Minimally invasive micro sclerostomy (MIMS) procedure in the treatment of open-angle glaucoma.

BACKGROUND: To evaluate the safety and efficacy of the Minimally Invasive Micro Sclerotomy (MIMS) procedure in the management of uncontrolled open-angle glaucoma. METHODS: A prospective, open-label, single-arm clinical evaluation with intra-subject comparisons performed at the Ophthalmologic Center after S.V. Malayan, Yerevan, Armenia. Included were adults with primary open-angle glaucoma (OAG) (N = 114) or exfoliative glaucoma (N = 6) who were uncontrolled (IOP > 21) on tolerated topical medication. Mild (N = 7), moderate (N = 66) and severe (n = 47) cases were prospectively included without preselection. Following subconjunctival Mitomycin C, an ab-interno MIMS procedure was performed alone (N = 100) or combined with phacoemulsification (N = 20). Patients were followed for 52 weeks. Procedure-related complications and adverse events were recorded. Success criteria were defined as -5 < IOP ≤ 21mmHg OR a reduction in IOP of ≥ 20% from baseline with (qualified success) or without (complete success) hypotensive medications. RESULTS: Mean patient age was 69 ± 10.1 years. The mean duration of the procedure was 2:01 ± 0:41 min:sec. Scleral drainage channels were achieved in all cases. No device malfunctions, intraoperative complications, or serious adverse events were reported. Iris plugging of the sclerostomy site and early spikes in IOP were the most common adverse events. The only reason for failure was final IOP > 21 mmHg on tolerated medication. At 52 weeks (n = 93), mean IOP decreased by 38% from baseline (P < 0.001), from 27.9 ± 3.7 to 17.5 ± 5.3 mmHg, a difference of 10.5 mmHg (95% CI: -11.7, -9.3). One-year qualified success was documented in 82.1% (95% CI: 72.9%,89.2%) of the patients and complete success, in 70.5% (60.3-79.4%). 60% (95 CI:49.4%,69.9%) of the patients achieved maximum IOP level of 14 mmHg or at least 30% reduction in IOP. CONCLUSIONS: MIMS procedure is a relatively simple, short and safe minimally invasive bleb-forming procedure. Its efficacy, as found in this short-term evaluation, lends it suitable for mild and moderate uncontrolled open-angle glaucoma patients. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04503590 2019-05-29.

Concurrent ciliary body detachment in patients presenting with serous choroidal detachment following glaucoma surgery.

PURPOSE: To examine the rate of ciliary body detachment in patients with choroidal detachment following glaucoma surgery and its effect on the clinical course, management, and prognosis. METHODS: A prospective observational case-series study. Patients with choroidal detachment following glaucoma surgery in 2018-2019 were included. All underwent complete ophthalmological examination and ultrasound biomicroscopy for evaluation of the presence and extent of ciliary body detachment. Follow-up examinations including ultrasound biomicroscopy scans were performed at 1 week, 1 month, 3 months, and 6 months. RESULTS: Eight patients (8 eyes) were enrolled, 4 male and 4 female, of mean age 72 years (range 60-83). Five patients underwent trabeculectomy with mitomycin C (0.02%), which was combined with phacoemulsification cataract extraction in one; two underwent Ahmed glaucoma valve implantations, and one underwent ab-interno Xen45 gel stent implantation with mitomycin C (0.02%). The mean intraocular pressure was 26.0 ± 7.65 mmHg preoperatively, dropping to 6.9 ± 2.64 mmHg on first postoperative day one. Mean time from surgery to diagnosis of choroidal detachment was 11.6 ± 5.73 days. Ciliary body detachment was identified by ultrasound biomicroscopy in all patients, ranging between one and four quadrants. All patients were treated with topical steroids and cycloplegics; three (37.5%) received oral steroids. No surgical intervention for the choroidal or ciliary body detachments was indicated. CONCLUSIONS: In this real-world prospective study, concurrent ciliary body detachment was identified in all patients who presented with choroidal detachment following glaucoma surgery. This observation may deepen our understanding of the mechanism underlying the hypotony that is often seen after glaucoma surgery.

