Refractive outcomes of immediately sequential bilateral cataract surgery in eyes with long and short axial lengths.

PURPOSE: To report the refractive outcomes of long (≥25.00 mm) and short (≤22.00 mm) axial length (AL) eyes undergoing immediately sequential bilateral cataract surgery (ISBCS). METHODS: In this retrospective cohort study, patients who underwent ISBCS were identified and eyes of patients with bilateral long and short ALs were included. Pre- and postoperative biometry, autorefraction, and ocular comorbidities or complications were recorded. The primary outcome was the mean refractive prediction error. RESULTS: Thirty-seven patients (74 eyes) with long ALs and 18 patients (36 eyes) with short ALs were included. The means ± standard deviations of the ALs were 26.40 ± 1.38 mm and 21.44 ± 0.46 mm in the long and short AL groups, respectively. In long AL eyes, the mean absolute error from the biometry-predicted refraction was - 0.16 ± 0.46 D, corresponding to 74% of eyes achieving a refraction within ±0.50 D of the predicted value. In short AL eyes, the mean absolute error was - 0.63 ± 0.73 D, corresponding to 44% of eyes achieving a refraction within ±0.50 D of the predicted value. Eight (44.4%) patients with short AL eyes had a myopic deviation greater than ±0.50 D from the predicted result in both eyes. CONCLUSIONS: Compared to patients with long AL eyes, ISBCS in patients with short ALs had a wider variance in refractive outcome and a lower rate of achieving a postoperative refraction within ±0.50 D of the predicted target.

Efficacy of ab-interno gelatin microstent implantation in primary and refractory glaucoma.

OBJECTIVE: To evaluate the outcomes of ab interno gelatin microstent implantation alone and in combination with phacoemulsification for the reduction of intraocular pressure (IOP). DESIGN: Retrospective cohort study. PARTICIPANTS: 141 eyes of 141 patients with any glaucoma subtype, including refractory glaucoma, operated in the Centre Hospitalier de l'Université de Montréal (CHUM) from 2015-2018. Patients were included if they were over 40 years of age and had a preoperative IOP of >18 mm Hg on maximum tolerated medical therapy. METHODS: All patients received ab-interno microstent implantation (XEN-45, Allergan, Madison, NJ) with mitomycin C +/- combined phacoemulsification. The primary outcome was complete surgical success (IOP 6-18 mm Hg and <20% reduction from baseline without IOP medications or reoperations or cyclophotocoagulation); secondary outcomes included qualified success allowing for medications, percentage reduction in mean IOP and medications, and reduction in number of complications, interventions, and reoperations. RESULTS: Mean follow-up was 30.5 ± 10.2 months (±SD). Mean IOP was 23.3 ± 7.0 mm Hg on 3.4 ± 0.8 medications at baseline and 13.3 ± 4.7 mm Hg on 1.9 ± 1.5 medications at 24 months of follow-up (p < 0.001). From 24-month survival analysis estimates, complete success was achieved in 34.1% of microstent eyes versus 20.7% with combined phacoemulsification (p = 0.02); 79.1% versus 75.1% achieved qualified success, respectively (p = 0.86). Cases with combined phacoemulsification had a higher rate of failure (hazard ratio [HR] = 1.6, 95% CI 1.1-2.3, p = 0.02). Needling with mitomycin-C or 5-fluorouracil postoperatively occurred in 54 eyes (38.3%). Complications included transient hypotony (10.6%), transient hyphema (6.4%), macular edema (4.3%), and microstent exposure (2.8%). There were 33 eyes (23.4%) with reoperations and 14 (9.9%) requiring subsequent cyclophotocoagulation lasers. CONCLUSIONS: Microstent implantation required topical therapy in most cases 24 months following surgery in primary and refractory glaucoma and, when combined with phacoemulsification, had a higher risk of failure.

Assessment of the Role and Timing of Glaucoma Surgery in Boston Keratoprosthesis Type 1 Patients.

