The Association of Cardiovascular and Neurological Comorbidities in Geriatric Patients Sustaining Ocular Trauma.

Purpose: Falls are associated with ocular trauma in the elderly. However, it is unlikely for a fall to cause ocular injury unless there is a disruption in the protective maneuvers that shield the face. We suspect ocular injury may be an early indicator of systemic or neurologic degeneration. This study investigates the 5-year incidence of cardiovascular and neurodegenerative diseases in older patients who sustained ocular or periorbital injuries. Patients and Methods: This was a retrospective cohort study. The study population included 141 patients over the age of 65 who sustained trauma to the eye, orbit, or eyelid between April 2011 and June 2016. The control population included 141 patients with a similar range of comorbidities who received cataract surgery during the same period. The study measured new diagnoses of various disorders during the 5-year period following presentation. Results: There were a total of 180 females and 102 males in the study. The mean ages of the control and subject group were 76 and 81.8, respectively. Of our twelve tested comorbidity types, patients that suffered a periocular trauma were more likely to develop heart failure (p=0.00244), dementia (p=0.00002), Alzheimer's disease (p=0.00087), and vascular disease (p=0.00037). Conclusion: Geriatric patients who sustained ocular and periocular injuries had a greater incidence of heart failure, dementia, Alzheimer's disease, and atherosclerosis diagnoses in the 5-year period following injury. The findings of this study suggest that periocular trauma may be an early indicator of underlying degenerative or systemic disease. Ophthalmologists should ensure proper primary care follow-up in conjunction with recovery from injury.

The effect of a brief, unplanned treatment delay on neovascular age-related macular degeneration patients: a retrospective cohort study.

Non-compliance to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy can result in increased disease activity in neovascular age-related macular degeneration (nAMD). Our study aims to determine effects of unplanned delay in anti-VEGF injection treatment for nAMD. This retrospective observational study included patients with delays in receiving intravitreal injections for nAMD treatment from March to May 2020 by at least 21 days. Baseline demographic and clinical characteristics, visual acuity (VA), central macular thickness (CMT) measured on optical coherence tomography (OCT), and duration of delayed treatment were analyzed for 3 time points, the pre-delay visit (v1) and post-delay visits (v2 and v3). Data were compared to age-matched controls treated for nAMD in 2019 without delay. Demographic characteristics were compared using two-sample t-tests for continuous variables and Pearson's chi-square tests for categorical variables. For the two primary outcomes of interest, VA and CMT, means and standard deviations were reported for each combination of group and time. Each outcome was modeled using a linear mixed model with the group, time and group-time interaction as fixed effects. A total of 69 patients (99 eyes) in the treatment delay group and 44 patients (69 eyes) in the control group were identified. Statistically significant differences between control and delayed groups were detected for VA (difference in mean logMAR = 0.16; 95% CI 0.06, 0.27; p = 0.002) and CMT (difference in mean CMT = 29; 95% CI 12, 47; p = 0.001) at v2. No differences were detected for v1 and v3 time points for both outcomes. An unplanned delay in intravitreal injection treatment for nAMD resulted in an increase in CMT and worsening of VA compared to controls observed at v2. At v3, CMT and VA recovered to near v1 levels. This study demonstrates that a one-time, brief interruption in treatment for nAMD results in reversible, temporary worsening.

A case of JOAG in a patient with Rett syndrome.

Purpose: In this report, we describe a case of juvenile open angle glaucoma in a patient with Rett syndrome. Observations: A 39- year-old white woman with a notable history of Rett syndrome was referred to our center with a ten-year diagnosis of juvenile open angle glaucoma. Initial exam was notable for complete cupping of the optic nerve. Upon follow up visits, intraocular pressures were elevated and remained refractory to multiple therapies, including SLT and pressure-lowering drops. Medical management was continued due to the risk of surgery and limited visual potential. Because it was declared that patient did not have substantial feedback to visual stimuli and did not exhibit any signs of pain, conservative management with drops was continued. Conclusion and importance: This is the first report of a patient with concurrent Rett syndrome and juvenile open angle glaucoma, thus expanding on the literature of an ocular manifestation occurring presumably coincidentally with this disorder.

A Pilot Study Assessing Treatment Outcomes in Neovascular Glaucoma Using Ahmed Glaucoma Valve with and without Cyclophotocoagulation.