Elevated intraocular pressure in children with acute lymphoblastic leukaemia: A prospective study.

Most childhood acute lymphoblastic leukaemia (ALL) protocols include high-dose steroid therapy. However, the known potential of high-dose steroids to significantly elevate intraocular pressure (IOP) and lead to glaucomatous optic neuropathy has not been intensively investigated in children with ALL. Moreover, as children with ALL do not routinely undergo IOP measurements, the need for IOP monitoring and therapy is unknown. We prospectively measured IOP in 90 children with newly diagnosed ALL attending a tertiary paediatric haematology/oncology centre, at diagnosis and at the middle and end of induction therapy. Ocular hypertension (IOP > 21 mm Hg) at any time point was documented in 64 children (71%), and the prevalence increased during induction. Thirty-six children (40%) had elevated IOP at ALL diagnosis before therapy initiation, and stratification to non-standard ALL was a risk factor. IOP reduction therapy was administered to 13 children (14%); none required surgery. Values normalised in all cases. On multivariate logistic regression analysis, dexamethasone therapy was a significant risk factor for ocular hypertension. High body mass index was an additional risk factor in children with elevated IOP at ALL diagnosis. Routine evaluation of IOP during steroid therapy is very important in children with ALL to ensure early intervention which may prevent permanent ocular damage.

Neuroprotective Effect of Azithromycin Following Induction of Optic Nerve Crush in Wild Type and Immunodeficient Mice.

This study evaluated the potential neuroprotective effect of azithromycin (AZ) intraperitoneal injections in male C57Bl/6 (wild type, WT) and female NOD scid gamma (NSG) mice subjected to optic nerve crush (ONC) as a model for optic neuropathy. Histologically, reduced apoptosis and improved retinal ganglion cell (RGC) preservation were noted in the AZ-treated mice as shown by TUNEL staining-in the WT mice more than in the NSG mice. The increased microglial activation following ONC was reduced with the AZ treatment. In the molecular analysis of WT and NSG mice, similar trends were detected regarding apoptosis, as well as stress-related and inflammatory markers examining BCL2-associated X (Bax), heme oxygenase 1 (Ho-1), interleukin 1 beta (Il1ß), superoxide dismutase 1 (Sod1), and nuclear factor-kappa B (Nfkb) levels. In the optic nerve, AZ increased the levels of expression of Sod1 and Nfkb only in the WT mice and decreased them in the NSG mice. In the retinas of the WT and NSG mice, the Bax and Ho-1 levels of expression decreased following the AZ treatment, while the Sod1 and Nfkb expression decreased only in the WT mice, and remained stable near the baseline in the NSG mice. Il1ß remained at the baseline in WT mice while it decreased towards the baseline in AZ-treated NSG mice. The neuroprotective effects demonstrated by the reduced RGC apoptosis in AZ-treated WT mice retinae, and in the optic nerves as stress-related and inflammatory gene expression increase. This did not occur in the immunodeficient NSG mice. AZ modulated the inflammatory reaction and microglial activation. The lack of an effect in NSG mice supports the assumption that AZ acts by immunomodulation, which is known to play a role in ONC damage. These findings have implications for the development and repurposing of drugs to preserve RGCs after acute optic neuropathies.

Characterization of Diabetic Retinopathy in Two Mouse Models and Response to a Single Injection of Anti-Vascular Endothelial Growth Factor.

