Long-Term Structural Changes Observed on Gonioscopy and Anterior-Segment OCT Following Gonioscopy-Assisted Transluminal Trabeculotomy.

Objectives: To evaluate the long-term structural changes of the anterior chamber (AC) angle following gonioscopy-assisted transluminal trabeculotomy (GATT). Methods: The AC angle of 10 eyes that underwent GATT at least 6 years previously was assessed for structural changes. A detailed gonioscopy was performed to determine the state of the cleft and the position of the trabecular flap. An anterior segment optical coherence tomography (AS-OCT) examination was performed on the corresponding areas on gonioscopy. Results: The typical finding of the angle following GATT was an open cleft with a visible trabecular flap. However, the gonioscopy of our patients revealed three different cleft appearances: open, closed, and segmentally open cleft. In the long-term, the trabecular flap re-approximated the incision site in some areas resulting in the appearance of a closed cleft on gonioscopy. On AS-OCT the cleft was identified when the lumen of Schlemm's canal was connected to the AC, while the position of the flap differed. The cleft was observed as open in median 4.0 (IQR: 2.8-6.0) clock hours. The cleft was found open mostly in the superior quadrants of the angle (nine eyes). No correlation was found between the extent of open cleft and the percentage of IOP reduction. Conclusion: AS-OCT, when used in conjunction with gonioscopy, was found helpful to evaluate the structural changes following GATT. As observed in the study, the cleft tended to close in some areas. It was found preserved mostly in the superior half of the angle in the long term.

Efficacy of gonioscopy-assisted transluminal trabeculotomy and trabeculectomy in patients with primary open-angle glaucoma and pseudoexfoliative glaucoma: A single surgeon's experience.

PURPOSE: To compare the intraocular pressure (IOP)-lowering efficiency of gonioscopy-assisted transluminal trabeculotomy (GATT) and trabeculectomy (TRAB) with mitomycin C in patients with primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG). METHODS: In this retrospective comparative study, consecutive patients with POAG or PEXG who underwent GATT or TRAB by a single surgeon and with a follow-up period of at least 1 year were included. Surgical success rates, change in best-corrected visual acuity, IOP, the need for antiglaucoma medication, surgical complications, and the need for additional glaucoma surgery were compared. Surgical success was defined as an IOP reduction of ≥30% or an IOP of ≤18 mmHg. Complete success was defined as without medication. Qualified success was defined as with or without topical medication. RESULTS: The mean baseline IOP was 27.4 ± 8.3 and 24.6 ± 7.6 mmHg (P = 0.13) with the mean number of medications being 3.7 ± 1.0 and 3.7 ± 1.1 (P = 0.98) in TRAB and GATT, respectively. At 12 months, the mean IOP was 15.3 ± 3.5 and 12.5 ± 4.6 mmHg (P = 0.24) with the mean number of medications being 0.9 ± 1.2 and 0.8 ± 1.4 (P = 0.76) after GATT and TRAB, respectively. IOP was lowered from baseline by 52.7% ± 17.5% after TRAB and 45.7% ±18.6% after GATT (P = 0.12). There was no decrease in best-corrected visual acuity in either group. The qualified surgical success rate was 94.4% in the GATT group and 94.9% in the TRAB group (P = 0.75). Percentage of complete success was 64.1% and 52.8% (P = 0.22) after TRAB and GATT, respectively. CONCLUSION: In patients with POAG and PEXG, GATT was as effective and safe as TRAB in lowering IOP and reducing the number of antiglaucomatous drugs.

Evaluation of pericardium patch graft thickness in patients with Ahmed glaucoma valve implantation: an anterior segment OCT study.

PURPOSE: To evaluate the changes in thickness of tissues, specifically the pericardium patch graft (PPG) covering the silicone tube in Ahmed Glaucoma Valve (AGV) surgery. STUDY DESIGN: Prospective observational study. METHODS: This study included cases with refractory glaucoma that underwent AGV implantation with PPG coverage. Conjunctival epithelium, stroma and PPG thickness covering the tube were measured using anterior segment optical coherence tomography (AS-OCT) at 1, 6 and 12 months. Additionally, the same measurements were taken 1500 µm away from the tube as a control for the central measurements. RESULTS: Twenty-seven eyes of 27 patients were evaluated in the study. Although PPG thickness decreased significantly in both regions, the amount of reduction was more pronounced centrally. Centrally, the reduction rate was 21.2% and 34.8% during the 1-6 months period and 6-12 months period, while peripherally it was 3.5% and 5.1%, respectively. No change was observed in the thickness of the epithelium during the follow-up period. There was a significant thinning of the stroma in the central and peripheral regions during the 1-6 months period (30.5% and 17%, respectively). No cases of exposure were observed during the follow-up period. CONCLUSION: Although the most evident thinning of the layers covering the tube was observed in the early postoperative period, PPG showed a stable decrease even in the late period. The progressive reduction in the PPG thickness observed also in the peripheral region indicates that factors beyond mechanical forces contribute to this degenerative process. AS-OCT could be a valuable non-invasive tool in clarifying this process.

