Baerveldt Aqueous Shunt with or without Mitomycin C Augmentation: A Retrospective Comparison Study.

OBJECTIVE: To evaluate if intraoperative mitomycin C (MMC) influences the success of Baerveldt aqueous shunts. DESIGN: Retrospective comparative case series. PARTICIPANTS: The study population consisted of 88 patients. Fifty-five received intraoperative MMC and 33 did not (controls). METHODS: The medical records of consecutive patients who underwent standalone Baerveldt aqueous shunts at Birmingham Midland Eye Centre, United Kingdom, were retrospectively reviewed. Patients in the MMC group received 0.2 to 0.4 mg/mL of MMC intraoperatively whereas controls did not. MAIN OUTCOME MEASURES: Primary outcome was survival, which was defined as an intraocular pressure (IOP) > 6 mmHg and ≤ 21 mmHg or ≤ 18 mmHg and > 20% IOP reduction from baseline. Further analysis of patients who required medications (qualified) or no medications (complete) was undertaken. Secondary outcomes were IOP, number of glaucoma medications, complications, intraluminal ripcord removal (IRR), and interventions. RESULTS: Average follow-up was 4.7 ± 1.4 years. At year 5, complete success with the ≤ 21 mmHg threshold was significantly higher in MMC vs controls (39.3% vs 17.8%; log rank P = 0.016). Final complete success with the ≤ 18 mmHg threshold was higher in patients with MMC shunts vs controls (38% vs 15.6%; log rank P = 0.0042). Qualified success was not different between patients with MMC shunts and controls with ≤ 21 mmHg (82% vs 93%; log rank P = 0.29) and ≤ 18 mmHg thresholds (70.3% vs 79.3%; log rank P = 0.44). Uveitic patients were also more likely to achieve complete success at both 21 and 18 mmHg thresholds among the patients receiving MMC compared with controls. Mitomycin C was correlated with lower number of medications between month 3 and year 2 post operatively (P < 0.001) and with a lower rate of IRR at all timepoints (P < 0.001). There were no significant differences in the incidence of prolonged hypotony, although MMC cases had higher transient hypotony at year 1 (P = 0.049). CONCLUSIONS: Mitomycin C provides a significant advantage in Baerveldt aqueous shunt survival when considering medication-free success but not in qualified success. Control patients required more medications to control IOP. This study suggests that intraoperative MMC augmentation of Baerveldt aqueous shunt surgery may be advantageous in achieving IOP control without the need for medication but that it may be associated with more transient hypotony episodes. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Case Report: Pediatric Ocular Ischemia and Neovascular Glaucoma in Neurofibromatosis Type 1.

SIGNIFICANCE: Neovascular glaucoma is an important subset of secondary glaucoma in neurofibromatosis patients. Vasculopathy of the ophthalmic circulation needs to be borne in mind while evaluating their etiology. PURPOSE: This study aimed to report the presentation, diagnostic work-up and management of an unusual case of neovascular glaucoma in a child. CASE REPORT: A 7-year-old boy presented with uniocular ischemic fundus and secondary neovascular glaucoma. Detailed family history and evaluation led to a diagnosis of familial neurofibromatosis type 1. Fundus fluorescein angiography revealed compromised retinal and choroidal circulations in the affected eye. Ocular ultrasound B scan and neuroimaging did not show any contributory lesions. Cardiovascular evaluation was within normal limits. Ophthalmic Doppler imaging revealed normal proximal ophthalmic arteries in both eyes; however, the central retinal artery of the affected eye showed low flow in its proximal part and absent flow in the distal part, as compared with the fellow eye showing regular flow until the optic disc margin. Corroborating the clinical, fundus fluorescein angiography and Doppler findings, a diagnosis of neurofibromatosis type 1-related vasculopathy of the distal ophthalmic artery was made. Poor visual prognosis for the affected eye was explained, and anterior retinal cryopexy along with cyclocryotherapy was performed to treat the neovascular glaucoma. CONCLUSIONS: Vasculopathy of the ophthalmic circulation is an important cause of neovascular glaucoma in neurofibromatosis patients. The morphology of Lisch nodules may be altered in an ischemic eye, and therefore, careful examination of the other eye and systemic evaluation is vital in such unusual scenarios.

Juvenile-onset open-angle glaucoma - A clinical and genetic update.

