma , Humanos , Estudos Prospectivos , Glaucoma/diagnóstico , Glaucoma/cirurgia , Glaucoma/tratamento farmacológico , Pressão Intraocular , Implantação de Prótese/métodos , Imageamento por Ressonância Magnética , Resultado do Tratamento , Estudos Retrospectivos , SeguimentosRESUMO
PURPOSE: Cataract and glaucoma are two of the most common ocular comorbidities. Cataract surgery has been shown to influence intra-ocular pressure (IOP) in patients with glaucoma; nevertheless, the extent of this effect remains controversial, especially in patients with open-angle glaucoma (OAG). The aim of this review is to determine the real effect of cataract surgery on IOP change in patients with OAG, focusing on data retrieved from randomised controlled trials (RCTs). METHODS: A systematic review was performed, including six different RCTs that studied the net effect of cataract surgery on IOP. Eligibility criteria required a full washout from hypotensive therapy, allowing accurate measurement of unmedicated IOP, both before and after surgery. RESULTS: Included studies revealed a consistent reduction on IOP occurring after surgery, varying between 4.1 and 8.5 mmHg depending on the RCT. There was also a decrease in the number of glaucoma medications, with a mean reduction of 0.2-1.0 agents postoperatively. Evaluation of adverse outcomes of cataract surgery showed a very favourable safety profile. CONCLUSION: Although the role of cataract surgery in the algorithm of glaucoma treatment remains to be established, this review highlights a consistent decrease on IOP following surgery and a reduced dependency on glaucoma medications. Potential downgrade in medication can thus be considered in well-controlled glaucoma patients after phacoemulsification. PROSPERO registry: CRD42022343378.
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Extração de Catarata , Catarata , Glaucoma de Ângulo Aberto , Glaucoma , Facoemulsificação , Humanos , Pressão Intraocular , Tonometria Ocular , Glaucoma/cirurgia , Catarata/complicações , Glaucoma de Ângulo Aberto/cirurgia , Glaucoma de Ângulo Aberto/tratamento farmacológicoRESUMO
INTRODUCTION: The implantation of the PRESERFLO™ MicroShunt (PMS) device has been shown to significantly lower increased intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG). However, guidelines on best practice for patient selection and pre-/peri-/postoperative care management are lacking. The aim of this modified Delphi panel was to achieve expert consensus on the role of the PMS to treat patients with glaucoma in Europe. METHODS: Twelve European glaucoma surgeons experienced with the PMS procedure participated in a three-round modified Delphi panel. A targeted literature review and expert steering committee guided round 1 questionnaire development. Consensus was set at a pre-defined threshold of at least 70% of panellists selecting 'Strongly disagree'/'Disagree' or 'Strongly agree'/'Agree' for six-point Likert scale questions, or at least 70% selecting the same option for multiple-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions. RESULTS: Consensus was achieved for 60.3% (n = 38/63), 60.0% (n = 18/30), and 100.0% (n = 11/11) of Likert/multiple-choice questions in rounds 1, 2, and 3, respectively. There was agreement that the PMS procedure is effective at reducing IOP in patients with high-tension POAG (greater than 21 mmHg). Although surgical techniques may vary slightly, consensus was reached on several points, including the importance of posterior application of mitomycin C (MMC). Panellists agreed that the PMS postoperative follow-up appointment schedule is reasonably predictable and mostly characterised by fewer visits than with trabeculectomy, particularly in the early phase. Although panellists agreed that combined cataract/PMS surgery and the use of non-MMC wound-healing modulators/antifibrotics during the procedure are possible, further data are needed to determine efficacy. CONCLUSION: The expert consensus reached in this panel will help inform best practice guidelines in the treatment of patients with glaucoma in Europe. Panellists also highlighted key areas for future research to improve understanding of the PMS in the treatment algorithm of glaucoma.