PURPOSE: To determine the role and optimal timing of glaucoma surgery in relation to Boston keratoprosthesis type 1 (KPro) implantation. DESIGN: Retrospective, comparative, nonrandomized clinical study. METHODS: Single-center study of a total of 100 eyes (100 patients) implanted with a KPro between 2008 and 2017, and diagnosed with glaucoma before or after KPro. Patients were separated into 2 groups: those with preexisting glaucoma and those who developed de novo glaucoma after KPro. Groups were then divided based on whether patients were medically or surgically managed. Glaucoma surgery included glaucoma drainage device (GDD) implantation, trabeculectomy, and cyclophotocoagulation (CPC). Primary outcomes included best-corrected visual acuity (BCVA), glaucoma progression, and complications. Differences in outcomes were compared using parametric and nonparametric tests, as well as log-rank test to compare time-to-outcome events. RESULTS: Among 72 eyes with preexisting glaucoma, 27 (38%) had glaucoma surgery before KPro (18 GDD), whereas 45 (62%) were medically managed only. Among the latter, 19 (42%) needed glaucoma surgery post-KPro (16 GDD). Among 28 eyes with de novo glaucoma, 12 (43%) had glaucoma surgery post-KPro (9 GDD). For eyes with preexisting glaucoma, glaucoma progression was greater with glaucoma surgery performed post-KPro (100%) compared with pre-KPro (74%, P = .016) and to medical management (54%, P = .002). No increase in complications were observed with glaucoma surgery compared to medications only (P > .05), whereas fewer eyes maintained a BCVA of 20/200 or better over time with medical management (P = .013). Eyes with de novo glaucoma had similar progression, BCVA, and complications between medical and surgical care (P > .05). CONCLUSIONS: Glaucoma surgery should be performed before or at the same time as KPro implantation in eyes with preexisting glaucoma. Complication rates are not increased when glaucoma surgery is performed in KPro eyes with either preexisting or de novo glaucoma. To ensure optimal glaucoma control, glaucoma surgery should be performed as early as possible in KPro eyes with good visual potential.

Laminar and prelaminar tissue displacement during intraocular pressure elevation in glaucoma patients and healthy controls.

OBJECTIVE: To determine the response of the anterior lamina cribrosa and prelaminar tissue to acute elevation of intraocular pressure (IOP) in glaucoma patients and healthy subjects. DESIGN: Prospective case-control series. PARTICIPANTS AND CONTROLS: Patients with open-angle glaucoma (n = 12; mean age ± standard deviation [SD], 66.8 ± 6.0 years), age-matched healthy controls (n = 12; mean age ± SD, 67.1 ± 6.2 years), and young controls (n = 12; mean age ± SD, 36.1 ± 11.7 years). METHODS: One eye was imaged with spectral-domain optical coherence tomography to obtain 12 high-resolution radial scans centered on the optic disc. Imaging was repeated at precisely the same locations with an ophthalmodynamometer held perpendicular to the globe via the inferior lid to raise the IOP. A line joining Bruch's membrane opening in 4 radial scans was used as reference in the baseline and elevated IOP images. The vertical distance from the reference line to the anterior prelaminar tissue surface and anterior laminar surface was measured at equidistant points along the reference line in the 2 sets of images. The difference between the 2 sets of corresponding measurements were used to determine laminar displacement (LD) and prelaminar tissue displacement (PTD). MAIN OUTCOME MEASURES: Laminar displacement and PTD. RESULTS: Intraocular pressure elevation among patients, age-matched controls, and young controls was similar (mean ± SD, 12.4 ± 3.2 mmHg). The mean ± SD LD and PTD were 0.5 ± 3.3 µm and 15.7 ± 15.5 µm, respectively. The LD was not statistically different from 0 (P = 0.366), but PTD was (P < 0.001). The mean ± SD LD was similar among the groups (-0.5 ± 3.7 µm, 0.2 ± 2.0 µm, and 2.0 ± 3.6 µm, respectively; P = 0.366), whereas the mean ± SD PTD was different (6.8 ± 13.7 µm, 20.8 ± 17.5 µm, and 19.6 ± 11.8 µm, respectively; P = 0.045). In all subjects, the PTD was greater than LD. In multivariate regression analyses, LD was negatively associated with optic disc size (P = 0.007), whereas PTD was positively associated with the degree of IOP elevation (P = 0.013). CONCLUSIONS: In glaucoma patients and controls, the anterior laminar surface is noncompliant to acute IOP elevation. Acute optic disc surface changes represent compression of prelaminar tissue and not laminar displacement.