Long-Term Results of Transscleral Diode Laser Cyclophotocoagulation in Glaucoma: A Real-Life Study.

PRCIS: Transscleral diode laser cyclophotocoagulation (TDLC) is effective and safe in a large population and different types of glaucoma but is least effective in the neovascular glaucoma (NVG) group. OBJECTIVE: We aimed to investigate the clinical outcomes of TDLC in a large cohort of patients with different types of refractory glaucoma. PATIENTS AND METHODS: Using patient charts, we retrospectively analyzed the success and complications of TDLC performed on eyes categorized into 6 groups: primary glaucoma (116 eyes), trauma (41 eyes), NVG (84 eyes), post-vitreoretinal surgery (post-VRS, 79 eyes), penetrating keratoplasty (47 eyes), and miscellaneous (40 eyes). Failure was defined as intraocular pressure (IOP) >22 mm Hg or <5 mm Hg, the need for further glaucoma surgery, and the loss of light perception during follow-up. RESULTS: Overall, the mean follow-up time was 33.4 ± 17.4 months, the mean total energy delivered was 109.2 ± 56.5 J, and the mean IOP reduction rate was 41.8%. Total energy delivered and IOP reduction rates were similar between the groups (all P > 0.05). The probability of success at 36 months was 71.5%, 70.7%, 55.9%, 77.2%, 72.3%, and 72.5% in primary glaucoma, trauma, NVG, post-VRS, penetrating keratoplasty, and miscellaneous groups, respectively. The NVG group showed a significantly lower success rate ( P = 0.009) than the other groups. Significant complications consisted of phthisis bulbi in 1 eye (0.2%) in the NVG group and chronic hypotony in 7 eyes (1.7%) in the NVG (3 eyes), trauma (2 eyes), post-VRS (1 eye), and primary glaucoma (1 eye) groups. CONCLUSIONS: Although TDLC was found to be a safe, effective method in the long term, it was least effective in eyes with NVG.

The role of anterior segment optical coherence tomography in the evaluation of the pterygium.

BACKGROUND: To evaluate the ability of anterior segment optical coherence tomography (AS-OCT) to visualize the anatomic features of the pterygium and its invasion of the corneal layers. METHODS: Seventy-five eyes of 54 patients diagnosed with pterygium were included. All subjects underwent complete ophthalmologic examinations, including AS-OCT. The limbus-apex distance, vertical height at the limbus, invasion of the Bowman's and stromal layers, and other morphologic structures of the pterygium tissue were analyzed. RESULTS: The mean age of the patients was 49.67 ± 16.49 (20-85) years. The mean apex-limbus distance was 2548.37 ± 1026.32 (933-4597) µm, and the mean vertical height at the limbus was 4843.89 ± 1374.10 (1740-7784) µm. A space was observed beneath the pterygium tissue in 44 (58.67%) eyes. The mean width and height of this space were 1756.33 ± 560.22 (1009-3095) µm and 231.70 ± 85.88 (109-465) µm, respectively. Invasion of the Bowman's layer was apparent in 74 (98.67%) eyes, and invasion of the stromal layer was detected in 33 (44%) eyes. A hyperreflective layer was observed beneath the epithelial layer at the edge of the pterygium apex in 31 (41.33%) eyes. In 24 (92.31%) of the 26 advanced pterygium cases and 20 (40.82%) of the 49 early pterygium cases, a subpterygium space was found beneath the lesion (p = 0.0001). CONCLUSION: AS-OCT enables measurement of the actual size and thickness of pterygia, assessment of invasion of the Bowman's and stromal layers of the cornea, and evaluation of the pterygium structure. Over half of the eyes exhibited space beneath the pterygium.

Glaucoma Detection in Myopic Eyes: Structural and Vascular Assessment by Optic Coherence Tomography Methods.

