Same-site trabeculectomy with mitomycin and Ologen™ following failed non-penetrating deep sclerectomy.

PURPOSE: To assess the effectiveness and safety of same-site trabeculectomy (TRAB) with mitomycin C (MMC) and Ologen™ (Aeon Astron Europe BV. Leiden, The Netherlands) in patients with a failed non-penetrating deep sclerectomy (NPDS). METHODS: A retrospective study of 24 consecutive eyes (22 patients) undergoing reintervention by same-site TRAB with at least one-year follow-up after failed NPDS. Mean visual acuity (VA), intraocular pressure (IOP) and use of glaucoma medications were compared before and one year after surgery. Early and late postoperative complications were registered. Kaplan-Meier survival analysis was performed according to four levels of success criteria. RESULTS: Overall the mean IOP reduced significantly (24.9 ± 7.1 vs. 14.4 ± 4.5 mmHg; p < 0.001), and the number of glaucoma medications (2.80 ± 1.01 vs. 0.55 ± 0.94; p < 0.001) significantly decreased, one year after surgery. The mean VA remained stable one year after surgery (p = 0.516). Hypotony, defined as IOP ≤ 5 mmHg, in the early postoperative period was observed in 62.5% of eyes, but only in 2 patients (8.33%) in the long term. The mean survival time ranged from 10 months (CI 95% 5-15) to 29 months (CI 95%: 26-32) according to the most stringent and lenient success criteria respectively. CONCLUSION: Same-site TRAB augmented with MMC and Ologen™ may provide an effective, safe and lasting alternative following failed NPDS, especially when sparing of the conjunctiva is highly desirable. Postoperative hypotony is the most common postoperative complication.

Ocular toxicity after inadvertent overdose of intracameral cefuroxime during cataract surgery.

PURPOSE: To describe intracameral toxic effects of cefuroxime at a higher dose than recommended in cataract surgery. METHODS: Retrospective study of 8 eyes of 8 patients who inadvertently received 12.5 mg/0.1 ml of intracameral cefuroxime due to a dilution error, at the end of the cataract surgery. All patients underwent a strict ophthalmology follow-up for 6 months. RESULTS: All patients presented with a marked anterior segment inflammation with corneal oedema that resolved completely in all cases (between 5 days and 3 months). At 6 months of follow-up a statistically significant difference was found in the corneal endothelial cell density when compared with the fellow eye (P = .038), being <1000 cells/mm2 in 3 cases. Three patients (37.5%) showed early macular oedema, with subfoveal ellipsoid layer disruption in one case as a permanent sequel. One patient developed an optic neuropathy with associated afferent pupillary defect. CONCLUSIONS: Although 1 mg/0.1 ml of intracameral cefuroxime has been shown to reduce the incidence of endophthalmitis, its overdose can have potentially toxic eye effects in both anterior and posterior segments.

Aniridic glaucoma: An update.

Aniridia is a congenital bilateral ocular disorder with dominant autosomal inheritance. More than 50% of patients will develop aniridic glaucoma (AG) during their lives. Open angle glaucoma is more common in aniridia, but a closed angle mechanism has been described in relation with anterior rotation of the rudimentary iris, occluding trabecular meshwork. Diagnosis and follow-up of AG is difficult in relation with the presence of keratopathy, nystagmus and foveal hypoplasia. Central corneal thickness usually measures more than 600 microns, which prevents achieving a reliable value of intraocular pressure. Medical treatment of AG is no different from the rest of glaucoma. It is recommended to use preservative free formulations, and combined therapy is often required. Surgical treatment is needed in many cases. There is no consensus on the first line surgery for AG, but in open angle AG, angle surgery is usually first choice, and glaucoma drainage devices are the next preferred surgical technique. In closed angle AG glaucoma drainage devices are usually the first choice, with trabeculectomy as the second preferred surgical technique.

Aniridic glaucoma: An update. / Actualización en glaucoma anirídico.