Juvenile-onset open-angle glaucoma (JOAG) is a subset of primary open-angle glaucoma that is diagnosed before 40 years of age. The disease may be familial or non-familial, with proportions varying among different populations. Myocilin mutations are the most commonly associated. JOAG is characterized by high intraocular pressures (IOP), with many patients needing surgery. The mean age at diagnosis is in the 3rd decade, with a male preponderance. Myopia is a common association. The pathophysiology underlying the disease is immaturity of the conventional outflow pathways, which may or may not be observed on gonioscopy and anterior segment optical coherence tomography. The unique optic nerve head features include large discs with deep, steep cupping associated with high IOP-induced damage. Progression rates among JOAG patients are comparable to adult primary glaucomas, but as the disease affects younger patients, the projected disability from this disease is higher. Early diagnosis, prompt management, and life-long monitoring play an important role in preventing disease progression. Gene-based therapies currently under investigation offer future hope.

The high-pressure bleb.

A 45-year-old male presented with a slowly progressive, painless swelling in his right eye for the past 6 months. He had undergone an open globe injury repair 10 years back and an eventful cataract surgery 5 years back. The presenting visual acuity in the affected eye was perception of light with inaccurate projection of rays. The intraocular pressure was 44 mm Hg with advanced glaucomatous cupping. The swelling was identified to be a communicating sub-tenon cyst secondary to scleral wound dehiscence from secondary angle closure glaucoma. Wound re-suturing, cyst excision and diode laser cyclophotocoagulation was performed in a single sitting, with explained poor visual prognosis.

Trabeculectomy on Animal Eye Model for Resident Surgical Skill Training: The Need of the Hour.

Purpose: To describe a goats' eye training model for teaching of trabeculectomy and releasable suture techniques for Ophthalmology residents. Methods: A descriptive report explaining the methodology for setting up a goats' eye wet-lab model for teaching trabeculectomy for Ophthalmology residents. It details the approaches to eyeball preparation, steps of surgery, application and release of two representative types of 'releasable sutures' in a step-by-step manner. Conclusion: A systematic approach using goats' eye model to teach trabeculectomy and releasable suture techniques can enhance residents' understanding, confidence and expertise to operate upon human eyes.

Trabeculectomy in an unsuspected extramedullary iris-ciliary body plasmacytoma.

Extramedullary plasmacytoma of the iris and ciliary body is extremely rare. We present a case which was misdiagnosed as granulomatous uveitis with neovascular glaucoma, and underwent a trabeculectomy with mitomycin-c along with iris biopsy. The post-operative period showed early bleb failure and catastrophic growth of the suspected mass. Histopathological examination revealed a diagnosis iris plasmacytoma. Subsequent ultrasound biomicroscopy showed involvement of the iris and ciliary body. A prompt systemic workup was done, and an associated systemic plasma cell dyscrasia was ruled out. The affected eye was enucleated, and the patient remains disease free at the end of 3-year follow-up.

Clinically useful smartphone ophthalmic imaging techniques.

Imaging devices in ophthalmology are numerous, and most of them are sophisticated and specialized for specific regions of the eye. In addition, these are fixed and involve close interaction of the patient and the examiner; therefore, simple, portable and tele facility-imbibed imaging tools can be considered optimal alternatives to routine exercises. In the last 10 years, utility of smartphones in ophthalmology is being continuously explored to unearth their potential benefits. In this direction, a smartphone device with/without simple attachments has been noted to aid in detailed, high-quality imaging of the ocular adnexa, cornea, angle, iris, lens, optic disc, and the retina including its periphery. In addition, such utility has also been extended in strabismology workup and intraocular pressure measurements. Hence, using these clinician friendly tools and techniques or by devising newer and more comprehensive tool kits, ophthalmic care can be well-managed with apt use of technology. Also, the smartphone companies are encouraged to collaborate with the medical experts to endeavor more, and help and serve the people better.

Achieving low target intraocular pressures in severe glaucoma.