In this study, we characterized diabetic retinopathy in two mouse models and the response to anti-vascular endothelial growth factor (VEGF) injection. The study was conducted in 58 transgenic, non-obese diabetic (NOD) mice with spontaneous type 1 diabetes (n = 30, DMT1-NOD) or chemically induced (n = 28, streptozotocin, STZ-NOD) type 1 diabetes and 20 transgenic db/db mice with type 2 diabetes (DMT2-db/db); 30 NOD and 8 wild-type mice served as controls. Mice were examined at 21 days for vasculopathy, retinal thickness, and expression of genes involved in oxidative stress, angiogenesis, gliosis, and diabetes. The right eye was histologically examined one week after injection of bevacizumab, ranibizumab, saline, or no treatment. Flat mounts revealed microaneurysms and one apparent area of tufts of neovascularization in the diabetic retina. Immunostaining revealed activation of Müller glia and prominent Müller cells. Mean retinal thickness was greater in diabetic mice. RAGE increased and GFAP decreased in DMT1-NOD mice; GFAP and SOX-9 mildly increased in db/db mice. Anti-VEGF treatment led to reduced retinal thickness. Retinas showed vasculopathy and edema in DMT1-NOD and DMT2-db/db mice and activation of Müller glia in DMT1-NOD mice, with some response to anti-VEGF treatment. Given the similarity of diabetic retinopathy in mice and humans, comparisons of type 1 and type 2 diabetic mouse models may assist in the development of new treatment modalities.

Histological and molecular characterization of glaucoma model induced by one or two injections of microbeads to the anterior chamber of mice.

PURPOSE: To characterize glaucoma-induced damage following injections of plastic microbeads into the anterior chamber of mice. METHODS: Mice were divided into three groups: a single plastic microbeads injection (n = 21); two consecutive plastic microbead injections to the right eye at 1-week intervals, 4 of which with two consecutive saline injections in the left eye (n = 15); and an additional control group of two consecutive saline injections at 1-week intervals (n = 6). Intraocular pressure (IOP) was measured weekly. Retinal thickness, ganglion cells (RGCs) and axonal loss, inflammatory and gliosis reactions were measured at week four. Molecular analysis using qRT-PCR in the microbeads injection groups focused on expression levels of inflammation and glaucoma-related genes. RESULTS: Mean IOP following single injection at 4 weeks was significantly elevated compared to baseline in injected eyes (14.5 ± 3.3 mmHg vs. 11.1 ± 2.5 mmHg, respectively, p = 0.003) and not in fellow eyes (13.2 ± 2.9 mmHg vs. 12.2 ± 2.9, respectively, NS). Six (35.3%) bead-injected eyes had IOP ≥ 17 mmHg compared with 2 (11.8%) saline-injected control eyes. Retinal thickness in injected and fellow eyes was 193.7 ± 15.5 µm and 223.9 ± 15.5 µm, respectively (p = 0.03). RGC loss in injected and fellow eyes was 16.0 ± 0.5 and 17.6 ± 0.7 cells per 200 µm, respectively (p = 0.005). Retinal gliosis, axonal loss and inflammatory cell infiltration to the bead-injected eyes were noted. Molecular analysis following double injection showed STAT3 expression decreased in the glaucoma-induced optic nerves (0.69 ± 0.3 vs. 1.16 ± 0.3, p = 0.04), but increased in the glaucoma-induced retinae (p = 0.05) versus saline; retinal IL-1ß decreased significantly (0.04 ± 0.04 vs. 0.36 ± 0.2, p = 0.02). TNF-α, NFkB and SOD-1 expression did not change. CONCLUSION: One/two injections of microbeads elevated IOP, with measurable neuronal damage. An inflammatory response was detected in the injured retina and optic nerve. The therapeutic significance of these findings should be explored.

The association between toxic anterior segment syndrome and intraocular pressure.

PURPOSE: To investigate the association between toxic anterior segment syndrome (TASS) and intraocular pressure (IOP). METHODS: This is a retrospective, controlled, single-site study. Patients who developed TASS following a clear corneal incision cataract surgery in Rabin Medical Center (Petah Tikva, Israel), between the years 2010-2018, were enrolled. The primary outcome was IOP measured 1, 7 (± 2), and 30 (± 7) days after surgery. The need for ocular hypotensive treatment was the secondary outcome. RESULTS: The study and control groups included 374 and 127 eyes, respectively. The mean IOP in the study and the control groups were 16.3 ± 7.1 and 15.3 ± 3.0 (p = 0.02) at day 1, 13.2 ± 5.0 and 13.7 ± 2.9 (p = 0.18) at day 7, and 13.7 ± 4.1 and 13.5 ± 2.8 (p = 0.65) at day 30. Prevalence of high IOP (> 21 mmHg) was significantly higher in the study group solely on the first postoperative day (12.7% and 3.2%, p = 0.002). In the study group, 9%, 3.7%, and 1.6% of the patients required hypotensive medications at day 1, 7, and 30, respectively. Four patients (~ 1%) in the study group developed acute angle closure due to pupillary block, 1-3 weeks after surgery and required laser iridotomy and topical treatment. CONCLUSION: High IOP is considered a concerning characteristic of the late stages of TASS although such association lack supporting evidence. This study did not detect such an association. High IOP was found only in a small group of TASS patients in the early perioperative period.

