Minimally Invasive Glaucoma Surgery: Latest Developments and Future Challenges.

The development of minimally invasive glaucoma surgeries (MIGSs) was intended to provide safe and modestly efficacious modalities for early intervention of mild-to-moderate glaucoma, with minimal trauma and rapid recovery. They were mainly ab interno procedures that reduce intraocular pressure by facilitating the aqueous outflow by bypassing the trabecular meshwork resistance, reinforcing the uveoscleral flow via the supraciliary space, and reducing aqueous production by the ciliary body. While the cumulating evidence helps shape the role of the available MIGS, the exponential new development and advancement in this field has expanded the territory of MIGS. Apart from developing subconjunctival MIGS filtration devices (Xen gel stent and PRESERFLO MicroShunt), there is a tendency to revisit the "traditional" MIGS for alternative use and to modify the procedures with consideration of the fundamental aqueous outflow physiology. Combined MIGS has also been suggested, based on the theory that their different mechanisms may provide additive or synergistic effects. The advancement of laser procedures is also promising and could supplement unmet needs along the glaucoma treatment algorithm. This review examines the broad array of MIGS, updates the recent findings, discusses their potential alternative applications, and explores future challenges.

Applications of Extended Reality in Ophthalmology: Systematic Review.

BACKGROUND: Virtual reality, augmented reality, and mixed reality make use of a variety of different software and hardware, but they share three main characteristics: immersion, presence, and interaction. The umbrella term for technologies with these characteristics is extended reality. The ability of extended reality to create environments that are otherwise impossible in the real world has practical implications in the medical discipline. In ophthalmology, virtual reality simulators have become increasingly popular as tools for surgical education. Recent developments have also explored diagnostic and therapeutic uses in ophthalmology. OBJECTIVE: This systematic review aims to identify and investigate the utility of extended reality in ophthalmic education, diagnostics, and therapeutics. METHODS: A literature search was conducted using PubMed, Embase, and Cochrane Register of Controlled Trials. Publications from January 1, 1956 to April 15, 2020 were included. Inclusion criteria were studies evaluating the use of extended reality in ophthalmic education, diagnostics, and therapeutics. Eligible studies were evaluated using the Oxford Centre for Evidence-Based Medicine levels of evidence. Relevant studies were also evaluated using a validity framework. Findings and relevant data from the studies were extracted, evaluated, and compared to determine the utility of extended reality in ophthalmology. RESULTS: We identified 12,490 unique records in our literature search; 87 met final eligibility criteria, comprising studies that evaluated the use of extended reality in education (n=54), diagnostics (n=5), and therapeutics (n=28). Of these, 79 studies (91%) achieved evidence levels in the range 2b to 4, indicating poor quality. Only 2 (9%) out of 22 relevant studies addressed all 5 sources of validity evidence. In education, we found that ophthalmic surgical simulators demonstrated efficacy and validity in improving surgical performance and reducing complication rates. Ophthalmoscopy simulators demonstrated efficacy and validity evidence in improving ophthalmoscopy skills in the clinical setting. In diagnostics, studies demonstrated proof-of-concept in presenting ocular imaging data on extended reality platforms and validity in assessing the function of patients with ophthalmic diseases. In therapeutics, heads-up surgical systems had similar complication rates, procedural success rates, and outcomes in comparison with conventional ophthalmic surgery. CONCLUSIONS: Extended reality has promising areas of application in ophthalmology, but additional high-quality comparative studies are needed to assess their roles among incumbent methods of ophthalmic education, diagnostics, and therapeutics.

MP3 Plus: A Modified Micropulse Transscleral Cyclophototherapy Technique for the Treatment of Refractory Glaucoma.