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Eagle syndrome is a rare entity that occurs when an elongated styloid process compresses the neck vasculonervous structures. A 47-year-old female patient was referred to our glaucoma clinic for a second opinion concerning bilateral visual field progression despite maximal tolerated medical therapy. After aggressive intraocular pressure lowering and resorting to surgical and optimised medical treatment, the visual field kept stable in the right eye but was still showing progression in the left eye. As optic disc was paler in the left eye and after full appreciation of systemic complaints, including left neck, ear and eye pain, a multidisciplinary approach with otorhinolaryngology was prompted. Plain radiographs of the skull showed an elongated styloid process on the left side, compatible with Eagle syndrome. Surgical resection of the styloid process provided definitive relief of the patient's eye, ear and neck pain. Since this intervention, there was no further deterioration of visual field defect in the left eye.
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Ossificação Heterotópica , Doenças Vasculares , Feminino , Humanos , Pessoa de Meia-Idade , Cervicalgia/etiologia , Ossificação Heterotópica/diagnóstico , Ossificação Heterotópica/diagnóstico por imagem , Osso Temporal/anormalidades , Osso Temporal/diagnóstico por imagem , Osso Temporal/cirurgiaRESUMO
PRCIS: The PAUL Glaucoma Implant is an effective intraocular pressure (IOP)-lowering device with an acceptable safety profile. Its design as a nonvalved device with a small tube diameter using a vicryl ligation suture around the tube that is posteriorly reabsorbed instead of an ab luminal stent makes it an option in cases selected for glaucoma drainage device implantation. PURPOSE: The aim was to determine the 1-year efficacy and safety of PAUL Glaucoma Implant using a uniform, standardized surgical procedure. MATERIALS AND METHODS: Retrospective, cohort study. Patient charts were screened between December 2018 and January 2020, with inclusion requiring a minimum follow-up of 12 months. Primary outcome was IOP-lowering at 12 months, with surgical success defined as ≤18 mm Hg and at least 30% reduction and higher than 5 mm Hg. Absolute success was achieved if no IOP-lowering medication was needed and qualified success if otherwise. Safety outcomes were also analyzed. A standardized protocol was followed in all cases, which included mitomycin C application and 1 vicryl ligation of the tube. RESULTS: A total of 24 eyes from 21 patients fulfilled inclusion criteria. Median patient age at time of surgery was 42 years (range: 1 to 76 y). IOP decreased from 31.4 (10.0) mm Hg in preoperative period to 12.5 (4.3) mm Hg in the last follow-up (P<0.001). Qualified success criteria were fulfilled by 75% of cases, while absolute success was 33%. The mean number of IOP-lowering drugs used before surgery was 3.0 and 0.9 at the 12-month visit (P<0.001). No postoperative hypotony requiring intervention was recorded. CONCLUSIONS: PAUL Glaucoma Implant appears to be a safe and effective glaucoma drainage implant for the treatment of moderate and advanced glaucoma.
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Implantes para Drenagem de Glaucoma , Glaucoma , Estudos de Coortes , Seguimentos , Glaucoma/cirurgia , Humanos , Pressão Intraocular , Implantação de Prótese , Estudos Retrospectivos , Resultado do TratamentoAssuntos
COVID-19 , Tomografia de Coerência Óptica , Angiofluoresceinografia , Humanos , Projetos Piloto , SARS-CoV-2RESUMO
BACKGROUND: Microvascular rarefaction due to hypertension has been linked to disease severity and end-organ complications. Optical coherence tomography angiography (OCTA) has been explored as a potential tool to evaluate the retinal microvascular network in hypertensive patients. METHODS: PubMed, Scopus, Web of Science, and Cochrane were systematically searched to 10th of September of 2021, along with a manual search. Studies that used OCTA as a primary diagnostic method to evaluate the macular microvasculature of hypertensive patients were included. Meta-analysis was performed using a random-effects model. Primary outcomes were macular vessel density (VD) and foveal avascular zone (FAZ) at the superficial and deep capillary plexus. RESULTS: Of 947 screened articles, 9 were found eligible for qualitative and quantitative analysis. VD in hypertensive patients was reduced when compared with controls in the fovea (0.93, 95% confidence interval [CI] 0.87-0.99, P = 0.023) and the parafovea (0.95, 95% CI 0.93-0.97, P < 0.001) of the superficial capillary plexus. FAZ was larger in the deep plexus of hypertensive patients (1.10, 95% CI 1.03-1.18, P = 0.003). VD reduction was found in patients with worsening blood pressure control in 3 studies and prolonged disease in 2 studies. CONCLUSIONS: Microvascular rarefaction of the macula is found in hypertensive patients with a reduction of foveal and parafoveal VD and an increase of FAZ area. Disease duration and severity might be related to a microvascular rarefaction. OCTA could offer a novel tool for the assessment and follow-up of hypertensive patients.