Diagnosis of Pseudoexfoliation Syndrome in Pseudophakic Patients.

OBJECTIVE: The aim of this study was to evaluate the sensitivity and specificity of pseudoexfoliation syndrome diagnosis in pseudophakic patients and potential means of improving it. METHODS: This prospective, nonrandomized study comprised 41 consecutive patients (41 eyes) scheduled for cataract surgery at a tertiary medical center during 2016 and 2017. Preoperatively, all patients underwent a detailed slit-lamp examination, including gonioscopic assessment of the iridocorneal angle. The examination was performed by a glaucoma specialist who completed an assessment form documenting the presence/absence of clinical signs of pseudoexfoliation syndrome. It was repeated 1-2 weeks postoperatively by a second, masked, glaucoma specialist. RESULTS: Sixteen patients (39.0%) were diagnosed with pseudoex-foliation syndrome preoperatively. The diagnosis was confirmed postoperatively in 11/16 patients (68.8% sensitivity) and in an additional patient not diagnosed preoperatively (96% specificity). The ability to diagnose pseudoexfoliation syndrome postoperatively was significantly worse than preoperatively (Z = 12.161, p < 0.0001). Pupillary border deposits (75% of cases) and the Sampaolesi line (83.3%) were the cornerstones of the postoperative diagnosis; anterior capsular deposits were evident in only 41.6% of cases diagnosed postoperatively (31.3% of the originally diagnosed cases). CONCLUSIONS: Underdiagnosis of pseudoexfoliation syndrome is common in pseudophakic patients and may have significant implications for future management. Careful attention to pupillary border anatomy and meticulous gonioscopic assessment of the iridocorneal angle are essential for accurate diagnosis. Preoperative documentation of pseudoexfoliation syndrome could help prevent this diagnostic pitfall.

Proptosis due to intraorbital space-occupying lesions in children.

PURPOSE: To report the 10-year experience of two tertiary medical centers with children presenting with proptosis due to an intraorbital space-occupying lesion. METHODS: Patients were identified by file review. Data were collected on demographics, findings on ophthalmologic and imaging evaluations, etiology, treatment, and outcome. RESULTS: Nineteen children (7 male) were included. Eleven patients had optic nerve glioma, including 9 with substantially decreased visual acuity. Treatment consisted of chemotherapy alone or with radiation, resection or anti-VEGF agents, MEK inhibitor, or observation only (n = 1). Visual and cosmetic outcomes were poor in all cases. Outcome for arteriovenous malformations was good following corticosteroid treatment (n = 1), but catheterization led to persistent proptosis and fluctuating visual acuity (n = 1). Compound capillary hemangioma (n = 1) was treated with laser and systemic beta blockers with satisfactory results. Rhabdomyosarcoma had a good prognosis in one patient treated with resection and radiation but was fatal in another even after chemotherapy. Juvenile xanthogranuloma, frontal bone osteoma, and localized hypertrophic neuropathy of the supraorbital nerve (n = 1 each) were treated by resection with good visual and cosmetic outcomes. CONCLUSIONS: Proptosis accompanied by visual loss is an uncommon presentation in children and suggests an orbital tumor. We found that visual outcome was better when the nerve was not involved by tumor. Optic nerve glioma was the most common cause and failed to respond to various treatments. Catheterization for arteriovenous malformation did not prevent proptosis, and final visual acuity fluctuated. Surgery for rhabdomyosarcoma and xanthogranuloma led to remission with preservation of vision in 2 of 3 cases.