PRCIS: Retinal nerve fiber layer (RNFL) thickness is helpful in the diagnosis of glaucoma in myopic eyes but neuroretinal rim (NRR) thickness is the most valuable measure. However, changes in optical coherence tomography angiography (OCT-A) parameters are insufficient for the diagnosis of mild to moderate glaucoma in myopia. PURPOSE: To detect how a multimodal evaluation, which includes RNFL, NRR thickness, and optic nerve head (ONH) OCT-A, affects glaucoma diagnosis in myopic patients. MATERIALS AND METHODS: Parameters of healthy myopic and myopic glaucoma eyes with an axial length of ≥24 mm were compared. The ONH structural features and peripapillary RNFL thickness were determined with Cirrus 5000 HD-OCT (Cirrus HD-OCT; Carl Zeiss Meditec, Dublin, CA). The Cirrus 5000 HD-OCT with AngioPlex was utilized to perform OCT-A imaging. The sensitivity and specificity levels were calculated by the best cut-off values with area under curve (AUC). RESULTS: One hundred healthy myopic and 54 myopic glaucoma eyes were evaluated. In all areas, myopic glaucoma patients exhibited lower RNFL and NRR thickness than healthy myopic individuals ( P <0.05), with the exception of nasal quadrant RNFL thickness ( P =0.152). The mean entire and 4 quadrants of global radial peripapillary capillary (RPC)-perfusion and global RPC flux index (FI) were significantly lower in the group of myopic glaucoma patients except for the nasal quadrant mean RPC perfusion ( P =0.224). The average RNFL and NRR thickness had a significant difference in AUC for the diagnosis of glaucoma in myopic individuals ( P =0.001, for each). The average NRR showed excellent diagnostic performance, whereas the average RNFL showed good diagnostic performance. Average RPC perfusion and average RPC FI showed poor diagnostic ability. The average NRR AUC was more significant than average RPC perfusion and average RPC FI AUC ( P <0.001). CONCLUSIONS: Although RNFL thickness was helpful to diagnose glaucoma in patients with myopia, the diagnostic power of NRR thickness performed best. OCT-A parameters showed poor diagnostic accuracy for glaucoma and the observed perfusion decrease in myopic glaucoma eyes was not sufficiently discriminative compared with NRR and RNFL thickness measurements.

Fellow-eye asymmetry on optical coherence tomography angiography and thickness parameters in unilateral pseudoexfoliation syndrome / Assimetria do olho oposto na angiografia por tomografia de coerência óptica e parâmetros de espessura na síndrome de pseudoexfoliação unilateral

ABSTRACT Purpose: To investigate inter-eye retinal vessel density and thickness asymmetry in unilateral pseudoexfoliation syndrome and understand its use for the early detection of glaucoma. Methods: Thirty patients with unilateral pseudoexfoliation syndrome were enrolled in our study. Optical coherence tomography angiography macular scans were used measure the retinal vessel density, and optical coherence tomography scans were used to assess the thickness parameters of the peripapillary retinal nerve fiber layer and the macular ganglion cell complex. Inter-eye asymmetry was determined by taking the absolute value of the difference in the vessel density and thickness parameters between the pseudoexfoliation syndrome eye and fellow eye. Results: The mean patient age was 64.20 ± 7.05 y in the study group. Inter-eye asymmetry in the peripapillary retinal nerve fiber layer thickness and macular ganglion cell complex measurements were significant in the study group (p=0.03 and p=0.001, respectively). The vessel density of the macular superficial inner region was significantly lower in eyes with pseudoexfoliation syndrome than in fellow eyes (p=0.035). However, there was no inter-eye asymmetry in the central and full region macular superficial vessel density of eyes with pseudoexfoliation syndrome and fellow eyes (p>0.05). Conclusion: Retinal vessel density can be evaluated using optical coherence tomography angiography measurements. There was inter-eye asymmetry in the inner region macular superficial vessel density, peripapillary retinal nerve fiber layer, and macular ganglion cell complex thickness of the unilateral pseudoexfoliation syndrome eyes and fellow eyes. Further studies on a larger number of subjects might provide more clarity regarding the relationship between the inter-eye asymmetry of the retinal vessel density and thickness parameters with early detection of glaucomatous damage.

