Safety and efficacy of iStent Inject trabecular micro-bypass stents in combination with phacoemulsification for chronic open angle glaucoma associated with cataract.

BACKGROUND: The goal of this study was to assess the efficacy and safety of phacoemulsification combined with iStent Inject® implantation for the treatment of chronic open-angle glaucoma controlled on topical anti-glaucoma medications and associated with cataract. METHODS: This study was a retrospective analysis of patients who underwent phacoemulsification and implantation of an iStent Inject® for chronic open-angle glaucoma associated with cataract. For all patients, pre- and postoperative characteristics, including number of glaucoma medications and intraocular pressure (IOP), were compared using Paired-sample t-tests and Wilcoxon signed-rank tests, respectively. Postoperative visits were scheduled at 7 days and 1, 3, 6, and 12 months after surgery. RESULTS: Forty-nine eyes of 39 patients were included in the study. Mean preoperative IOP at baseline was 16.3±4.3mmHg (range, 10-29mmHg) with a mean of 2.2±1.0mmHg antiglaucoma medications. At 1 month, the mean IOP reduction was 16% (P<0.05) along with an 18.7% reduction in the mean number of medications. At 6 months, the mean IOP was 12.8±2.6, with a mean of 1.1±0.9 antiglaucoma medications. The mean IOP reduction at 6 months was 22% (P<0.05) along with a 49% reduction in the mean number of medications. At 12 months, the mean IOP was 13.8±2.5 with a mean of 1.1±1.2 medications. The mean IOP reduction at 12 months was 15% (P<0.05) along with a 47% reduction in the mean number of medications. No severe device-related side effects were observed. CONCLUSIONS: iStent Inject® implantation combined with phacoemulsification resulted in effective IOP reduction and medication burden in patients with mild to advanced chronic open-angle glaucoma and preoperative IOP well controlled with topical hypotensive medications.

Pragmatic adjunctive usage of netarsudil: A retrospective chart review from a tertiary care center.

Purpose: This retrospective chart review of netarsudil (Rhopressa) characterizes intra-ocular pressure (IOP) reduction, drug tolerance, drug cost, and compliance in a tertiary university Midwest clinic in a variety of glaucoma diagnoses on patients prescribed netarsudil 01/2017 to 5/2020. Methods: Patient demographics, primary diagnosis, indication for medication, prescription date, prescription fill status, duration of use, discontinuation reason, and number of IOP-lowering medications were noted. Confounding medication changes were excluded from IOP analysis. The IOP difference between the first visit after starting netarsudil and the baseline (mean before starting netarsudil on the stable medication regimen) was calculated. Results: A total of 133 patients were prescribed netarsudil (age 69 ± 20 years, 59% females, 79% white, 86% primary glaucoma) as adjunct glaucoma medication (mean medications 3.2 ± 0.9). Indications were lowering IOP (mean baseline IOP 20.0 ± 6 mmHg) and drug regimen simplification. Prescription was not filled by 22/133 subjects because of the cost (68%) and the need for surgery (23%). No demographic factors were associated with prescription fill status. A total of 101 eyes of 76 patients were used for IOP analysis. The mean change in IOP was -0.8 ± 6.4 mmHg, (IOP decrease in 67%, increase or no change in 33% eyes). Netarsudil was discontinued in 52% (50/96) patients; the reasons include surgery for IOP control (42%), allergies (30%), cost (14%), and paradoxical rise in IOP (12%). Conclusion: Netarsudil was used as adjunct third or fourth line medication at a glaucoma practice in Midwestern USA. 17% of prescriptions went unfilled; netarsudil was discontinued in 52% of patients. IOP response was variable in this population with severe complex glaucoma.

Optic Disc Edema and Posterior Globe Flattening Secondary to Ocular Hypotony: Case Report and Discussion Regarding Pathophysiology and Clinical Findings.