PATIENTS WEARING FACE MASKS DURING INTRAVITREAL INJECTIONS MAY BE AT A HIGHER RISK OF ENDOPHTHALMITIS.

PURPOSE: To investigate the safety of face masks worn by patients during intravitreal injections. METHODS: A prospective, qualitative, interventional study performed in a tertiary university hospital. Healthy volunteers were asked to wear three different professional surgical face masks while air leaks around the eyes were monitored. Three types of masks were investigated as follows: 1) surgical face mask with four tying strips, 2) surgical face mask with elastic ear loops and 3) 2200 N95 tuberculosis particulate face mask. For each session the periocular area was inspected for air leak during normal respiration, speech, and deep respiration. Detection of air leak was performed using the following two professional thermal cameras: FLIR A310-thermal camera and EyeCGas 2.0-super sensitive infrared camera used for detection of minute fugitive emissions of industrial gases. RESULTS: Ten healthy volunteers were enrolled in this study. The experiment was repeated 45 times for each camera; 3 times for each of 3 mask types, on 5 volunteers, for a total of 90 trials. Air jets were detected originating from the superior edges of the masks radiating toward the eyes in 81% (73/90) of cases in total; 71% (32/45) with the FLIR camera and 91% (41/45) with the OPGAL camera. Air leaks were detected with all investigated mask types. CONCLUSION: Patients wearing face masks during intravitreal injections may be at a higher risk of endophthalmitis. Until further data are available, we recommend verifying proper face mask fitting and either taping the upper edges of the face masks with a medical adhesive tape or using an adhesive surgical drape around the injected eye.

Management of severe persistent fetal vasculature: case series and review of the literature.

PURPOSE: Persistent fetal vasculature (PFV) is a unique ocular disorder usually presenting early in life. The unregressed embryonal hyaloid vasculature poses a risk of severe ocular complications leading to decreased visual acuity. Surgery is the mainstay of therapy in complicated cases. We describe the clinical presentation and surgical treatment of PFV managed at our center from 2012 to 2015. METHODS: The study is a case series comprised eight patients who were diagnosed with complicated severe PFV. All were managed with a tailored surgical approach. The clinical characteristics, medical and surgical treatment, and follow-up findings of each case are described. RESULTS: There were six males and two females. Surgical intervention involved anterior or posterior vitrectomy, lens extraction, and intraocular lens implantation. Hyaloid stalk removal with release of ciliary traction was variably utilized in selected cases. Endodiathermy controlled intraocular bleeding, and intraocular scissors proved helpful in anterior PFV for disinserting the ciliary process from an abnormally thickened posterior lens capsule. Visual outcomes differed in each case, depending on multiple clinical factors. CONCLUSION: Severe complex PFV presents a therapeutic challenge. A tailored surgical approach with meticulous postoperative management is essential for visual rehabilitation.

Difficulty in Distinguishing Posterior Reversible Encephalopathy Syndrome, Hypoxic-Ischemic Insult, and Acute Toxic Leukoencephalopathy in Children.

AIM: This study aims to describe our experience of unique pediatric neurological cases and associated difficulty in differentiating posterior reversible encephalopathy syndrome (PRES) from hypoxic-ischemic insult (HII), and acute toxic leukoencephalopathy (ATL). METHODS: The study included three children with a clinical picture suggestive of PRES, HII, and ATL of different etiologies who were diagnosed and treated at a tertiary pediatric medical center in 2011 to 2014. RESULTS: All patients presented with blindness following seizures with asphyxia/aspiration in a syndromatic child, too-rapid lipid infusion in a child with acute lymphoblastic leukemia, and repeated vomiting in a child with cerebral palsy, hydrocephalus, and malfunction of ventriculoperitoneal shunt. All patients had cortical blindness and high-signal foci in the cortical and subcortical regions on magnetic resonance imaging. All children improved. CONCLUSIONS: Familiarity with the clinical and radiological characteristics of neurological conditions leading to reversible cortical blindness is essential for diagnosis and management. Distinguishing PRES from HII and ATL can be challenging. Our cases most likely combined these etiologies, with the first patient diagnosed with PRES with HII, the second with PRES with ATL, and the third with focal HII. Given the diversity of the findings and the unclear prognostic significance, studies of the pathophysiology of PRES are warranted.