Aniridia is a congenital bilateral ocular disorder with dominant autosomal inheritance. More than 50% of patients will develop aniridic glaucoma (AG) during their lives. Open angle glaucoma is more common in aniridia, but a closed angle mechanism has been described in relation with anterior rotation of the rudimentary iris, occluding trabecular meshwork. Diagnosis and follow-up of AG is difficult in relation with the presence of keratopathy, nystagmus and foveal hypoplasia. Central corneal thickness usually measures more than 600 microns, which prevents achieving a reliable value of intraocular pressure. Medical treatment of AG is not different from the rest of glaucoma. It is recommended to use preservative free formulations, and combined therapy is often required. Surgical treatment is needed in many cases. There is no consensus on the first line surgery for AG, but in open angle AG, angle surgery is usually first choice, and glaucoma drainage devices are the next preferred surgical technique. In closed angle AG glaucoma drainage devices are usually the first choice, with trabeculectomy as the second preferred surgical technique.

Ocular toxicity after inadvertent overdose of intracameral cefuroxime during cataract surgery. / Toxicidad ocular tras sobredosificación accidental de cefuroxima intracameral en cirugía de catarata.

PURPOSE: To describe intracameral toxic effects of cefuroxime at a higher dose than recommended in cataract surgery. METHODS: Retrospective study of 8 eyes of 8 patients who inadvertently received 12.5mg/0.1ml of intracameral cefuroxime due to a dilution error, at the end of the cataract surgery. All patients underwent a strict ophthalmology follow-up for 6 months. RESULTS: All patients presented with a marked anterior segment inflammation with corneal oedema that resolved completely in all cases (between 5 days and 3 months). At 6 months of follow-up a statistically significant difference was found in the corneal endothelial cell density when compared with the fellow eye (P=.038), being<1000 cells/mm2 in 3 cases. Three patients (37.5%) showed early macular oedema, with subfoveal ellipsoid layer disruption in one case as a permanent sequel. One patient developed an optic neuropathy with associated afferent pupillary defect. CONCLUSIONS: Although 1mg/0.1ml of intracameral cefuroxime has been shown to reduce the incidence of endophthalmitis, its overdose can have potentially toxic eye effects in both anterior and posterior segments.

Recommendations for eye care during the alarm state by the coronavirus disease pandemic COVID-19. / Recomendaciones para la atención oftalmológica durante el estado de alarma por la pandemia de enfermedad por coronavirus COVID-19.

OBJECTIVE: Minimize exposure to the SARS-CoV-2, reduce the chances of cross-transmission between patients and healthcare personnel, and prevent the development of postoperative complications from the management of patients with eye diseases during the 2019 coronavirus disease pandemic (COVID-19). METHODS: COVID-19 literature review and consensus establishment between different Spanish ophthalmology societies in order to provide guidelines and recommendations of maximum resources primarily conditioned by the state of alert, confinement and social distancing that occurs in Spain since March 16, 2020. RESULTS: The recommendations will promote the adoption of action and protection measures for eye care in outpatient clinics, surgical areas and hospitalization, for unconfirmed (asymptomatic and symptomatic) and confirmed COVID-19 patients. Measures must be adapted to the circumstances and availability of personal protective equipment in each of the centers and Autonomous Communities, which will be updated according to the pandemic phases and the measures adopted by the Spanish Government. CONCLUSIONS: During the COVID-19 pandemic, attention to the potential health risks to the population caused by coronavirus should prevail over the possible progression of the common eye diseases. Ophthalmologists and other eye care professionals must assume a possible progression of these diseases due to the impossibility of adequate patient follow-up.

New therapeutic targets in the treatment of age-related macular degeneration. / Nuevas dianas terapéuticas en el tratamiento de la degeneración macular asociada a la edad.

Age-related macular degeneration and especially neovascular age-related macular degeneration is the leading cause of low vision in developed countries. Even though the introduction of anti-VEGF drugs in recent years completely changed the management of this condition, its cost, the need for repeated intravitreal injections, and loss of efficacy in the long term are still issues to deal with. Currently, a new generation of novel therapies under development is attempting to address some of these limitations. Some of the most prominent among them are new anti-VEGFs such as brolucizumab or abicipar, drugs against angiopoietin-2 receptor such as faricimab, sustained-release systems, or tyrosine kinase inhibitors. As regards dry age-related macular degeneration, neuroprotection, the complement pathway, and stem cell therapy are the most promising targets currently under investigation.