Purpose: The purpose of this retrospective pilot study was to examine the short-term effect of simultaneous Ahmed Glaucoma Valve implantation and cyclophotocoagulation on postoperative outcomes in patients with neovascular glaucoma. Methods and materials: Patient charts were selected for inclusion in this study if they carried a diagnosis of neovascular glaucoma and underwent Ahmed glaucoma valve implantation only, Ahmed glaucoma valve implantation with cyclophotocoagulation, or cyclophotocoagulation only. A total of 55 eyes of 54 patients were selected for data collection and analysis. Main outcome measures included 1-, 3-, and 6-month intraocular pressure and occurrence of the hypertensive phase. Other outcomes included visual acuity, surgical complication rate, and a number of 6-month postoperative ophthalmic medications. Results: A significantly lower intraocular pressure was seen in the group that received Ahmed glaucoma valve implantation + cyclophotocoagulation compared to the Ahmed glaucoma valve-only group at 3 and 6 months (p = 0.03 and <0.001, respectively). The difference in the occurrence of the hypertensive phase between the Ahmed glaucoma valve-only group and the Ahmed glaucoma valve + cyclophotocoagulation group approached but did not reach significance (p = 0.052). A significantly lower intraocular pressure was also seen in the cyclophotocoagulation-only group compared to the Ahmed glaucoma valve-only group at 3 months (p = 0.006). Conclusion: Simultaneous Ahmed glaucoma valve implantation and cyclophotocoagulation significantly lowered intraocular pressure at 3 and 6 months compared to Ahmed glaucoma valve implantation alone in patients with neovascular glaucoma. Clinical significance: Neovascular glaucoma is difficult to manage medically and surgically. When surgery is performed, intraocular pressure often remains elevated postoperatively despite aggressive medical management. This study examines a novel method to lower intraocular pressure after Ahmed glaucoma valve implantation in patients with neovascular glaucoma. How to cite this article: Ford RL, Knight ORJ, Klifto MR, et al. A Pilot Study Assessing Treatment Outcomes in Neovascular Glaucoma Using Ahmed Glaucoma Valve with and without Cyclophotocoagulation. J Curr Glaucoma Pract 2022;16(1):4-10.

Comparison of Time-to-Surgery and Outcomes in Transferred Vs Non-Transferred Open Globe Injuries.

Purpose: It is widely accepted in the field of ophthalmology that closure of open globes within 24 hours of the injury results in the best visual outcomes. This study investigates the time-to-surgery and visual outcomes of open globe injury patients in North Carolina that were transferred to our institution before receiving surgical intervention as compared to those that were not transferred. Patients and methods: This is a retrospective cohort study using data from UNC Hospitals trauma registry. Demographics, time of injury, final clinical outcomes, time to surgical intervention, and transfer history were extracted and analyzed. The study population includes open globe injury patients of all ages that were seen and treated at our institution from 2005 to 2020. Patients were divided based on transfer history. The transfer group consisted of patients who were transferred from an outside hospital to our tertiary care facility for surgical treatment. The non-transfer group consisted of patients who arrived at our tertiary care facility directly after injury. Results: In total, 238 open globe injuries were evaluated. Of those, 197 were transferred and 41 were not transferred. Compared to non-transfer patients, transfer patients had longer delays between injury and surgery, between presentation at the initial ED and surgery, and between injury and arrival at the tertiary care center. On average, the delay between injury and surgical intervention was 3 hours and 51 minutes longer for transfer patients compared to non-transfer patients. Eight patients in the transfer group were delayed >24 hours due to inter-hospital transfer. Additionally, transfer patients on average suffered from poorer final visual acuities, with an average final visual acuity of 1.84 logMAR in the transfer group and 1.35 logMAR in the non-transfer group. Conclusion: Our study found that inter-hospital transfer leads to significant delays in primary closure of open globe injuries. Injuries that were transferred to a tertiary care center before receiving surgical intervention on average resulted in worse final visual acuities.

Central Retinal Vein Occlusion Associated with Fibromuscular Dysplasia: A Case Report.