Time trends of viral meningitis among young adults in Israel: 1978-2012.

Viral meningitis (VM) is a medical condition of public health concern, as it is a common sporadic and epidemic illness. However, there is limited data on the epidemiology of VM. The purpose of this study was to analyze long-term and seasonal trends of VM in a young adult military population. VM is a obligatory notifiable disease in the Israel Defense Forces. For the present study, the archives of the Army Health Branch were reviewed for all cases of VM from January 1, 1978 to December 31, 2012, and the annual, monthly, and seasonal rates were calculated. The annual incidence over the 35-year period showed a high peak every 3-5 years followed by a quiescent period of 2-3 years, reaching as high as 58.4 per 100,000 in 1980 and as low as 3.0 per 100,000 in 2005. This cyclic pattern has diminished over the last decade, reflected by a decline in mean incidence (10.46 per 100,000 in 2003-2012 compared to 19.79 per 100,000 in 1978-2002). Average monthly rates ranged from 1.0 cases per 100,000 soldiers in January/February to 2.2 per 100,000 in July/August. The difference in average rates between winter (1.2 cases per 100,000) and summer (1.9 cases per 100,000) was statistically significant (p < 0.001). Analysis of the long-term epidemiology of VM shows an epidemic pattern, with predominance in the warmer months. Identifying viral causes of meningitis may spare patients unnecessary treatment while prompting the introduction of public health interventions and control measures, especially in crowded settings.

[Isolated sixth nerve palsy--presenting sign of multiple myeloma].

Multiple myeloma is a disease caused by neoplastic plasma cells. Initial symptoms in most cases described in the literature include chest and lumbar pain, paresthesia, paraplegia, general weakness and renal failure. We report a case of isolated sixth nerve palsy causing diplopia as the presenting sign of multiple myeloma. Awareness of such a rare clinical presentation - especially when the existence of multiple myeloma is ignored after visualization of a cranial mass with magnetic resonance imaging (MRI) and computerized tomography (CT)--can prevent unnecessary surgical intervention and delay the appropriate treatment.

Descemet membrane endothelial keratoplasty compared with ultrathin Descemet stripping automated endothelial keratoplasty: a meta-analysis.

AIMS: This study aims to compare the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) and ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) in patients with corneal endothelial dysfunction due to Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy. METHODS: We conducted a meta-analysis using a literature search of Embase, PubMed, Cochrane CENTRAL, ClinicalTrials.gov and WHO ICTRP databases. We included randomised controlled trials (RCTs) and cohort studies that compared DMEK and UT-DSAEK (graft<130 µm), with a follow-up of ≥12 months, published until 20 February 2022. We used the Revised Cochrane risk-of-bias tool for RCTs and the Risk of Bias in Non-Randomised Studies-of Interventions system for cohort studies. RESULTS: Out of 144 records, 8 studies (3 RCTs, 2 fellow-eye studies and 3 cohort studies) were included, encompassing 376 eyes, (N=187 DMEK vs N=189 UT-DSAEK). The 12-month logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) was better post-DMEK (mean difference -0.06 (95% CI -0.10 to -0.02)), but with higher rebubbling risk: OR 2.76 (95% CI 1.46 to 5.22). Heterogeneity was significant I2=57%. Findings were consistent when excluding retrospective studies, including only studies with low risk of bias or RCTs only. An analysis of studies with mean DSAEK grafts <70 µm showed no significant difference in BCVA between the procedures. Publication bias was found in the BCVA analysis (Egger's test p=0.023). CONCLUSIONS: Post-DMEK BCVA is superior to post-UT-DSAEK when using <130 µm grafts. DSAEK grafts <70 µm may not significantly differ from DMEK. The higher risk of rebubbling with DMEK necessitates an appropriate selection of patients. PROSPERO REGISTRATION NUMBER: CRD42022340805.

Ocular Torsion in Children with Horizontal Strabismus or Orthophoria.