PURPOSE: This study aimed to assess details of therapy required to achieve an intraocular pressure (IOP) of ⩽12 mmHg in patients with severe glaucoma of different etiologies. METHODS: Patients with a follow-up of at least 1 year, who fulfilled inclusion criteria were selected, and data analyzed with respect to baseline IOP, number of medications, and/or surgeries required to achieve an IOP of ⩽12 mmHg and ⩾6 mmHg. Final IOP, visual field status and medications/surgery required were noted. RESULTS: About 127 eyes of 85 patients met all criteria. There were 48 eyes having primary angle closure glaucoma (PACG), 16 eyes with primary open angle glaucoma (POAG), 17 eyes of juvenile open angle glaucoma (JOAG), and 46 eyes of secondary glaucoma. The mean baseline IOP was 33.14 ± 11.07 mmHg and final IOP 10.25 ± 1.81 mmHg. In the age group >40 years, 29.63% of patients were controlled on medication as compared to 9.09% and 5.71% in the age group of <20 years and 20-40 years (p = 0.007). With a baseline IOP of <25 mmHg, 48.65% required a trabeculectomy, whereas for 25-30, and >30 mmHg, 62.5% and 97.29% respectively, required surgery (p < 0.001).66.67% of patients having mean deviation of -12 to -16 dB (decibels) on Humphrey field analyzer (HFA) underwent surgery to achieve target IOP in comparison to 83.52% who had mean deviation greater than -16 dB (p = 0.036). CONCLUSION: Only 21.26% of severe glaucoma eyes could be controlled on medications alone. A baseline IOP of >25 mmHg, age <40 years and mean deviation worse than -16 dB, had a higher frequency of trabeculectomies to achieve an IOP of ⩽12 mmHg.

Intralenticular changes in eyes with mature senile cataract on modified posterior segment optical coherence tomography.

PURPOSE: To study the morphological changes within mature senile cataracts on modified posterior segment optical coherence tomography (OCT). METHODS: A cross-sectional observational study recruiting patients of mature cataracts admitted for elective cataract surgery in tertiary eye care. A modified OCT imaging of the lens was done and lenticular findings were noted by a single observer. Corresponding slit-lamp biomicroscopic findings and intraoperative experiences were also noted by a second observer and respective surgeons. RESULTS: Forty-four eyes of 44 patients were included. The mean age of patients was 65 ± 5.7 years. The intralenticular findings were uniform in groups of eyes, and they were characterized into three stages. First was a stage of early lamellar separation where small intralenticular clefts were noted superficially. Second was the stage of established lamellar separation where crescentic fluid clefts appeared interspersed between the lens fibers, and the depth increased as a function of severity. Both these stages did not show any distinct slit-lamp or intraoperative findings. A third stage of liquefaction identified as extensive lamellar separation with subcapsular fluid pockets. This was also reflected in slit-lamp biomicroscopy, showing the hydrated cortex with intraoperative challenges. Two cases showed peculiar changes, one of a hyperreflective subcapsular sheath and another of superficial nuclear lamellar separation. CONCLUSION: Mature cataracts may also show graded progression, which could be delineated on lenticular OCT. This could be of immense help in pre-operative planning and optimal management of these high-risk cases.

Preoperative assessment of posterior capsular integrity using a posterior segment OCT with a +20 D lens: The 'conical sign' to suggest capsular deficiency in posterior polar cataracts.

PURPOSE: To study the morphology of posterior polar cataracts and posterior lens capsules using modified posterior segment optical coherence tomography (m-OCT). SETTING: Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: A prospective observational case series. METHODS: Patients with clinically diagnosed posterior polar cataracts were included. The routine posterior segment OCT was modified by placing an aspheric +20.00 diopter lens along its aperture, enabling it to visualize the anterior segment structures. Cases of posterior polar cataract were assessed preoperatively using this method to study the morphology of posterior lens cortex and the posterior capsule. All m-OCT observations were performed by 2 observers, and findings were recorded. RESULTS: A total of 26 eyes of 17 patients were included. The mean age of patients was 53 years. The morphology of the cataract appeared as hyperreflective opacity just anterior to the posterior capsule, subsequently involving it, and with variable hyporeflective spaces. An intact posterior capsule showed a regularly convex contour, whereas a loss in the tracing of posterior capsule at the paracentral region and disturbance in contour with a localized protrusion of lens matter (the conical sign) depicted a possible posterior capsule dehiscence. Four (15.38%) of 26 eyes showed the conical sign, and this posterior capsule defect was confirmed intraoperatively in all cases. CONCLUSIONS: In posterior polar cataracts, the conical sign could be a valuable clue to predict preexisting posterior capsule dehiscence and could be identified on a m-OCT.

Severity of visual field defects in primary congenital glaucoma and their risk factors.