RESUMO Objetivo: Investigar a densidade dos vasos interoculares da retina e assimetria na espessura na síndrome de pseudoexfoliação unilateral e o seu uso para a detecção precoce de glaucoma. Métodos: Trinta pacientes com síndrome de pseudoexfoliação unilateral foram incluídos no estudo. As varreduras maculares de angiografia por tomografia de coerência óptica mediram a densidade dos vasos da retina, e as varreduras por tomografia de coerência óptica obtiveram parâmetros de espessura da camada de fibras nervosas da retina peripapilar e do complexo macular de célula ganglionar. A assimetria interocular foi determinada tomando o valor absoluto da diferença entre o olho da síndrome de pseudoexfoliação e o olho oposto nos parâmetros de densidade e espessura dos vasos. Resultados: A média de idade foi 64,20 ± 7,05 anos no grupo de estudo. A assimetria interocular na espessura da camada de fibra nervosa da retina peripapilar e as medidas do complexo macular de célula ganglionar foram estatisticamente significativas no grupo de estudo (p=0,03 e p=0,001, respectivamente). Para os olhos com síndrome de pseudoexfoliação, a densidade do vaso da região macular superficial interna foi significativamente menor do que em olhos opostos (p=0,035). No entanto, não houve assimetria interocular estatisticamente significativa na densidade macular dos vasos superficiais da região central e completa entre os olhos da síndrome de pseudoexfoliação e os olhos opostos (p>0,05). Conclusões: A densidade dos vasos da retina pode ser avaliada por medidas de angiografia por tomografia de coerência óptica. Houve assimetria interocular na densidade macular do vaso superficial da região interna, camada de fibra nervosa da retina peripapilar e espessura do complexo macular de célula ganglionar entre olhos com síndrome de pseudoexfoliação unilateral e olhos opostos. Novos estudos com um número maior de indivíduos podem fornecer a relação entre a assimetria interocular da densidade do vaso da retina e os parâmetros de espessura com detecção precoce de dano glaucomatoso.

Effects of Topical Antiglaucomatous Medications on Conjunctival Thickness: A Prospective Anterior Segment Optical Coherence Tomography Study.

Purpose: Our aim was to evaluate the effects of topical antiglaucomatous medications on conjunctival thickness using anterior segment optical coherence tomography (AS-OCT). Methods: Thirty eyes of 30 patients with primary open angle glaucoma, who had never used any antiglaucomatous medications, enrolled in this prospective study. Followed by a full ophthalmologic examination, the conjunctival thickness was measured before treatment and at 1, 3, and 6-month post-treatment by AS-OCT. Measurements were taken from the superior bulbar conjunctiva, 3-4 mm from the limbus. Results: The mean age of patients was 67.7 ± 8.6; fourteen cases (46.7%) were given latanoprost, 2 cases (6.7%) brinzolamide+timolol, 2 cases (6.7%) betaxolol, 4 cases (13.3%) travoprost, and 8 cases (26.7%) brimonidine. The mean baseline conjunctival thickness was 222.9 ± 38 µm, while the mean conjunctival thickness was 212.8 ± 36.0 µm in the first month, 198.2 ± 35.8 µm in the third month, and 187.5 ± 40.2 µm in the sixth month. Decrease in conjunctival thickness at each examination was statistically significantly compared to baseline. (P < 0.05) Decrease in conjunctival thickness in Latanoprost subgroup was statistically significant, whereas the decreases in other active ingredients were not. Conclusion: Topical antiglaucomatous medications especially prostaglandin analogs may affect conjunctival thickness even during the first few months. This thinning effect may be crucial for the conjunctiva, as the basis of the possible filtration surgery.

Surgical management of glaucoma following different keratoplasty techniques.

PURPOSE: To investigate the results of surgical management of glaucoma following different keratoplasty techniques. METHODS: Medical records of 628 cases who underwent keratoplasty were reviewed. One hundred and eighty-eight patients (29.9%) who developed post-keratoplasty glaucoma were evaluated. Patients who could not be controlled with maximal medical treatment and underwent glaucoma surgery were included in this study. Trabeculectomy, Ahmed glaucoma valve (AGV) implantation or diode laser cyclophotocoagulation (DLC) were applied. RESULTS: Glaucoma surgery was performed in 55 (29.3%) patients who had uncontrolled post-keratoplasty glaucoma. In penetrating keratoplasty group (n = 42), DLC was applied to 30 (71.4%) eyes, AGV to 11 (26.2%) eyes, and trabeculectomy in 1 (2.4%) eye. In Descemet's membrane endothelial keratoplasty group (n = 8), DLC was applied to 4 (50%) eyes, trabeculectomy for 3 (37.5%) eyes and AGV for 1 (12.5%) eye. In deep anterior lamellar keratoplasty group (n = 5), DLC was applied to 2 (40%) eyes, trabeculectomy to 2 (40%) eyes and AGV to 1 (20%) eye. While a statistically significant decrease was found in intraocular pressure (IOP) and anti-glaucomatous medication after surgery (p < 0.05 for each), no significant difference was found in best corrected visual acuity (BCVA). During follow-up, DLC was applied as re-glaucoma surgery in 19 (34.5%) cases. A significant reduction in IOP together with number of anti-glaucomatous medications was found with re-operation; however, a significant decrease in BCVA was noted (p < 0.05 for each). CONCLUSION: Glaucoma surgeries after keratoplasty are effective in decreasing IOP and the number of anti-glaucomatous medication. While BCVA doesn't change after the first glaucoma surgery, after re-operation significant decrease may occur.