In this report, we detail a rare presentation of central retinal vein occlusion (CRVO) in a patient with fibromuscular dysplasia (FMD). A 45-year-old woman with a 12-year history of FMD presented to the ophthalmology clinic with symptoms and exam findings consistent with CRVO. Dilated fundus examination revealed disc edema, diffuse flame, and dot-blot hemorrhages, and tortuous, engorged retinal veins. The patient was diagnosed with CRVO, and she was treated with monthly anti-VEGF monoclonal antibody followed by a VEGF inhibitor. At her most recent follow-up, her macular edema was resolved and her visual acuity had markedly improved. FMD has been shown to rarely present with retinal manifestations, especially in patients with hypertension. This appears to be first case report to document CRVO in the context of known FMD. We suggest that CRVO be considered as a potential complication for young patients with FMD.

Cerebrospinal fluid and ophthalmic disease.

PURPOSE OF REVIEW: The purpose of this review is to discuss the contemporary body of literature examining the relationship between cerebrospinal fluid (CSF) and ophthalmic disease. This review focuses on diseases that have a pathogenesis related to the translaminar pressure difference, defined as the pressure difference between the orbital subarachnoid space (OSAS) and the intraocular pressure. The diseases discussed include glaucoma, idiopathic intracranial hypertension, and spaceflight associated neuro-ocular syndrome. RECENT FINDINGS: The relationship between cerebrospinal and ophthalmic disease has been investigated for over 100 years. Recent research provides insight into the mechanisms that dictate CSF circulation in the OSAS and how alterations in these mechanism lead to disease. This review discusses these recent findings and their relationship to major ophthalmic diseases. SUMMARY: The recent findings provide insight into diseases that have pathogenic mechanisms that are not fully understood. This information will help physicians gain a clearer understanding of the relationship between CSF and ophthalmic disease and guide future research.

Chronic Kidney Disease as a Predictor of Postoperative Choroidal Effusions After Glaucoma Surgery.

PRCIS: Patients with chronic kidney disease (CKD) are at increased risk for choroidal effusion development following glaucoma surgery. PURPOSE: Choroidal effusion is a postoperative complication of glaucoma surgery that results from a transudative fluid collection in the suprachoroidal space. Kidney disease alters bodily fluid dynamics through a variety of mechanisms. The relationship between CKD and choroidal effusion following glaucoma surgery has not previously been studied. The purpose of this study was to determine the relationship between CKD and choroidal effusion development after glaucoma surgery. PATIENTS AND METHODS: This retrospective cohort study consisted of 86 eyes from 86 patients who received glaucoma filtering surgery or transscleral cyclophotocoagulation within the study timeframe. Forty-three patients had CKD, and 43 patients did not have kidney disease. The main outcome of this study was the development of choroidal effusion measured by the Pearson χ2 test and multivariate analysis using a binomial regression with a log link. RESULTS: Ten patients (23.3%) in the CKD group developed choroidal effusion, while 2 patients (4.7%) in the no-kidney disease group developed choroidal effusion (relative risk, 5.0; 95% confidence interval: 1.16-21.5; P=0.013). The association between CKD and choroidal effusion showed mixed results in the multivariate analysis, with some analyses showing a significant association and others showing no significant association. CONCLUSIONS: In both the univariate and multivariate analyses, CKD was found to be significantly associated with choroidal effusion after glaucoma surgery.

Evolution of a Glaucoma Fellow's Surgical Training: Improvements in Tube Shunt Case Times during the Academic Year.

Purpose The aim of the study is to report changes in tube shunt placement surgical case times for glaucoma fellows during the course of the academic year. Patients and Methods Electronic health records were retrospectively reviewed to determine patient demographics, surgical case times (defined as procedure start time to procedure end time), and glaucoma fellow involvement. Only cases with a glaucoma fellow as the primary surgeon were included. Operative case times were compared by first and second halves of the academic year (beginning in July and ending in June) using a two-tailed t -test. Results Five hundred and seventy-three individual tube shunt surgeries (385 Ahmed, 188 Baerveldt) performed by 28 glaucoma fellows (17 females, 11 males) at Duke University Eye Center and University of North Carolina Medical Center were included. Overall, case times were significantly shorter in the second half of the academic year as compared with the first (55.3 ± 17.1 minutes vs. 61.0 ± 17.4 minutes, p <0.001). Both male (57.3 ± 16.8 minutes vs. 63.2 ± 18.6 minutes, p = 0.008) and female (53.5 ± 17.3 minutes vs. 59.3 ± 16.4 minutes, p = 0.003) fellows demonstrated shorter case times over the academic year; additionally, female fellows trended toward shorter case times than male fellows in both the first half ( p = 0.072) and second half ( p = 0.053) of the academic year. Fellows also exhibited shorter case times with both Ahmed implants (54.1 ± 16.2 minutes vs. 59.3 ± 15.8 minutes, p = 0.002) and Baerveldt implants (57.8 ± 18.9 minutes vs. 64.2 ± 20.0 minutes, p = 0.025) cases over the academic year. Baerveldt case times were significantly longer than Ahmed cases in the first half ( p = 0.028) and trended toward being longer than Ahmed cases in the second half ( p = 0.070). Conclusion Across 5 years at two academic institutions, glaucoma fellows had shorter primary tube shunt surgical case times in the second half of the academic year. These findings reflect improvement in surgical efficiency throughout glaucoma fellowship. These findings should be taken into consideration when scheduling trainee surgeries at academic medical centers at different points in the academic year.