ABSTRACT: We describe a case of a young female patient presenting with ocular hypotension (4 mm Hg) secondary to cyclodialysis, and optic disc edema (ODE) after a blunt trauma in the right eye (right eye). MRI showed posterior globe flattening of the right eye, drawing our attention to the pathophysiology behind these findings. The combination of ODE and posterior globe flattening, as observed in the present case of ocular hypotony, is known from other conditions such as intracranial hypertension and space-flight neuro-ocular syndrome, pointing to a common pathophysiological mechanism, possibly resulting from axoplasmic stasis at the level of the lamina cribrosa due to a high translaminar pressure difference.

Ocular Perfusion Pressure and the Risk of Open-Angle Glaucoma: Systematic Review and Meta-analysis.

Low ocular perfusion pressure (OPP) has been proposed as an important risk factor for glaucoma development and progression, but controversy still exists between studies. Therefore, we conducted a systematic review and meta-analysis to analyze the association between OPP and open-angle glaucoma (OAG). Studies were identified by searching PubMed and EMBASE databases. The pooled absolute and standardised mean difference in OPP between OAG patients and controls were evaluated using the random-effects model. Meta-regression analysis was conducted to investigate the factors associated with OPP difference between OAG patients and controls. A total of 43 studies were identified including 3,009 OAG patients, 369 patients with ocular hypertension, and 29,502 controls. The pooled absolute mean difference in OPP between OAG patients and controls was -2.52 mmHg (95% CI -4.06 to -0.98), meaning significantly lower OPP in OAG patients (P = 0.001). Subgroup analyses showed that OAG patients with baseline IOP > 21 mmHg (P = 0.019) and ocular hypertension patients also had significantly lower OPP than controls (P < 0.001), but such difference in OPP was not significant between OAG patients with baseline IOP of ≤21 mmHg and controls (P = 0.996). In conclusion, although no causal relationship was proven in the present study, our findings suggest that in patients with high baseline IOP, who already have a higher risk of glaucoma, low OPP might be another risk factor.

Rate of hypotony and intraocular pressure fluctuation immediately after intravitreal dexamethasone implantation in vitrectomized eyes.

PURPOSE: To observe the rate of hypotony and intraocular pressure (IOP) fluctuations immediately following intravitreal dexamethasone implantation in vitrectomized eyes. METHODS: The study included previously vitrectomized eyes scheduled to receive intravitreal dexamethasone implants. IOP measurements were performed at minute 1, minute 10, hour 1, hour 2, hour 3 and day 1. The primary outcome measure of the study was the rate of hypotony at the various time points, while the secondary outcome measure was the IOP profile over time. RESULTS: A total of 26 eyes were enrolled in the study. Immediately following the injection, 11 (42.3%) of the eyes exhibited an IOP<6mm Hg. Hypotony was observed in one eye (3.8%) at hour 3 and day 1. After the immediate IOP reduction, IOP recovered rapidly and showed a peak at hour 1, with 5 eyes (19.2%) exhibiting IOP levels ≥25mmHg and 1 eye (3.8%) ≥30mm Hg. Aside from the eye with persistent hypotony resulting in a choroidal effusion, no other complication was observed. CONCLUSIONS: Injection of dexamethasone implants in vitrectomized eyes resulted in immediate IOP reduction. Hypotony showed a short, self-limited course in the majority of eyes. In the presence of additional risk factors for wound incompetency, regular follow-up in the early post-injection period appears to be needed.

Is Beta Radiation Better than 5 Flurouracil as an Adjunct for Trabeculectomy Surgery When Combined with Cataract Surgery? A Randomised Controlled Trial.