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Hipertensão , Macula Lutea , Angiofluoresceinografia/métodos , Humanos , Hipertensão/complicações , Hipertensão/diagnóstico por imagem , Macula Lutea/irrigação sanguínea , Macula Lutea/diagnóstico por imagem , Vasos Retinianos/diagnóstico por imagem , Tomografia de Coerência Óptica/métodosRESUMO
PURPOSE: To compare outcomes of primary trabeculectomy using either mitomycin C (MMC) alone versus MMC augmented with intracamerular bevacizumab in patients with open-angle glaucoma. METHODS: Retrospective, cohort, two-centre, comparative study. Patients' data were screened between October 2015 and March 2019, with inclusion requiring a minimum follow-up of 24 months. Primary outcome was intraocular pressure (IOP) lowering at 24 months, with surgical success defined with different maximum IOP targets (≤18, ≤16 and ≤14 mm Hg) and at least 30% reduction and higher than 5 mm Hg. Absolute success was achieved if no IOP-lowering medication was needed and a qualified success if otherwise. Safety outcomes were analysed. RESULTS: A total of 110 eyes underwent trabeculectomy with MMC, 51 of these combined with intracamerular bevacizumab. Both strategies were effective in terms of IOP lowering (baseline vs 2 years postoperatively: 24.4 (8.0) mm Hg vs 12.1 (5.3) mm Hg in the MMC group; 25.1 (8.7) vs 10.8 (3.8) mm Hg in the MMC+bevacizumab group; p<0.001 in both comparisons). The MMC+bevacizumab group had a significant difference towards higher efficacy on absolute success rates at all targets (IOP≤14 or ≤16 or ≤18 mm Hg; p=0.010, p=0.039 and p=0.007, respectively). The large majority (93%) of the MMC+bevacizumab group was drop-free at 24 months, and 41% had IOP below 10 mm Hg. Complication rates were low and similar between groups, with no systemic adverse events. CONCLUSIONS: Intracamerular bevacizumab in MMC-augmented primary trabeculectomy increases the chances of obtaining low IOP outcomes. This strategy may be useful when planning for surgeries aiming at target pressures in the low teens. TRIAL REGISTRATION NUMBER: ISRCTN93098069.
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Glaucoma de Ângulo Aberto , Trabeculectomia , Adolescente , Inibidores da Angiogênese/uso terapêutico , Bevacizumab/uso terapêutico , Seguimentos , Glaucoma de Ângulo Aberto/tratamento farmacológico , Glaucoma de Ângulo Aberto/cirurgia , Humanos , Pressão Intraocular , Mitomicina/uso terapêutico , Estudos Retrospectivos , Resultado do Tratamento , Fator A de Crescimento do Endotélio VascularRESUMO
BACKGROUND/AIMS: Optical coherence tomography angiography (OCTA) allows the study of vessel density (VD). We intended to perform a systematic review of studies focusing on longitudinal changes in peripapillary and macular VD measurements in glaucoma. METHODS: A search was performed across MEDLINE, Scopus, ISI Web of Science and Google Scholar, using the following query from inception until 20 September 2019: (("optical coherence tomography angiography"[tiab]) OR (optical coherence tomography angiography[MeSH]) OR ("OCTA"[tiab]) OR ("OCT-A"[tiab]) OR ("angio-OCT"[tiab]) OR ("OCT- angiography"[tiab]) OR ("OCT-angio"[tiab]) OR ("OCT-angiographie"[tiab])) AND (glaucom*[tiab] OR glaucoma[MeSH]). Prospective studies that quantitatively assessed the longitudinal changes in VD in glaucoma with at least 3 months of follow-up were included. RESULTS: Ten out of 4516 studies were included. The rate of VD change in glaucoma varied from 0.036/year to 1.08/year and 1.3% to 3.2% per year, with significantly different rates between glaucoma and healthy controls. Five studies assessed VD change after glaucoma surgery, obtaining variable results, ranging from a temporary VD decrease to increase after 3 months. Meta-analysis was not possible due to a wide variation in methods, measurements and region of VD. CONCLUSION: OCTA is a non-invasive technology, which shows promise in glaucoma. Measures should be taken to increase the quality and standardise the methodology of VD measures in OCTA longitudinal studies, for future meta-analyses.