The Relationship of Travel Distance to Postoperative Follow-up Care on Glaucoma Surgery Outcomes.

PRéCIS:: This study addresses the paucity of literature examining glaucoma patients' distance from clinic on postoperative follow-up outcomes. Greater distance from clinic was associated with higher likelihood of loss to follow-up and missed appointments. PURPOSE: To investigate the relationship of patient travel distance and interstate access to glaucoma surgery postoperative follow-up visit attendance. METHODS AND PARTICIPANTS: Retrospective longitudinal chart review of all noninstitutionalized adult glaucoma patients with initial trabeculectomies or drainage device implantations between April 4, 2014 and December 31, 2018. Patients were stratified into groups on the basis of straight-line distance from residence to University of North Carolina at Chapel Hill's Kittner Eye Center and distance from residence to interstate access. Corrective procedures, visual acuity, appointment cancellations, no-shows, and insurance data were recorded. Means were compared using 2-tailed Student t-test, Pearson χ, analysis of variance, and multivariate logistical regression determined odds ratios for loss to follow-up. RESULTS: In total, 199 patients met all inclusion criteria. Six-month postoperatively, patients >50 miles from clinic had greater odds of loss to follow-up compared with patients <25 miles (odds ratios, 3.47; 95% confidence interval, 1.24-4.12; P<0.05). Patients >50 miles from clinic had significantly more missed appointments than patients 25 to 50 miles away, and patients <25 miles away (P=0.008). Patients >20 miles from interstate access had greater loss to follow-up than those <10 miles (t(150)=2.05; P<0.05). Mean distance from clinic was 12.59 miles farther for patients lost to follow-up (t(197)=3.29; P<0.01). Patients with Medicaid coverage had more missed appointments than those with Medicare plans (t(144)=-2.193; P<0.05). CONCLUSIONS: Increased distance from clinic and interstate access are associated with increased missed appointments and loss to follow-up. Glaucoma specialists should consider these factors when choosing surgical interventions requiring frequent postoperative evaluations.

pH of Mitomycin-C Formulations for Filtration Surgery.

PRECIS: The use of mitomycin-C as a mixed formulation with lidocaine and epinephrine for filtration surgery may alter its pH and consequently affect clinical effectivity.

Intraoperative optical coherence tomography-assisted retrocorneal fibrous membrane biopsy and excision.

PURPOSE: We report a case of retrocorneal fibrous membrane (RCFM) formation following penetrating keratoplasty (PK) and intraoperative optical coherence tomography (OCT)-guided excision of this membrane. OBSERVATIONS: A 68-year-old woman with primary open angle glaucoma and corneal decompensation of the right eye secondary to tube shunt presented for 3-month follow-up of PK. On examination of the right eye, the patient was noted to have a glassy pupillary membrane with traction on the iris. Anterior segment OCT confirmed a membrane connecting the iris to host cornea. The patient underwent biopsy and excision of the membrane assisted by intraoperative OCT. Pathological examination was consistent with Descemet's membrane proliferation. We suspect that this membrane represents retained host's Descemet's membrane following corneal transplantation. CONCLUSIONS: This case highlights the existence of RCFM formation in the context of retained host cornea following PK and the role of intraoperative OCT in management.

Schockmed Valve: A Novel Surgical Option for Uncontrolled Glaucoma in Eyes with Poor Conjunctiva and Encircling Bands.