INTRODUCTION: In an African setting surgery is generally accepted as the treatment of first choice for glaucoma. A problem with trabeculectomy surgery for the glaucomas is the frequent co-existence and exacerbation of cataract. We report a randomized controlled trial to compare the use of beta radiation with 5FU in combined cataract and glaucoma surgery. PARTICIPANTS AND METHODS: Consenting adults aged >40 years with glaucoma, an IOP>21mmHG and cataract were enrolled and randomised to receive either 1000cG ß radiation application or sub-conjunctival 5fluorouracil (5FU) at the time of combined trabeculectomy and phaco-emulsification with lens implant surgery. RESULTS: 385 individuals were eligible for inclusion of whom 301 consented to inclusion in the study (one eye per patient). 150 were randomised to the 5FU arm and 151 received ß radiation. In the 12 months following surgery there were 40 failures (IOP>21mmHg) in the 5FU arm and 34 failures in the beta arm. The hazard ratio for the beta radiation arm compared to the 5FU arm, adjusted for IOP at baseline, was 0.83 (95% c.i. 0.54 to 1.28; P = 0.40). The improvement from mean presenting visual acuities of 0.91 and 0.86 logMAR to 0.62 and 0.54 in the 5FU and beta arms respectively was comparable between groups (P = 0.4 adjusting for baseline VA). Incidence of complications did not differ between the two groups. DISCUSSION: This study highlights several important issues in the quest for a therapeutic strategy for the glaucomas in an African context. Firstly, there is no evidence of an important difference between the use of 5FU and beta radiation as an anti-metabolite in phacotrabeculectomy. Secondly phacotrabeculectomy is a successful operation that improves visual acuity as well as controlling IOP in a majority of patients. Although the success of trabeculectomy in lowering IOP is reduced when combined with phacoemulsification compared with trabeculectomy alone, this finding has to be set against the possible need for subsequent cataract surgery following trabeculectomy alone, which represents a second trip and expense for the patient and results in 10-61% failure of the trabeculectomy at one year post-cataract surgery. TRIAL REGISTRATION: ISRCTN Registry ISRCTN36436933.

Enxerto de retalho escleral de doador como tratamento definitivo de maculopatia hipotônica pós trabeculectomia / Scleral patch as a definitive treatment for hypotonic maculopathy after trabeculectomy

RESUMO Paciente do sexo feminino, portadora de glaucoma juvenil sem controle clínico adequado, foi submetida à trabeculectomia com mitomicina C, após a qual, desenvolveu hipotensão ocular refratária às medidas conservadoras, evoluindo com um quadro de maculopatia hipotônica. Foi realizado um implante de enxerto de retalho escleral de doador sobre a fístula, com resolução do quadro e ganho de acuidade visual. A enxertia de retalho escleral de doador mostrou-se uma terapia adequada para correção da hipotensão ocular por bolha hiperfiltrante pós trabeculectomia. O cirurgião deve considerar o emprego dessa técnica ao programar a revisão destes casos.

ABSTRACT A female patient with juvenile glaucoma without clinical control underwent a trabeculectomy with mitomycin C, and developed eye hypotension which did not respond to conservative treatment, with subsequent hypotonic maculopathy. The patient was treated using a scleral patch provided by a donor above the fistula, which improved intraocular pressure and visual acuity. The use of the scleral patch above the fistula seems an adequate therapy to treat ocular hypotension due to the over-filtering trabeculectomy bubble. The surgeon should consider this technique when planning surgical solutions for such cases.

Translamina Cribrosa Pressure Difference as Potential Element in the Pathogenesis of Glaucomatous Optic Neuropathy.