Parallel Suture: A Simple Approach to Enable Early Laser Suture Lysis and Prevent Hypotony after Trabeculectomy.

PURPOSE: To define a modified flap suture approach and evaluate its effectiveness. METHODS: Clinical data of patients undergoing trabeculectomy with modified parallel suture technique (Group 1, N = 38 eyes) were compared to patients operated with classical flap suture technique (Group 2, N = 42 eyes). In the modified technique, two parallel sutures (one tight and one loose) are placed simultaneously in one of the flap corners with the aim of obtaining a safety stitch when the tight one needs to be cut. Data from preoperative and postoperative visits at day 1, week 1, months 1, 3, 6 and year 1 were recorded from patient charts and compared between the groups. RESULTS: In Group 1, seven eyes underwent laser suture lysis (LSL) between postoperative days 2 to 8 and in Group 2 two eyes at days 29 and 37. No complication related to LSL was observed. Rate of postoperative hypotony decreased with the parallel suture approach (P= .002). Number of eyes experiencing any of the complications related to hypotony was lower in Group 1 (P= .004). No significant difference was noted in the mean IOP between the groups (P> .05 for all). CONCLUSION: The modified approach with parallel suture technique was found to be effective and safe. By enabling early LSL, it provided more precise IOP modulation in the early postoperative period. Thus, in our series, the rate of hypotony and hypotony-related complications decreased, while the success of the surgery was preserved.

Anterior chamber laser flare photometry after diode laser cyclophotocoagulation.

BACKGROUND: The aim of this study was to evaluate changes in intraocular inflammation according to energy delivered per eye during transscleral diode laser cyclophotocoagulation (TDLC) in refractory glaucoma using laser flare (LF) photometry and to investigate the relationship between the change in anterior chamber flare values ​​and the success of TDLC. METHODS: Patients who underwent TDLC for refractory glaucoma and had LF photometry data were analyzed retrospectively. We recorded the best-corrected visual acuity, intraocular pressure (IOP) with Goldmann applanation tonometer, number of anti-glaucoma medications, LF photometry values (ph/ms) on pre-and postoperative days 1, 10 and 30. RESULTS: The mean laser power applied during TDLC procedure was 2.45±0.35 W. The mean laser duration was 2.09±0.28 s. The mean total energy applied per eye was 114.69±16.13 J, the mean number of pulses was 22.43±4.3. While the mean LF value was 49.71±11.99 ph/ms preoperatively, it was 63.94±12.41 ph/ms at the postoperative 30th day. Possible predictors of success of TDLC were investigated using linear regression analysis (R adjusted 0.454 p = 0.001). The IOP decrease at postoperative 30th day was significantly related to the difference between the postoperative 1st day and the preoperative LF (p = 0.025, B/95% CI -0.358/-0.107- -0.008), and total cyclodiode energy delivered per eye (joules) (p = 0.016, B/95% CI -0.396/-0.287 to -0.031). CONCLUSIONS: Anterior chamber flare values increases after TDLC, though it does not regress to the preoperative level on the postoperative 30th day. Total cyclodiode energy delivered per eye and the difference between the postoperative 1st day and the preoperative LF can be used to predict TDLC response.

Fellow-eye asymmetry on optical coherence tomography angiography and thickness parameters in unilateral pseudoexfoliation syndrome.

PURPOSE: To investigate inter-eye retinal vessel density and thickness asymmetry in unilateral pseudoexfoliation syndrome and understand its use for the early detection of glaucoma. METHODS: Thirty patients with unilateral pseudoexfoliation syndrome were enrolled in our study. Optical coherence tomography angiography macular scans were used measure the retinal vessel density, and optical coherence tomography scans were used to assess the thickness parameters of the peripapillary retinal nerve fiber layer and the macular ganglion cell complex. Inter-eye asymmetry was determined by taking the absolute value of the difference in the vessel density and thickness parameters between the pseudoexfoliation syndrome eye and fellow eye. RESULTS: The mean patient age was 64.20 ± 7.05 y in the study group. Inter-eye asymmetry in the peripapillary retinal nerve fiber layer thickness and macular ganglion cell complex measurements were significant in the study group (p=0.03 and p=0.001, respectively). The vessel density of the macular superficial inner region was significantly lower in eyes with pseudoexfoliation syndrome than in fellow eyes (p=0.035). However, there was no inter-eye asymmetry in the central and full region macular superficial vessel density of eyes with pseudoexfoliation syndrome and fellow eyes (p>0.05). CONCLUSION: Retinal vessel density can be evaluated using optical coherence tomography angiography measurements. There was inter-eye asymmetry in the inner region macular superficial vessel density, peripapillary retinal nerve fiber layer, and macular ganglion cell complex thickness of the unilateral pseudoexfoliation syndrome eyes and fellow eyes. Further studies on a larger number of subjects might provide more clarity regarding the relationship between the inter-eye asymmetry of the retinal vessel density and thickness parameters with early detection of glaucomatous damage.