PURPOSE: To report the rate of ocular torsion in children with horizontal strabismus or orthophoria. METHODS: A retrospective study design was used. Nineteen children were included in the study, including seven girls, aged 4-16 years. All patients were examined for strabismus and 12 were scheduled for surgical intervention. All participants had digital fundus photos (DRSplus, Padova, Italy) of both eyes at presentation, and 5 of 12 also had fundus photos following the strabismus operation. Patient files were reviewed for age, demographic data, type of strabismus, clinical symptoms and signs, orthoptic exams, subjective and objective reports of torsion, inferior oblique overaction, and V pattern. Fundus photos were analyzed for torsion by ImageJ software [ImageJ 1.54f, National Institute of Health, USA]. The disc-foveal angle was calculated for ocular torsion. Disc-foveal angle was defined as the angle formed between a line passing through the center of the optic disc to the fovea and another horizontal line passing through the center of the optic disc, using fundus photographs. RESULTS: Of the 19 children, 18 had horizontal strabismus: 9 with exotropia and 9 with esotropia. One child was orthophoric with torsional strabismus. Inferior oblique overaction was detected in all but 3 children, while V pattern was documented in 10. Visual acuity was reduced (under 6/12) in four eyes of four children. None were symptomatic for ocular torsion. Although extorsion was documented clinically in 3 of 19 children, it was measurable on fundus photos in all patients before surgery with a mean of 8.7 ± 8.5 degrees and 8.5 ± 9.7 degrees in the right and left eyes, respectively. The mean extorsion in both eyes was 19.7 ± 10.1 degrees and improved to a mean of 15.3 ± 7.9 degrees in the children who were operated on and had documented postoperative fundus photographs. CONCLUSIONS: Extorsion was detected on fundus photos at a significantly higher rate than in clinical examination. Notably, inferior oblique overaction was mainly associated with torsion. This study demonstrated that torsion is underdiagnosed in clinical examinations, as the children are often asymptomatic, but fundus photos which are easily obtained can improve its detection.

Optical Coherence Tomography Angiography for the Differentiation of Glaucoma from Pituitary Macroadenoma Related Optic Disc Measurements.

OBJECTIVE: To determine the potential of optical coherence tomography (OCT) and OCT angiography (OCTA) to distinguish between glaucoma and pituitary macroadenoma by optic disc appearance. METHODS: This prospective case-control study comprised 31 patients: 23 with glaucoma (18 male, 5 female) and 8 with pituitary macroadenoma and chiasmatic compression (3 male, 5 female). The corresponding mean ages were 72.8 years (range 58-90) and 60.7 years (range 43-73). All participants underwent complete ophthalmological examination, spectral domain OCT and OCTA, and visual field testing. Clinical, imaging, and visual field results were compared between the groups. RESULTS: On OCT analysis, the glaucoma group had relatively lower peripapillary retinal nerve fiber layer (RNFL) thickness (65.79 ± 15.46, 86.0 ± 11.37, respectively, P = .002) and lower rim area (1.00 ± 0.22 mm2 and 1.2 ± 0.15 mm2, respectively, P = .005). On OCTA, peripapillary vessel density was significantly lower in all quadrants in the glaucoma group. The significance of these between-group differences was maintained when patients were stratified by visual field mean deviation. CONCLUSIONS: This is the first comparative analysis of optic disc morphology between glaucoma and pituitary macroadenoma using combined OCT and OCTA. The results yielded lower peripapillary RNFL thickness, lower rim area, and lower peripapillary vessel density in the glaucoma group. These parameters may aid in the initial differentiation between these two optic neuropathies.

Long-Term Evaluation of Pseudoexfoliation Syndrome Post-Cataract Extraction.