Micropulse trans-scleral laser therapy outcomes for uncontrolled glaucoma: a prospective 18-month study.

OBJECTIVE: To evaluate the efficacy and safety of micropulse trans-scleral laser therapy (mTLT) in glaucomatous patients. DESIGN: Prospective, interventional study in a university hospital setting. PARTICIPANTS: Fifty-two eyes of 52 adult patients with uncontrolled glaucoma despite maximal tolerated medical treatment, and/or poor candidates for filtering surgery. METHODS: Participants received a 360-degree mTLT diode laser treatment (2000mW, 31.33% duty cycle), with duration adjusted to iris pigmentation and glaucoma severity (160-320 seconds). They were followed for 18 months to assess intraocular pressure (IOP), number of medications, corrected distance visual acuity (CDVA), glaucoma progression based on Humphrey Sita 24-2 perimetry and Cirrus high-definition optical coherence tomography, and complications. The primary outcome measure was the absolute success at 18 months. Absolute success was defined as an IOP 6-21 mm Hg and at least 25% IOP reduction, with equal or less number of IOP medications. Qualified success allowed for an increased number of IOP medications. Failure was defined as an inability to meet the criteria for success or the need for incisional glaucoma surgery. RESULTS: Treatment absolute success was 61.5% at 12 months and 59.6% at 18 months. Mean IOP was reduced by 35.6% at 18 months (23.6 ± 6.5 mm Hg at baseline; 15.2 ± 4.1 mm Hg at 18 months, p < 0.001). mTLT did not significantly reduce the number of topical glaucoma medications (p = 0.075); however, 15 eyes (29%) had systemic oral glaucoma treatment at baseline and 10 eyes (20%) at 18 months. Eight patients (15%) experienced vision loss of ≥2 lines after the procedure. Three patients (6%) regained their preoperative CDVA by 1 month, and 3 patients (6%) by 3 months, while 2 patients (4%) sustained persistent visual loss. No ocular complications were noted in 84.6%. Incisional surgery was required in 25% of eyes owing to inadequately controlled glaucoma despite mTLT. CONCLUSIONS: mTLT is a good therapeutic option for moderate IOP reduction, while being safe and predictable. This improved safety profile makes mTLT a treatment to be considered earlier in the management of glaucoma.

Tear Film Cytokine Profile of Patients With the Boston Keratoprosthesis Type 1: Comparing Patients With and Without Glaucoma.

Purpose: Inflammatory cytokines are involved in glaucoma pathogenesis. The purpose is to compare cytokine levels in the tear film of Boston keratoprosthesis (KPro) patients with and without glaucoma, relative to controls, and correlate levels with clinical parameters. Methods: This cross-sectional study enrolled 58 eyes (58 patients): 41 KPro eyes with glaucoma, 7 KPro eyes without glaucoma, and 10 healthy controls. Twenty-seven cytokines were measured by multiplex bead immunoassay. Intraocular pressure (IOP), cup-to-disk ratio (CDR), retinal nerve fiber layer, visual acuity, topical medications, and angle closure were assessed in all KPro eyes. Cytokine levels between groups were analyzed by nonparametric tests, and correlations with clinical parameters by Spearman's test. Results: Levels of TNF-ɑ, IL-1ß, FGF-basic, and IFN-É£ were significantly higher in KPro with glaucoma compared to KPro without (P = 0.020; 0.008; 0.043; 0.018, respectively). KPro groups had similar characteristics and topical antibiotic/steroid regimen. Levels of IL-1Ra, IL-15, VEGF, and RANTES were significantly higher in KPro with glaucoma compared to controls (P < 0.001; = 0.034; < 0.001; = 0.001, respectively). IL-1ß and IFN-É£ levels were positively correlated with CDR (r = 0.309, P = 0.039 and r = 0.452, P = 0.006, respectively) and IOP (r = 0.292, P = 0.047 and r = 0.368, P = 0.023, respectively). TNF-α and FGF-basic levels were positively correlated with CDR (r = 0.348, P = 0.022 and r = 0.344, P = 0.021, respectively). Conclusions: TNF-α, IL-1ß, FGF-basic, IFN-É£ are elevated in tears of KPro patients with glaucoma and correlate with CDR and IOP. These results show, for the first time in humans, concordance with documented elevations of TNF-α and IL-1ß in the murine KPro model. Ocular surface inflammation may reflect inflammatory processes of KPro glaucoma.