Acute and chronic optic nerve head biomechanics and intraocular pressure changes in patients receiving multiple intravitreal injections of anti-VEGF.

PURPOSE: To evaluate acute and chronic changes in optic nerve head (ONH) structures and intraocular pressure (IOP) in patients receiving intravitreal injections (IVIs) of anti-VEGF. METHODS: Twenty-nine eyes receiving IVIs for the first time were studied. IOP, retinal nerve fiber layer (RNFL) thickness, and ONH structures were evaluated by Spectralis optical coherence tomography with enhanced depth imaging technology. Structures were measured before and 5 min after each one of the three monthly injections of a loading dose treatment. In 13 eyes (44.8%) with more than six IVIs, another evaluation pre and immediately postinjection was performed after 1 year. RESULTS: A significant acute and transient IOP increase (all p ≤ 0.001), Bruch's membrane opening (BMO) enlargement (p ≤ 0.001), cup widening (p < 0.05) and deepening (p ≤ 0.001), and prelaminar tissue thinning (p ≤ 0.001) were observed 5 min after each injection. Compared with baseline values, a significant BMO expansion (p = 0.001) and RNFL thinning (p < 0.001) were observed in the third month. In eyes with more than six IVIs, similar immediate postinjection changes, including IOP increase (p = 0.001), prelaminar tissue thinning (p = 0.007), and cup deepening (p = 0.012) were observed at 1 year, while BMO expansion was not significant (p = 0.556). Compared with baseline preinjection values, a significant BMO expansion (p = 0.003), prelaminar tissue thinning (p = 0.011), and cup deepening (p = 0.006) in the inferior region of the ONH occurred. No change in IOP was observed at the end of follow-up. CONCLUSIONS: Repeated IVIs could lead to irreversible changes in ONH structures. Large-scale, prospective studies are required to determine the long-term effects of anti-VEGF treatments in ONH tissues.

Effectiveness of oral counselling for smoke cessation in Graves orbitopathy patients. / Efectividad del consejo médico para dejar de fumar en pacientes con orbitopatía de Graves.

OBJECTIVE: Smoking is an important risk factor for Graves orbitopathy (GO) and it is modifiable. The advice to stop smoking has been included in all the clinical practice guidelines of GO. However, the effectiveness of this practice remains unknown. The purpose of this study is to assess the change in the smoking habit in patients affected with GO after an oral counselling for smoking cessation. MATERIAL AND METHODS: A retrospective cohort of GO patients was studied. The patients received a significant oral counsel during the first consultation with the ophthalmologist. 33 GO patients were explored in the ophthalmology clinic during 2013 and 2014 and the study was done throughout a telephone questionnaire in 2015. The main outcome was the number of cigarettes smoked daily before and after consultation with the endocrinologist and the ophthalmologist. Other medical and socioeconomic factors were recorded. RESULTS: The mean number of cigarettes that were smoked was 13.6 (SD 9.66) and 6.3 (SD 7.73) before and after the consultation done at the ophthalmology office (T-test paired, P=0.0006). 42.42% achieved smoking cessation and 30.3% decreased their smoking habit. Patients who stopped smoking suffered usually from active and severe GO, had more stable jobs and received greater support from their relatives and friends. CONCLUSION: A firm and strong oral counsel held for smoke cessation was effective in GO patients. This disease deeply affects patients' quality of life, making them more prone to change their habits.

Phaco-non-penetrating deep sclerectomy in ocular hypertension secondary to dexamethasone intravitreal implant. / Faco-esclerectomía profunda no perforante como tratamiento de la hipertensión ocular secundaria al implante intravítreo de dexametasona.