Does Ophthalmology Need Philosophy?

Although ophthalmology has made significant progress and awareness about eye care and the accessibility of health technology has increased, there are still aspects that might be improved. One of the ways to achieve improvement is philosophical investigation of some reasoning and behavior styles in ophthalmology. Philosophy means love of wisdom, and the philosophical approach can contribute to increasing the wisdom of ophthalmologists. Logical fallacies currently affecting the decisions of ophthalmologists can be reduced. "ontology" can contribute to a better understanding of "the nature of reality". A detailed inquiry about the basic concepts concerning ophthalmology may support better reasoning styles. Reflecting on epistemological questions such as "What is true knowledge?", justifying information, and having a skeptical attitude may help to make decisions with more accurate information. The philosophy of science is concerned with the detailed investigation, questioning, and understanding of ophthalmologists' scientific activities and may form the missing link between ophthalmology and philosophy. Moreover, the claim that philosophy's contribution to science is of no interest to scientists warrants consideration. The philosophers of science Karl Popper and Thomas Kuhn have made significant contributions to the perception of science that are still valid today. Karl Popper proposed that a demarcation between science and pseudo-science might be made through the concept of "falsification". According to this concept, a statement is scientific if it can be tested and falsified using valid methods. Thomas Kuhn stated that major scientific changes (i.e., revolutions) occur through paradigm shifts. Although the areas of moral philosophy/ethics/bioethics have generated useful ideas and practices for the improvement of the art of medicine, bioethics in particular deserves to be questioned philosophically by physicians living in real life. Ophthalmologists can develop more beneficial and realistic ophthalmology education, research, diagnosis, treatment, and rehabilitation practices by utilizing the basic methods of philosophy.

Evaluation of Successful and Failed Filtering Blebs after Trabeculectomy Using Anterior Segment Optical Coherence Tomography.

PURPOSE: To evaluate filtering bleb characteristics using anterior segment optical coherence tomography (AS-OCT) and analyze correlations between these parameters and intraocular pressure (IOP). METHODS: The study included 54 eyes of 43 patients who underwent trabeculectomy with mitomycin-C. The patients were divided into two groups based on mean postoperative IOP. The criterion for surgical success was mean unmedicated postoperative IOP ≤18 mmHg. Patients with IOP values >18 mmHg were prescribed anti-glaucoma drops and classified as a surgical failure. All patients underwent AS-OCT, and maximum bleb height, maximum bleb wall thickness, and maximum fluid-filled cavity height were measured. AS-OCT bleb parameters were compared between the successful and failed groups. RESULTS: Of the 54 eyes, 37 (68.5%) were in the successful group, and 17 (31.5%) were in the failed group. Mean preoperative IOP values in the successful and failed groups were 26.9 ± 6.5 mmHg and 22.9 ± 4.9 mmHg, preoperatively, versus postoperative values of 13.3 ± 2.1 mmHg and 22.8 ± 2.8 mmHg, respectively. Mean postoperative follow-up time was 17.4 ± 9.5 months in the successful group and 19.1 ± 10.1 months in the failed group (P = 0.22). In the successful and failed groups, mean bleb height was 1473.7 ± 150.6 µm and 1165.4 ± 217 µm (P < 0.001), bleb wall thickness was 670.5 ± 119.9 µm and 538.8 ± 144.3 µm (P = 0.001), and fluid-filled cavity height was 736.5 ± 196.8 µm versus 532.5 ± 226.2 µm (P = 0.001), respectively. CONCLUSIONS: The results of this study showed that higher AS-OCT values for bleb height, wall thickness, and fluid-filled cavity height were associated with greater functional success. These parameters may be helpful in determining bleb functionality.

Non-intraocular pressure-related revision surgeries after Ahmed glaucoma valve (AGV) implantation in refractory glaucoma.