Cyclophotocoagulation in the Control of Glaucoma in Patients With the Boston Keratoprosthesis Type 1.

PURPOSE: To evaluate the outcomes of transscleral cyclophotocoagulation (CPC) in the control of glaucoma in eyes with a Boston keratoprosthesis (KPro) type 1. METHODS: This study is a retrospective case series of patients who have undergone at least 1 CPC treatment after KPro implantation. Eighteen eyes of 17 patients were included. Intraocular pressure (IOP) (assessed by digital palpation) and the number of classes of glaucoma medications were recorded at 1 week, 1 to 3 months, 4 to 6 months, and 1 year postoperatively. Optic nerve status, visual field parameters, and perioperative and postoperative complications were recorded. RESULTS: Twenty-one CPC sessions were administered overall. Seven eyes (39%) had IOP < 20 mm Hg preoperatively, and this increased to 15 eyes (83%) at the 1-year postoperative follow-up. The mean number of glaucoma medications used was 3.9 preoperatively and did not change significantly after treatment. Seven eyes (39%) had glaucoma progression despite CPC treatment. Three eyes (17%) initially responded to CPC but later failed at 3, 6, and 12 months. Two of them responded to repeat CPC, and 1 continued to progress despite retreatment. Two eyes (11%) developed early postoperative hypotony, 1 eye (6%) developed cystoid macular edema, 1 eye (6%) developed bacterial endophthalmitis with subsequent enucleation, and 1 eye (6%) lost light perception because of glaucoma. CONCLUSIONS: CPC was useful to control IOP in some KPro eyes with refractory glaucoma, although it did not significantly reduce concurrent medical therapy. In addition, caution must be taken because microbial infection can occur after CPC because of the lack of biointegration between the host cornea and the device.

An unusual case of acute angle-closure glaucoma following deep anterior lamellar keratoplasty using the "big bubble" technique.

PURPOSE: To report the first case of acute angle closure due to a high-pressure Descemet membrane detachment following deep anterior lamellar keratoplasty (DALK) using the "big bubble" technique. OBSERVATIONS: A 25-year-old man underwent DALK surgery for keratoconus using the "big bubble" technique in which an air bubble is injected in deep stroma to promote dissection of underlying Descemet membrane from stroma. Surgery was uneventful and the patient was discharged home in good conditions. On post-operative day 1, the patient came back with severe periocular pain. Intra-ocular pressure was found to be 38 mmHg. Anterior-segment OCT revealed a "double anterior chamber" created by a high-pressure Descemet detachment that was occluding the pupil and causing secondary acute angle closure glaucoma. The patient was brought back promptly to the operating room where the high-pressure chamber was properly evacuated, allowing Descemet membrane to properly reattach to stroma. CONCLUSIONS AND IMPORTANCE: Inability to recognize stroma from Descemet membrane during the dissection of the "big bubble technique" can result in failure to evacuate the high-pressure Descemet membrane detachment, putting the patient at risk for acute angle closure glaucoma from occlusion of the pupil. Proper dissection of stroma from underlying DM is a challenging and crucial step in the "big bubble" technique. Several methods, such as the injection of small bubbles in the anterior chamber or the use of intra-operative anterior segment OCT could be employed to prevent such a complication.