PURPOSE: To evaluate the characteristics and progression of patients treated with a 0.7mg dexamethasone intravitreal implant (Ozurdex®) and required glaucoma filtering surgery (phaco-non-penetrating deep sclerectomy) to control ocular hypertension (OHT). METHODS: A retrospective observational study including patients treated with Ozurdex® in a tertiary-care university hospital from May 2011 to April 2016. RESULTS: In five years of follow-up, 1.10% (4/363) of patients treated with 0.7mg dexamethasone intravitreal implant required phaco-non-penetrating deep sclerectomy (PNPDS) to control OHT refractory to topical treatment. All four patients started or increased previous antihypertensive topical treatment since the first dexamethasone intravitreal implant. Three or more dexamethasone intravitreal implants were injected in the four cases before intraocular pressure (IOP) became uncontrolled and PNPDS was performed. All four patients have a successfully controlled IOP without treatment after PNPDS. Two patients required additional treatment with dexamethasone intravitreal implants after PNPDS, maintaining IOP under control without treatment. CONCLUSIONS: To the best of our knowledge, this is the first study describing the successful results of PNPDS in OHT secondary to dexamethasone intravitreal implant. All four patients have achieved controlled IOP without treatment. Re-treatment with dexamethasone intravitreal implant in those patients who underwent PNPDS is also possible, and IOP remains controlled.

Lifestyles guide and glaucoma (II). Diet, supplements, drugs, sleep, pregnancy, and systemic hypertension. / Guía de estilos de vida y glaucoma (II). Dieta, suplementos, drogas, sueño, embarazo e hipertensión arterial.

PURPOSE: To establish evidence based guidelines to advise patients on the relationship between habits, diet, certain circumstances, diseases and glaucoma. METHODS: Review of all published articles on glaucoma and sports or other activities. The papers were classified according to the level of scientific evidence based on the Oxford Centre for Evidence-based Medicine classification. RESULTS: The evidence on the relationship between diet or supplements and the incidence or progression of glaucoma is insufficient to make a general recommendation for glaucoma patients. Although some studies on normal tension glaucoma suggest that Gingko biloba could reduce glaucoma progression, the results do not allow a general recommendation for all these patients. Similarly, the evidence on the usefulness of vitamin supplements is not conclusive. The studies on smoking do not clearly demonstrate the relationship between this habit and incidence of glaucoma. Marihuana is not a useful treatment for glaucoma. Although the results on the relationship between sleep apnoea and glaucoma are heterogeneous, it is recommended that patients with moderate to intense apnoea are tested for glaucoma. Pregnancy does not influence the course of the disease, but several hypotensive drugs may be harmful for the foetus. Nocturnal systemic hypotension is a risk factor for glaucoma progression. CONCLUSIONS: Certain habits, circumstances, or diseases may have an influence on the onset or progression of glaucoma. It is important to have adequate information about the scientific evidence in the publications in order to properly advise patients.

The diagnostic usefulness of the negative electroretinogram. / La utilidad diagnóstica del electrorretinograma negativo.

The definition of the negative response of the full field electroretinogram is the presence of a b-wave with less amplitude than the a-wave (b/a ratio<1) in the combined response of cones and rods. The presence of this pattern reflects an alteration in the bipolar cells, the Müller cells, or in the transmission of the stimulus from the photoreceptors to the bipolar cells, with preserved photoreceptor function. This finding can be seen bilaterally and symmetrically in different hereditary conditions, such as congenital stationary night blindness, juvenile X-linked retinoschisis, and Duchenne and Becker muscular dystrophies. On the other hand, it can also be found unilaterally (or asymmetrically) in acquired pathologies, such as some types of immuno-mediated retinitis (Birdshot retinochoroiditis), autoimmune retinopathies, cancer/melanoma associated retinopathy, or retinal toxicity. The objective of this review is to summarise the characteristics of the pathologies in which this finding can be observed, in order to highlight its usefulness in the differential diagnosis of retinal conditions.

Traumatic cyclodialysis treated with transscleral ciclodiode laser: Anterior and posterior segment evolution. / Ciclodiálisis traumática tratada con láser ciclodiodo transescleral: evolución de la exploración del segmento anterior y posterior.

CASE REPORT: A 35-year-old man suffered a severe hipotension maculopathy after being kicked in his left eye. He presented a broad area of iridodialisis. Gonioscopy, ultrasound biomicroscopy and optic coherence tomography were not able to locate the suspected cyclodialysis. Medical treatment was ineffective. Five months later the patient received transcleral diode laser cyclophotocoagulation with clinical resolution. DISCUSSION: Transscleral diode laser constitutes an effective treatment, with low iatrogenia, that can solve cases of ocular hypotension, even when the location of the cyclodialysis has not been determined.