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Glaucoma de Ângulo Aberto , Glaucoma , Disco Óptico , Angiofluoresceinografia/métodos , Glaucoma/diagnóstico , Glaucoma de Ângulo Aberto/diagnóstico , Humanos , Pressão Intraocular , Disco Óptico/irrigação sanguínea , Estudos Prospectivos , Vasos Retinianos/diagnóstico por imagem , Tomografia de Coerência Óptica/métodosRESUMO
OBJECTIVE: To develop and test a deep learning (DL) model for semantic segmentation of anatomical layers of the anterior chamber angle (ACA) in digital gonio-photographs. METHODS AND ANALYSIS: We used a pilot dataset of 274 ACA sector images, annotated by expert ophthalmologists to delineate five anatomical layers: iris root, ciliary body band, scleral spur, trabecular meshwork and cornea. Narrow depth-of-field and peripheral vignetting prevented clinicians from annotating part of each image with sufficient confidence, introducing a degree of subjectivity and features correlation in the ground truth. To overcome these limitations, we present a DL model, designed and trained to perform two tasks simultaneously: (1) maximise the segmentation accuracy within the annotated region of each frame and (2) identify a region of interest (ROI) based on local image informativeness. Moreover, our calibrated model provides results interpretability returning pixel-wise classification uncertainty through Monte Carlo dropout. RESULTS: The model was trained and validated in a 5-fold cross-validation experiment on ~90% of available data, achieving ~91% average segmentation accuracy within the annotated part of each ground truth image of the hold-out test set. An appropriate ROI was successfully identified in all test frames. The uncertainty estimation module located correctly inaccuracies and errors of segmentation outputs. CONCLUSION: The proposed model improves the only previously published work on gonio-photographs segmentation and may be a valid support for the automatic processing of these images to evaluate local tissue morphology. Uncertainty estimation is expected to facilitate acceptance of this system in clinical settings.
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PRCIS: Automated gonioscopy is a recent method of recording angle pictures. Our study shows that agreement between observers is moderate in most categories used in clinical practice, underlying its clinical usefulness but also room for improvement. INTRODUCTION: Iridocorneal angle (ICA) imaging methods have been recently developed to record gonioscopic images. The purpose of this study was to perform an interrater agreement analysis of ICA photographs. METHODS: Multicentric cross-sectional observational study. Consecutive patients in 2 ophthalmology departments underwent automated gonioscopy. One picture per quadrant from each eye was selected for randomization. Pictures were graded and analyzed by 4 masked glaucoma specialists regarding angle opening, width, Shaffer and Spaeth gradings and other findings. Fleiss' κ statistics was performed to assess interrater agreement. RESULTS: A total of 50 patients were recruited, with the sample containing a variety of diagnosis including pseudoexfoliation (22%), angle-closure suspect (12%), and pigmentary glaucoma (4%). The sample included phakic (68%) and pseudophakic patients, as well as cases with gonio-implanted surgical devices (10%). There was moderate agreement on angle opening, angle width, presence of angle vessels, and peripheral anterior synechiae (κ=0.435, 0.511, 0.558, 0.488, respectively; P<0.01). Fair agreement was observed regarding Shaffer grading, site of iris root insertion, angle pigmentation features, and the presence of iris processes. Expectedly from a 2-dimensional picture, the configuration of peripheral iris was found to have a poor agreement. Subset analysis on higher quality pictures seemed to improve agreement on pigment but did not further improve on the overall good agreement on angle opening status. CONCLUSIONS: Our study shows that automated gonioscopy provides moderate agreement on most clinically relevant features. Binary characteristics such as angle opening or PAS seem to be more robust than more complex angle classification parameters.