PURPOSE: Ahmed glaucoma valve (AGV) is an effective treatment method for refractory glaucoma (RG), however, additional surgical interventions may be required over the course of follow-up due to complications. Our aim is to investigate the causes, types, and outcomes of revisional surgical interventions apart from revisions aiming IOP control, following AGV implantation in patients with RG. METHODS: The pre- and postoperative month 1-3-6-12 and last visit examination findings of the patients who underwent various surgical revisions of AGV between January 2015 and April 2018 in our clinic were recorded, as well as the interval between AGV implantation-revision surgery and the presence of any other complications necessitating additional surgery. The success criteria were defined on the basis of need for additional procedures. RESULTS: Twenty-six eyes of 24 patients were included. The follow-up time and the interval between AGV implantation-surgical revisions were median 12 (6-92) and median 9.7 (1-72) months, respectively. The most common complication requiring revision was tube exposure in 15 (57.7%) followed by tube malposition in 11 (42.3%) eyes. Further interventions were required only in one eye with recurrent exposure. CONCLUSION: AGV implantation has early and late tube-related complications necessitating revisional surgical interventions; which makes it important to have extended follow-up period for patients with AGV implants. Revisional interventions for AGV implants with tube-related complications are efficient procedures for the majority of patients, but recurrence may occur requiring additional revisions.

Pressure restoration and visual recovery time in hypotony after trabeculectomy.

OBJECTIVES: To asses the course of intraocular pressure (IOP) restoration and visual acuity (VA) recovery in eyes with hypotony after trabeculectomy. METHODS: Medical charts of patients undergoing trabeculectomy between January 2017 and June 2019 were reviewed. Cases with hypotony (IOP < 5 mmHg) due to over-filtration in the early postoperative period were assessed retrospectively. Primary outcome measures included change in IOP and VA in the postoperative period and percentage of eyes with hypotony on each follow-up. RESULTS: Thirty-five eyes of 31 patients (23 male, 8 female) were included. The mean follow-up was 18.3 ± 6.9 months. The mean IOP was 3.0 ± 3.2, 9.2 ± 6.2, 9.4 ± 5.6, 9.4 ± 4.0, 10.9 ± 3.6 and 10.2 ± 3.3 mmHg at week 1, months 1, 3, 6, 12 and last follow-up, respectively. Out of 35 hypotonic eyes, 8 (22.8%) had prolonged hypotony at month 1, 4 (11.4%) at month 3, 1 (2.9%) at month 6. The decrease in VA continued to be significant at months 1 and 3 (p = 0.015, p = 0.036, respectively) and returned to baseline after the sixth month (p > 0.524). CONCLUSIONS: In eyes with early hypotony after trabeculectomy while low IOP recovers at first month, it takes longer for the visual restoration. The postoperative month 1 appears to be decisive for recovery of hypotony.

Do We Conform with European Glaucoma Society Guidelines in the Medical Treatment of Primary Open-Angle Glaucoma/Ocular Hypertension? Data from a Real-Life Practice.

Purpose: To evaluate the prescribing habits of glaucoma specialists and of general ophthalmologists, and reveal the conformance with European Glaucoma Society (EGS) guidelines in the medical treatment of primary open-angle glaucoma (POAG) and ocular hypertension (OHT). Methods: Patients receiving medical treatment for POAG/OHT in the glaucoma clinic comprised the "naive group." Patients having a diagnosis and a treatment for POAG/OHT initiated in another center before presentation comprised the second group and were named as "treatment initiated elsewhere" (TIEW). All patients were retrospectively evaluated from the patients' charts. The outcome measures included the percentage of eyes treated with monotherapy, the molecule groups preferred, and the change in prescription trends over the years in both groups. Results: Seventy-two subjects were included in the naive group and 135 subjects in TIEW group. The rate of monotherapy was 76% and 36% in both groups, respectively. The molecule number was significantly higher in the TIEW group compared with naive group (1.98 ± 0.89 vs. 1.28 ± 0.56, P < 0.001). Until 2003, beta blockers, and in the 2003-2008 period, prostaglandin analogs (PGAs) were the mostly prescribed drugs in glaucoma clinic. From 2009, the rate of PGAs declined, with PGAs being replaced by combination drugs and alfa-2 agonists. Conclusions: Overtreatment rate was high among patients receiving a diagnosis and a treatment by general ophthalmologists, whereas glaucoma specialists were found to conform with EGS guidelines. A shift toward polypharmacy was observed from 2000 to 2017. The common guidelines to evaluate and treat glaucoma need to be adopted by the general ophthalmologists in their real-life practice.

Comparison of the efficacy of accelerated corneal cross-linking therapy in different pediatric age groups having progressive keratoconus.