The study aimed to examine the effect of cataract extraction on ophthalmologists' ability to detect pseudoexfoliation (PXF) syndrome. A total of 31 patients admitted for elective cataract surgery were enrolled in this prospective comparative study. Prior to surgery, patients underwent slit-lamp examination and gonioscopy conducted by experienced glaucoma specialists. Subsequently, patients were re-examined by a different glaucoma specialist and comprehensive ophthalmologists. Pre-operatively, 12 patients were diagnosed with PXF on the basis of a Sampaolesi line (100%), anterior capsular deposits (83%), and pupillary ruff deposits (50%). The remaining 19 patients acted as controls. All patients were re-examined 10-46 months post-operatively. Of the 12 patients with PXF, 10 (83%) were correctly diagnosed post-operatively by glaucoma specialists and 8 (66%) by comprehensive ophthalmologists. There was no statistically significant difference in PXF diagnosis. However, detection of anterior capsular deposits (p = 0.02), Sampaolesi lines (p = 0.04), and pupillary ruff deposits (p = 0.01) were significantly lower post-operatively. Diagnosis of PXF is challenging in pseudophakic patients as the anterior capsule is removed during cataract extraction. Therefore, PXF diagnosis in pseudophakic patients relies mainly on the presence of deposits at other anatomical sites, and careful attention to these signs is required. Glaucoma specialists may be more likely than comprehensive ophthalmologists to detect PXF in pseudophakic patients.

Azithromycin and Sildenafil May Have Protective Effects on Retinal Ganglion Cells via Different Pathways: Study in a Rodent Microbead Model.

Decreased blood flow to the optic nerve (ON) and neuroinflammation are suggested to play an important role in the pathophysiology of glaucoma. This study investigated the potential neuroprotective effect of azithromycin, an anti-inflammatory macrolide, and sildenafil, a selective phosphodiesterase-5 inhibitor, on retinal ganglion cell survival in a glaucoma model, which was induced by microbead injection into the right anterior chamber of 50 wild-type (WT) and 30 transgenic toll-like receptor 4 knockout (TLR4KO) mice. Treatment groups included intraperitoneal azithromycin 0.1 mL (1 mg/0.1 mL), intravitreal sildenafil 3 µL, or intraperitoneal sildenafil 0.1 mL (0.24 µg/3 µL). Left eyes served as controls. Microbead injection increased intraocular pressure (IOP), which peaked on day 7 in all groups and on day 14 in azithromycin-treated mice. Furthermore, the retinas and ON of microbead-injected eyes showed a trend of increased expression of inflammatory- and apoptosis-related genes, mainly in WT and to a lesser extent in TLR4KO mice. Azithromycin reduced the BAX/BCL2 ratio, TGFß, and TNFα levels in the ON and CD45 expression in WT retina. Sildenafil activated TNFα-mediated pathways. Both azithromycin and sildenafil exerted a neuroprotective effect in WT and TLR4KO mice with microbead-induced glaucoma, albeit via different pathways, without affecting IOP. The relatively low apoptotic effect observed in microbead-injected TLR4KO mice suggests a role of inflammation in glaucomatous damage.

Genetic Alteration Analysis of IDH1, IDH2, CDKN2A, MYB and MYBL1 in Pediatric Low-Grade Gliomas.

Objective: To investigate pediatric low-grade gliomas for alterations in IDH1, IDH2, CDKN2A, MYB, and MYBL1. Materials and Methods: DNA and RNA were extracted from 62 pediatric gliomas. Molecular methods included PCR, RT-PCR, and RNA sequencing; Sanger sequencing was used for validation. Results: Analysis for hotspot genetic alterations in IDH1 R132 and IDH2 R172 (45 and 33 samples) was negative in all cases. CDKN2A deletions were detected in exons 1 and 2 in 1 (pleomorphic xanthoastrocytoma) sample of 9 samples analyzed. Of 10 samples analyzed for MYB translocation, 4 each were positive for translocations with exon 2 and exon 3 of PCDHGA1. Six samples showed MYBL rearrangement. The lack of IDH1/2 genetic alterations is in accordance with the literature in pediatric tumors. Alterations in MYB, MYBL were recently reported to characterize diffuse grade II, but not grade I, gliomas. Conclusion: We optimized methods for analyzing gene variations and correlated the findings to pathological grade. The high incidence of MYB and MYBL need further evaluation. We also compared DNA, RNA, and RNA sequencing results for fusion, translocation, and genetic alterations. More accurate identification of the underlying biology of pediatric gliomas has implications for the development of targeted treatment.