The main proven risk factor for glaucomatous optic neuropathy (GON) is an intraocular pressure (IOP) higher than the pressure sensibility of the optic nerve head allows. Fulfilling Koch postulates, numerous studies have shown that the presence of high IOP leads to GON, that lowering IOP stops the progression of GON, and that a re-increase in IOP again causes the progression of GON. There are, however, many patients with glaucoma who have statistically normal or low IOP, and despite low IOP values, they develop progressing GON. These observations led to findings that IOP is only 1 of 2 determinants of the translamina cribrosa pressure difference (TLCPD), which is the main pressure-related parameter for the physiology and pathophysiology of the optic nerve head. The second parameter influencing TLCPD is orbital cerebrospinal fluid pressure (CSFP) as the counter pressure against IOP across the lamina cribrosa. Recent experimental and clinical studies have suggested that a low CSFP could be associated with GON in normal-pressure glaucoma. These investigations included studies with an experimental long-term reduction in CSFP in monkeys, population-based studies, and clinical retrospective and prospective investigations on patients with normal-pressure glaucoma. Besides TLCPD, other ocular parameters influenced by CSFP may be choroidal thickness, retinal vein pressure and diameter, occurrence of retinal vein occlusions, and occurrence and severity of diabetic retinopathy.

[Contribution of hemodynamic disturbances in magistral vessels to optic neuropathy progression and ocular tension changes in endocrine ophthalmopathy].

AIM: to investigate the contribution of various hemodynamic disturbances in magistral vessels to optic neuropathy (ON) progression and ocular tension changes in endocrine ophthalmopathy (EOP). MATERIAL AND METHODS: A total of 39 patients (78 eyes) with subclinical EOP (clinical activity score, CAS ≤ 2) associated with Graves' disease (n = 32, 64 eyes) or autoimmune thyroiditis (n = 7, 14 eyes) were examined. Orbit echography was performed in all patients. Blood flow was assessed with a Voluson 730 PRO ultrasound diagnostic system ("Kretz", Austria) in triplex mode (B-scan, color Doppler flow mapping in combination with pulse-wave Doppler). Thus obtained hemodynamic parameters in ophthalmic artery, central retinal artery (CRA), central retinal vein (CRV), short posterior ciliary arteries (SPCA), and long posterior ciliary arteries (LPCA) were analyzed. To reveal the role of hemodynamic disturbances in the above mentioned vessels in ON progression and eye pressure maintenance, the patients were divided into 7 groups. Only those eyes, whose peripheral indices were increased by more than 25% of normal values and diastolic blood flow decreased by not less than 25%, were selected for further study. Intraocular pressure changes were evaluated by group mean (Mmean = M ± m mmHg), optic neuropathy progression--by the difference in group mean depth (dB) and number of scotomas between the first and the last visit (6 months of observation). RESULTS: In almost all types of perfusion disturbances, the resultant chronic ocular ischemia causes a decrease in IOP. The only exception, as shown, is simultaneous involvement of CRA, SPCA, and LPCA. The level of blood flow disturbance determines the severity of qualitative and quantitative changes in eyes with EOP-associated ON. The rate of ON progression directly correlates with baseline IOP values on day zero. CONCLUSION: Long-lasting chronic impairment of blood supply of the eyeball leads to reduction in ocular tension and progression of optic neuropathy. Combined perfusion disturbances in CRA and LPCA as well as in CRA, LPCA, and SPCA can be considered a high-risk factor, while SPCA and/or LPCA involvement--a moderate-risk factor.

Corneal Ectasia and Hydrops in Ocular Hypotony: The Corneal Crease.

PURPOSE: To report the association of chronic ocular hypotony with the development of progressive corneal ectasia and hydrops. METHODS: Retrospective case series. RESULTS: Three patients with ocular hypotony were referred for corneal evaluation and found to have ectasia and acute corneal hydrops in their hypotonous eye(s). Clinically, the globes were easily deformable with either external digital palpation and/or simple blinking. All 3 patients had a history of chronic iridocyclitis, including one with juvenile idiopathic arthritis. In each case, the area of thinning was narrow and arcuate in configuration, distinctive from other ectatic disorders. Also uncharacteristically, the acute hydrops resolved rapidly within 2 to 3 weeks without surgical intervention. In 1 case, severe thinning with perforation occurred requiring urgent penetrating keratoplasty. CONCLUSIONS: This case series demonstrates a unique clinical entity in which corneal ectasia and hydrops developed in the setting of ocular hypotony and easily deformable corneas, in a pattern unlike previously described forms of ectasia. Acute hydrops, even with associated corneal perforation, demonstrated a short and self-limited course. Corneal ectasia and irregular astigmatism should be suspected as a cause of unexplained visual loss in the ever-increasing number of patients with chronic, stable ocular hypotony. Further study is warranted to determine the pathophysiology of corneal ectasia in this setting, which may include mechanical and inflammatory factors.