PURPOSE: To report a comparison analysis of accelerated corneal cross-linking (A-CXL) treatment for progressive keratoconus patients in different pediatric age groups. STUDY DESIGN: Retrospective, cross-sectional. METHODS: Patients with progressive keratoconus aged ≤ 18 were retrospectively reviewed. Forty-one eyes of 41 patients were included in the study. Patients were divided into two groups according to their age (≤ 14 years and 15-18 years). All patients underwent epithelium-off A-CXL protocol. Acquired data were compared between the two groups. RESULTS: The mean age was 14.3 ± 1.8 (10-18) years. Twenty-five (61%) of the participants were male, and 16 (39%) were female. Twenty (49%) patients were separated into group 1 (≤ 14 years of age), and 21 (51%) were in group 2 (15-18 years). Age at presentation was found to be the only factor in anticipating the progression of keratoconus at the second postoperative year visit (p < 0.001). Progression in keratometric values was detected in seven (35%) of the 20 eyes in group 1, and one (4%) of the 21 patients in group 2 (Z = - 2.44, p = 0.014). CONCLUSION: Even if proper treatment is applied, the progression of keratoconus is likely in patients younger than 14 years of age. Instead of evaluating pediatric patients as a whole, closer follow-up and early treatment may be useful in younger age groups (≤ 14 years).

Comparison of the lamina cribrosa parameters in eyes with exfoliation syndrome, exfoliation glaucoma and healthy subjects.

PURPOSE: This study aimed to compare lamina cribrosa (LC) parameters obtained by spectral-domain optical coherence tomography (SD-OCT) of eyes with exfoliation syndrome (PXS), exfoliation glaucoma (PXG) and healthy subjects. METHODS: In this cross-sectional comparative study, 206 eyes of 206 subjects were included. The Bruch's membrane opening distance (BMOd), the anterior and posterior borders of the LC (LC thickness) and the anterior laminar depth (ALD) were imaged using the enhanced depth imaging (EDI) mode of SD-OCT. RESULTS: There were 96 eyes in the PXG group, 55 eyes in the PXS group, and 55 eyes in the control group. The LC thickness was the thinnest in the PXG group (151.10 ± 51.18 µm), followed in the PXS group (158.76 ± 49.62 µm), and the thickest in the control group (181.00 ± 39.10 µm) (p = 0.002). In PXG cases where LC was observed in the deepest location, the ALD value was highest (423.92 ± 111.75 µm) in the PXG group, followed by the control group (403.08 ± 63.56 µm), and PXS group (357.43 ± 80.87 µm) (p < 0.001). The BMOd values were largest in the PXG group (1542.43 ± 152.99 µm), followed by the control group (1506.52 ± 169.09 µm) and PXS group (1435.74 ± 141.06 µm) (p < 0.001). In the PXG group, peripapillary retinal nerve fiber layer (pRNFL) thickness, BCVA, and cup to disc (C/D) ratio were also statistically different from the other groups (p < 0.001). CONCLUSION: We found thinner LC thickness in PXG and PXS cases relative to the control group. Although its severity is associated with the diagnosis and severity of glaucoma, LC thinning can be encountered as an isolated condition in the presence of exfoliation.

Effect of Insulin Therapy on Ocular Biometric Parameters in Diabetic Patients.

Purpose: To evaluate effects of insulin on ocular parameters in patients with type 2 diabetes mellitus who start insulin therapy. Methods: In this prospective study, ocular biometric parameters were obtained using optical biometer (Lenstar LS900®; Haag-Streit AG) and refraction test (ARK-510A Auto refracto-keratometer; Nidek Co. Ltd, Aichi, Japan) before and at 3 months after initiating insulin therapy. In addition, patients' fasting blood glucose (FBG), glycosylated hemoglobin (HbA1C), and blood lipid levels were measured at the same time points. Pretreatment and post-treatment results were compared. In addition, associations between ocular parameters with initial dose and type of insulin treatment regimen, HbA1C, and FBG levels were evaluated. Results: The patients' mean age was 51.2 ± 12.9 (18-73) years. Post-treatment HbA1C and FBG levels (8.5% ± 2.5% and 188.1 ± 111.2 mg/dL, respectively) were significantly lower than pretreatment values (12% ± 1.4% and 325.3 ± 95.7 mg/dL, respectively; P < 0.001 for both). There was a significant positive correlation between the change in HbA1C and the change in lens thickness (P = 0.03), and a significant negative correlation between the change in FBG and the change in the spherical equivalent refraction (P = 0.045). Insulin dose and treatment regimen type were not significantly correlated with ocular parameters (P > 0.05). Conclusion: HbA1C-lowering glycemic effect of insulin was correlated with a small decrease in lens thickness. Long-term, randomized controlled trials including larger patient numbers are needed to shed light on the long-term effects of insulin use and glycemic control on ocular parameters.