PRéCIS:: In advanced refractory glaucoma which has failed prior MP3 laser, MP3 Plus is effective in reducing intraocular pressure (IOP) without significant complications. It is also useful as a temporizing procedure before incisional surgery. PURPOSE: To evaluate the efficacy and safety of MP3 Plus, a novel technique using modified micropulse transscleral cyclophototherapy (MPTCP) in eyes with refractory glaucoma or failed MPTCP treatment. METHODS: This is a retrospective interventional case series. In total, 32 consecutive eyes from 29 patients with uncontrolled IOPs who had previous MPTCP or refractory glaucoma underwent MP3 Plus, a modified MPTCP where additional discrete pulses are applied. The main outcome measurement was IOP at 1, 3, 6, and 12 months postprocedure, with success defined as a 20% reduction in baseline IOP, an IOP of 25 mmHg or less, and no need for further reoperation. We collected and analyzed visual acuity, number of glaucoma medications, and complications. RESULTS: The patients had an average of 1.4±0.9 glaucoma procedures before treatment, where 87.5% underwent one or more previous MPTCP with suboptimal response. Of the eyes presenting for follow-up, 51.6% (n=31), 37.0% (n=27), 35.7% (n=28), and 25.9% (n=27) achieved the primary outcome at 1, 3, 6, and 12 months, respectively. Baseline IOP was 33.7±11.6 mmHg (n=32 eyes) and posttreatment IOP at 1, 3, 6, and 12 months were 21.0±9.0 mmHg (n=31; P<0.0001), 26.2±10.8 mmHg (n=25; P<0.0001), 23.2±9.4 mmHg (n=20; P<0.05), and 24.6±9.8 mmHg (n=16; P<0.001), respectively. There was a reduction in glaucoma medications from 3.4±0.8 preoperatively to 2.8±1.2 (n=16; P<0.05) at 12 months. There were no cases of prolonged inflammation or hypotony. CONCLUSIONS: MP3 Plus is effective and safe in lowering IOP in eyes with refractory glaucoma after previous failed MPTCP.

Periorbital muscle atrophy associated with topical bimatoprost therapy.

Topical Bimatoprost is a common and popular prostaglandin analog used as an ocular hypotensive agent in the treatment of glaucoma. Side effects include ocular hyperaemia, ocular pruritus, and periocular and iris pigmentary changes. Perioribital lipodystrophy is another well-documented outcome associated with chronic use of topical bimatoprost, which results in periorbital hallowing, upper eyelid sulcus deepening, eyelid retraction and enophthalmos. We report an unusual case of periocular muscle atrophy and weakness from unilateral topical bimatoprost use. Our patient had primary angle closure and experienced a right upper eyelid ptosis 2 months after she started to use topical bimatoprost in that eye. Clinical measurements of her eyelids clearly showed reduction in the function of her right levator muscle, suggesting that effects of topical bimatoprost may not be limited to periorbital fat. She was advised to stop topical bimatoprost and right ptosis correction surgery with levator muscle advancement was performed successfully. Ophthalmologists and patients should be aware of this potential rare side effect of topical bimatoprost, as it may be potentially disfiguring, especially with monocular use. However, its exact mechanism of action needs to be clarified further.

Survey on the management of orbital and intraocular tumors among oculofacial surgeons in the Asia-Pacific region.

A web-based anonymous survey was performed to assess the common practices of oculofacial surgeons in the management of orbital and intraocular tumors in the Asia-Pacific region. The questionnaire comprised a series of questions covering controversial topics sent via email to 131 oculofacial surgeons across 14 countries in the Asia-Pacific region. A total response rate of 61.7 % was achieved from May to December 2012. The most common benign orbital tumor was cavernous hemangioma (39.6 %) and the most common malignant orbital tumor was lymphoma (85.7 %). 40 % of surgeons recommended orbital radiation, for which the most common indications were thyroid eye disease (70.0 %) and malignancy (30.0 %). The most common orbitotomy approach was lateral (79.2 %). Most surgeons (87.1 %) offered enucleation for retinoblastoma, but there was also a significant proportion that offered chemoreduction with transpupillary thermotherapy or cryotherapy (58.1 %). Fewer surgeons offered brachytherapy (16.1 %) and intra-arterial chemotherapy (6.5 %). When performing enucleation for retinoblastoma, 81.8 % of surgeons performed a primary orbital implant placement. The most preferred type of implant was silicone/acrylic (90.2, 90.2 and 87.8 % for elderly, adults and children, respectively). The majority of surgeons used donor sclera (57.5 %) or no wrapping material at all (32.5 %). Almost all surgeons (95.1 %) did not drill and peg the implant for motility. We report the results of the first survey of oculofacial surgeons in the Asia-Pacific region on the management of intraocular and orbital tumors. In comparison with previous surveys performed in the USA and the UK, we found the practice patterns of the Asia-Pacific surgeons to be comparable.