Progressive hemifacial atrophy with ciliary body atrophy and ocular hypotony.

Progressive hemifacial atrophy (PHA) is a disease of unknown etiology affecting one-half of the face. Ocular involvement is uncommon. Atrophy of iris is rare, with only a few cases of partial atrophy being reported in the literature. We report a case of total atrophy of iris and ciliary body with associated ocular hypotony in a 16-year-old girl with PHA. We believe this is the first reported case of complete atrophy of iris and ciliary body in PHA. Ocular hypotony in PHA was thought to be due to intra-ocular inflammation. However in our case it appears to be secondary to severe atrophy of the ciliary body.

Bleb revision for resolution of hypotony maculopathy following primary trabeculectomy.

PURPOSE: To describe a surgical method of bleb revision for hypotony maculopathy, to evaluate its long-term efficacy, and to define the relationship between the duration of hypotony maculopathy and visual acuity (VA) outcomes. DESIGN: Noncomparative retrospective case series. METHODS: Medical records of 33 patients with hypotony maculopathy who underwent primary bleb revision between June 1999 and September 2012 by a single surgeon at an academic medical center were reviewed. Hypotony maculopathy was characterized by the presence of a decrease in VA, retinal striae, and macular edema in the setting of decreased intraocular pressure (IOP) after glaucoma filtering surgery. The main outcome measure was final logMAR VA after bleb revision at 6 and 12 months. RESULTS: Thirty-three eyes of 33 patients were followed for 4.68 ± 3.56 years (range 0.55-12.69 years). Mean duration of hypotony maculopathy was 4.98 ± 8.93 months. LogMAR VA improved from 0.78 ± 0.40 at baseline to 0.34 ± 0.34 (P < .001) 6 months after bleb revision and to 0.45 ± 0.55 (P < .001) 12 months after bleb revision. Spearman rank coefficient (rs) correlating duration of hypotony and BCVA at both 6 and 12 months was significant (P = .015 and rs = 0.426, P = .028 and rs = 0.416, respectively). Mean IOP increased from 3.51 ± 2.27 mm Hg to 12.06 ± 4.06 mm Hg (P < .001) at 12 months. Fifty-two percent were on no antiglaucoma medications at last follow-up. Five eyes (15%) required a second bleb revision to correct persistent hypotony maculopathy. CONCLUSION: Surgical repair for hypotony maculopathy provided a significant improvement in VA at 6 and 12 months. Surgical bleb revision is associated with good long-term control of IOP and improved VA in eyes with hypotony maculopathy after previous glaucoma filtering surgery.

Severe HLA B27-associated uveitis complicated by hypotony, serous retinal detachment, and ciliochoroidal effusion.

PURPOSE: To report on severe HLA B27-associated anterior uveitis complicated by vitritis, hypotony, and serous retinal detachment. METHODS: Retrospective case series. RESULTS: Five patients with HLA B27-associated uveitis presented with an acute anterior uveitis complicated by vitritis, hypotony, serous retinal detachment, and ciliochoroidal effusion. Two patients had previously acute anterior uveitis and two suffered from HLA B27-associated systemic disease. Laboratory and imaging examinations did not reveal another cause of uveitis. Despite the aggressive treatment a prolonged and slow recovery followed. Four patients developed macular edema and one additional patient developed a macular pucker. Finally, 3 eyes improved, 2 eyes developed atrophy, and 1 was lost at 4-month follow-up with visual acuity of hand movements. CONCLUSIONS: The authors conclude that severe uveitis with a serous retinal detachment might develop in HLA B27-positive patients and may be complicated by protracted hypotony, macular edema, and poor visual outcome.