Surgical management of elevated intraocular pressure (IOP) in an eye with scarred conjunctiva, an encircling band, and silicone oil has limited options. By combining the flow restrictor of the Ahmed Glaucoma Valve (New World Medical, Rancho Cucamonga, California) and the capsule of the encircling band as a conduit for aqueous flow, immediate pressure reduction could theoretically be achieved in eyes with limited conjunctival mobilization. This is a description of a surgical technique in a case of a patient with multiple ocular surgeries with uncontrolled multimechanism glaucoma despite using all available topical and oral glaucoma medications. A combination of the Ahmed valve with a modification of the Schocket shunt technique was used in this case of an encircling band and poor conjunctiva. At 10-month follow-up, the patient maintains controlled pressures on dorzolamide-timolol drops. The combined Ahmed-Schocket (or Schockmed) technique may be another surgical option for management of uncontrolled IOP in cases of scarred conjunctiva and encircling bands needing immediate pressure reduction. SCHOCKMED VALVE: A novel surgical option for uncontrolled glaucoma in eyes with poor conjunctiva and encircling bands.How to cite this article: Fleischman D, Kim B. Schockmed Valve: A Novel Surgical Option for Uncontrolled Glaucoma in Eyes with Poor Conjunctiva and Encircling Bands. J Curr Glaucoma Pract 2017;11(3):120-124.

Retrospective analysis of translaminar, demographic, and physiologic parameters in relation to papilledema severity.

OBJECTIVE: Some case reports suggest that the translaminar pressure difference is important in cases of papilledema. The purpose of this study was to determine ocular, physiologic, and demographic factors associated with papilledema severity. DESIGN: Retrospective, blinded study. PARTICIPANTS: Patients who had undergone a diagnostic lumbar puncture and had a diagnosis of papilledema in conjunction with idiopathic intracranial hypertension between 2004 and 2012 were included in the study. One-hundred and fifty-one patients were identified in initial screening. Sixty of 151 patients met all inclusion criteria, and 120 eyes were eligible for investigation. METHODS: A retrospective review of optic nerve photographs by 2 masked experts was used to grade papilledema severity using the Modified Frisén Scale (MFS). Patients with any systemic or neurologic disease that could affect cerebrospinal fluid pressure (CSFP) were excluded. Patients on acetazolamide were excluded. Assessments within 1 MFS grade were averaged and correlated to intraocular pressure, CSFP, translaminar pressure differential, MFS, age, weight, height, and systolic and diastolic blood pressure. RESULTS: In univariate and multivariate type 3 generalized estimating equation analyses, only age (Z = -2.70; p < 0.01) and sex (Z = 2.81; p < 0.0001) were significantly correlated with MFS. CONCLUSIONS: Papilledema severity decreased with advancing age and was higher for female sex. We found no association between severity of papilledema and CSFP, intraocular pressure, blood pressure, or any other physiologic parameter. Factors other than the translaminar pressure differential may be important in determining the severity of papilledema.

Intraocular and extraocular hemorrhage associated with ligature release of non-valved glaucoma drainage implant.

PURPOSE: To report a rare complication of non-valved glaucoma drainage device surgery. OBSERVATIONS: An 85-year-old pseudophakic white male presented with painless vision loss and bloody tears. He was 5 weeks removed from uncomplicated non-valved glaucoma drainage device (Baerveldt 101-350, [AMO, Santa Clara, CA]). There was serosanguinous discharge without apparent source and a 25% layering hyphema in the anterior chamber. The tube was unobstructed in the anterior chamber and not abutting the iris. There was no presence of neovascularization or other abnormal vessels in the angle. After clearing of the hyphema, the patient had persistent vitreous hemorrhage necessitating pars plana vitrectomy. No source of hemorrhage was identified. CONCLUSIONS AND IMPORTANCE: This is the first report of a rare occurrence of intraocular and extraocular hemorrhage associated following spontaneous release of ligature of a non-valved glaucoma drainage implant. The presumed mechanism was sudden shallowing of the anterior chamber resulting in the tube irritating uveal vasculature. We do not have an explanation for the extraocular blood.

Subcutaneous and periorbital emphysema following dental procedure.

Subcutaneous emphysema following a dental procedure is a relatively uncommon phenomenon that may produce a dramatic clinical presentation. The advent of high-powered dental equipment that uses directed and highly pressurized air has increased the risk of this complication, but few cases have been described in the ophthalmic literature. The authors present a case of subcutaneous periorbital emphysema in a young woman following a dental procedure. Aside from a temporary ptosis, there were no other ophthalmic complications. An attempt to decompress the air produced minimal relief. The condition resolved spontaneously within 1 week.