Prevalence, progression, and impact of glaucoma on vision after Boston type 1 keratoprosthesis surgery.

PURPOSE: To report glaucoma outcomes after Boston type 1 keratoprosthesis (KPro) surgery, in particular, glaucoma prevalence, progression, and treatment. DESIGN: Consecutive, retrospective, interventional case series. METHODS: setting: Tertiary care institution. study population: Thirty-eight eyes in 38 patients. intervention: KPro surgery. main outcome measures: Visual acuity (VA), intraocular pressure, visual fields, optic nerve status, and glaucoma treatment. RESULTS: Glaucoma diagnosis was known before surgery in 29 patients (76%; 14 had undergone previous surgery) and was diagnosed after surgery in 34 patients (89%) after a mean ± standard deviation of 16.5 ± 4.7 months of follow-up. The number of patients taking intraocular pressure-lowering medications increased from 19 (50%) before surgery to 28 (76%) after surgery (P = .017). Twenty-four patients (63%) were taking at least 1 additional glaucoma medication at their most recent postoperative visit. Eight patients (21%) had glaucoma progression (visual field progression, need for surgery, or both). Fifteen patients (40%) had a cup-to-disc ratio of 0.85 or more. Five patients required glaucoma surgery. VA was limited by glaucoma in 14 patients (37%), 11 of whom had a VA of 20/200 or worse. Five such patients (13%) had a dramatic improvement in VA, then progressed to end-stage glaucoma with fixation loss. Visual fields were limited by glaucoma in 25 patients (66%; mean Swedish Interactive Threshold Algorithm Fast mean defect, -20.3 ± 8.8 decibels; n = 18). CONCLUSIONS: Most KPro candidates have glaucoma, which may deteriorate in a subset of patients after surgery. Dramatic VA improvement after KPro surgery does not preclude the need for rigorous monitoring for glaucoma progression. A low threshold should be used to treat suspicion of even slightly elevated intraocular pressure.

Screening for glaucoma with Moorfields regression analysis and glaucoma probability score in confocal scanning laser ophthalmoscopy.

OBJECTIVE: To compare the validity of Moorfields regression analysis (MRA) and glaucoma probability score (GPS) of the confocal scanning laser ophthalmoscopy (Heidelberg retina tomograph 3; HRT3) in detecting glaucomatous optic nerve damage in a screening population. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: Subjects at high risk for development of open-angle glaucoma (OAG). METHODS: All subjects underwent confocal scanning ophthalmoscopy (Heidelberg retina tomograph; HRTII) testing, visual fields testing with frequency-doubling technology perimetry (FDT), and a standard ophthalmologic examination. All HRTII images were reprocessed with HRT3. Based on an ophthalmologic examination and FDT results, eyes were classified into 4 categories: normal, possible glaucoma, probable glaucoma, and definitive glaucoma. Main outcome measures included sensitivity and specificity of HRTII/MRA, HRT3/MRA, HRT3/GPS, and combination HRT3/MRA/GPS. RESULTS: The left eyes of 221 of 291 subjects were included; 4 (1.8%) eyes were classified as definitively having glaucoma. Depending on the reference standard diagnosis as well as on the borderline test-positive definition of the HRTII-3, sensitivity and specificity varied between 36.4% and 100%. For HRTII/MRA, 88.2% to 96.5%, 54.5% to 100%, and 74.5% to 93.6%; for HRT3/MRA, 61.9% to 100% and 64.3% to 85.2%; for HRT3/GPS, 85.7% to 100%; and for combination HRT3/MRA/GPS, 73.4% to 78.2%. CONCLUSIONS: In this pilot study, the MRA of the HRT3 appears to be more sensitive but less specific than the MRA in the HRTII version. The GPS, although somewhat less specific than MRA (and some discs are nonclassifiable by this technique), had greater sensitivity and as a screening method may have the additional advantage of being contour-line independent.