Descemet membranotomy to treat pre-descemet haematoma after deep sclerectomy and anterior segment-OCT related findings: A presentation of two clinical cases. / Hematoma pre-descemético tras EPNP, tratado mediante membranotomía de la Descemet y hallazgos de OCT de segmento anterior: presentación de 2 casos clínicos.

CASE PRESENTATION: An 81 year-old woman and a 63 year-old man developed a pre-Descemet haematoma after deep sclerectomy (DS), the former during the surgery itself and the latter during the early post-operative period. The surgical technique is decribed that led to the evacuation of the haematoma and the preservation of the integrity of trabeculo-Descemet membrane. The anterior-segment OCT findings after surgery are also presented. CONCLUSIONS: These are the first reported cases of pre-Descemet haematoma after DS that have been successfully repaired by an ab interno Descemet membranotomy. Surgeons should be aware of this rare, but potentially sight-threatening, complication.

Guidelines for treatment of chronic primary angle-closure glaucoma.

OBJECTIVE: To present a clinical practice guideline update on the medical, laser, and surgical treatment of primary angle closure glaucoma (PACG) in adults. METHODS: Following the formulation of key questions using the PICO scheme (Patient/Problem, Intervention, Comparison, Outcome), a systematic review was performed on the literature published to date, including international clinical practice guidelines. The AMSTAR and Risk of Bias tools were used for evaluating the quality of the information. The level of evidence and grade of recommendation was established following the Scottish Intercollegiate Guidelines Network (SIGN) system. RESULTS: Following the above methodology, recommendations of medical, laser and surgical treatment in adult PACG and levels of evidence are presented. CONCLUSIONS: Although the level of scientific evidence for many of the questions raised is not very high, a review is presented on updated treatment recommendations for adult PACG. Among the limitations for the implementation of these recommendations is that most studies have been conducted in Asian populations, and that the effectiveness is measured almost exclusively in terms of reducing intraocular pressure, and does not include visual function, quality of life or cost-effectiveness parameters.

Perioperative pharmacological management in patients with glaucoma.

REVIEWS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery. PROPOSED PROTOCOLS: In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery. CONCLUSIONS: this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.

Peripheral yttrium aluminium garnet (YAG) iridotomy versus phacoemulsification in primary angle closure: prospective comparative study.

PURPOSE: A study was designed to determine and describe the changes induced in the anterior segment of the eye and the intraocular pressure (IOP) after laser peripheral iridotomy (LPI) versus phacoemulsification in primary angle closure suspects (PACS) and primary angle closure (PAC). METHODS: Forty-seven eyes (47 patients) with Shaffer gonioscopy 0-II were included and split into 2 groups: cataract surgery (n=29) or LPI (n=18), depending on the lens sclerosis and visual acuity. Tonometry, gonioscopy, funduscopy, and automated measurements of the anterior chamber by Pentacam were performed before the intervention, and one and 3 months after the technique. RESULTS: Phacoemulsification reduces IOP after one and 3 months (P<.01). LPI reduces IOP after 3 months (P<.04), and after one month (P<.38). IOP was 16.2mmHg (SD: 3.59) in the phacoemulsification group vs. 16.83mmHg (SD: 2.36) in the LPI group after one month (P=.4), and 15.52 (SD: 2.95) vs. 16.05 (SD: 2.46) in the third month (P=.5). There were no significant differences in the antiglaucoma drugs. Shaffer gonioscopy grading was greater in the phacoemulsification group vs. in the LPI group one and 3 months after the intervention (P=.01). The highest difference between both techniques was found in the superior quadrant. The anterior chamber depth, angle and volume by Pentacam were wider in the phacoemulsification group after one and 3 months (P<.01). CONCLUSIONS: Although phacoemulsification and LPI could both be effective techniques in the prevention of pupillary block in PAC, faster and greater amplitude of the angle and the anterior chamber can be obtained after phacoemulsification than after LPI.