Ocular decompression retinopathy: a review.

Ocular decompression retinopathy (ODR) presents as retinal hemorrhages following acute lowering of the intraocular pressure (IOP). We review 32 articles published from 1992 to 2011 and address the pathogenesis, clinical features, management, and outcomes of ODR. ODR is defined as a multifocal hemorrhagic retinopathy that results from acute lowering of IOP and is not explained by another process. Hemorrhages occur in all retinal layers, and most patients are asymptomatic. The mean drop in IOP in ODR is 33.2 ± 15.8 mm Hg (range, 4-57 mm Hg). Eighty-two percent are diagnosed by the first postoperative day, all within 2 weeks. ODR resolved in a mean of 13 ± 12.4 weeks (range, 2-72 weeks). Vitrectomy was required for vitreous and subhyaloid hemorrhage in 14% of cases. Visual outcomes are generally good, with 85% of eyes returning to baseline vision. Although ODR infrequently results in significant ocular morbidity, gradual reduction in IOP might prevent this complication.

Low nocturnal ocular perfusion pressure as a risk factor for normal tension glaucoma.

OBJECTIVES: In the absence of raised intraocular pressure (IOP), haemodynamic parameters have been implicated in the development of normal tension glaucoma (NTG). The purpose of this study is to compare 24-hour IOP and haemodynamic parameters in NTG patients and non-glaucoma patients. METHODS: This is a cross sectional study involving 72 NTG patients from University of Malaya Medical Centre eye clinic glaucoma registry. The non-glaucoma patients were volunteers selected from eye clinic patients. All enrolled patients underwent 24-hour IOP and blood pressure monitoring via 2-hourly IOP and blood pressure (BP) measurements. All readings were taken in the sitting position during the diurnal period and in the supine position during the nocturnal period RESULTS: Comparison of the haemodynamic parameters, the nocturnal mean systolic BP, nocturnal mean diastolic BP and nocturnal mean arterial pressure (MAP) were significantly lower in the NTG group. The systemic ocular perfusion pressures (OPP), diastolic OPP and mean OPP taken at night were also significantly lower in the NTG group. The differences between the groups were still manifest after controlling for age and presence of hypertension. CONCLUSION: Our findings show that the nocturnal supine blood pressure parameters (systolic, diastolic and mean) and OPP were significantly lower in the NTG group compared to normals. This may reflect defective autoregulatory mechanisms in NTG patients.

Spectral domain OCT to diagnose clinically inapparent hypotony maculopathy using 3D image rendering software.

Three-dimensional (3D) image rendering capability of a commercially available 3D-optical coherence tomogram (OCT) system was used to diagnose a subclinical but symptomatic case of hypotony maculopathy in an eye with significant cataract and an only-eyed patient. Bleb revision improved intraocular pressure and symptoms, confirmed by repeat OCT imaging. Hypotony maculopathy may be subclinical and difficult to diagnose particularly in eyes with non-clear ocular media. Use of spectral domain OCT can be complementary to improve patient outcomes.

Spontaneous malignant glaucoma in a longstanding hypotonous eye.

A 38-year-old man with longstanding low intraocular pressure (IOP) in his right aphakic eye presented with severe pain and high IOP (35 mm Hg). On examination, visual acuity was light perception. The central and peripheral portions of the iris were directly opposed to the posterior corneal surface and synechial closure of the pupil margin. B-scan ultrasonography showed posterior vitreous detachment. The patient was treated with topical cycloplegics, a topical beta-blocker, and a systemic hyperosmotic agent. After 1 week, the anterior chamber was deep centrally, with peripheral synechiae between the iris and the cornea. The IOP of the right eye was 4 mm Hg. This case is an unusual spontaneous malignant glaucoma occurring in a longstanding hypotonous eye.