PURPOSE: The primary objective of the study was to assess the frequency and severity of visual field defects (VFD) in primary congenital glaucoma (PCG). The secondary objective was to ascertain any associated risk factors. METHODS: An ambispective review of patients with PCG on follow-up with a 'target' intraocular pressure (IOP) of ≤ 15 mmHg. Age, sex, laterality, duration of follow-up, baseline IOP, baseline cup-disc ratio (CDR), central corneal thickness (CCT), age during filtering surgery, second surgery if any, yearly IOP, glaucoma medications and best corrected visual acuity from 2013 (year 1) to the final review and final CDR were noted down. Children ≥ 5 years of age with best corrected visual acuity ≥ 6/60 were subjected to manual kinetic Goldmann perimetry, and visual field defects (VFD) were identified. RESULTS: Seventy-one of 90 eyes completed a reliable kinetic perimetry. The mean age of children was 12.34 ± 4.86 years, and the mean follow-up duration was 10.77 ± 4.69 years. Baseline IOP and CDR were 29.07 ± 8.83 mmHg and 0.66 ± 0.22, respectively. 86.67% of eyes underwent a trabeculotomy + trabeculectomy with mitomycin-C. Thirty-one eyes (34.44%) required a second surgery, 25 of which were bleb revisions and 3 trabeculectomies. Mean IOP and CDR during last visit were 10.23 ± 2.76 mmHg and 0.52 ± 0.25, p < 0.001 as compared with baseline. On Goldmann perimetry, 19 eyes, 26.76%, had defects, arcuate scotoma being most frequent. On the Fisher exact test, a baseline/final CDR > 0.8, undergoing just a trabeculectomy with MMC, needing ≥ 2 glaucoma medications on review or a repeat trabeculectomy was associated with greater severity of VFD. On univariate logistic regression, eyes that needed a bleb revision [OR, 95% CI 9.75 (2.66-35.67), p = 0.001], a repeat trabeculectomy with mitomycin-C [OR (CI) 18 (1.31-245.58), p = 0.03] and final CDR of > 0.8 [OR (CI) 23.1 (3.7-144.21), p = 0.001] were associated with VFD. On multivariable regression analysis, female sex [OR (CI) 18 (2.01-161.04), p = 0.01] was identified as the single most important risk factor for development of a VFD. CONCLUSION: At a 'target' IOP of ≤ 15 mmHg, 26.76% of PCG eyes manifested a VFD over 10 years. Baseline and/or final CDR > 0.8, necessity for ≥2 medications or a repeat glaucoma surgery, and female sex were identified as risk factors for development and greater severity of glaucomatous VFD.

Clinical and ASOCT evaluations of 'bleb-sparing epithelial exchange' in paediatric and adult dysfunctional blebs over 5 years.

PURPOSE: To evaluate the long-term outcome of 'bleb-sparing epithelial exchange' surgery for dysfunctional filtering blebs in paediatric and adult eyes. METHODS: Patients who had undergone bleb revision ≥ 5 years back and were on regular follow-up were included. Age, ocular diagnosis, details of primary filtering surgery including mitomycin-C (MMC) usage, indication and year of bleb revision were recorded. After bleb revision, the mean intraocular pressure (IOP), glaucoma medications and best corrected visual acuity (BCVA) up to 5 years were noted. On last review, clinical details, bleb characteristics and swept source anterior segment tomographic (SSOCT) assessment of bleb were recorded. Comparative analysis of paediatric and adult eyes was performed. MAIN OUTCOME MEASURES: Change in IOP and BCVA. 'Complete success' was defined as IOP ≥ 6 to ≤ 18mmHg without use of any topical glaucoma medications and 'Qualified success' when ≥ 1 topical glaucoma medication(s) was required. RESULTS: A total of 51 eyes of 51 consecutive patients were studied, among which 22 were children. The mean duration between filtering surgery and bleb revision was 4.54 ± 1.53 years in paediatric and 6.48 ± 3.5 years in the adult group, p = 0.04. Children underwent trabeculotomy + trabeculectomy with 0.04% MMC, while adults underwent trabeculectomy with 0.02% MMC. The mean pre-revision IOP was 6.38 ± 2.80 and 6.51 ± 2.78 mmHg in the paediatric and adult group respectively, p = 0.86. At 3 months post-revision, it increased to 11.81 ± 3.48 and 12.75 ± 3.52 mmHg respectively (p < 0.001). At final review, mean IOP of paediatric group was 10.90 ± 2.59 and adult group was 11.86 ± 2.66 mmHg, p = 0.20. At 5 years, complete success was 68.18% and 72.41%, and qualified success was 31.87% and 27.59% in the former and latter group respectively, p = 0.49. No failures were seen. Kaplan-Meier probability at 5 years for IOP target ≤ 18, ≤ 15 and ≤ 12 in children was 95.45%, 63.64% and 50% and in adults 93.10%, 65.52% and 41.38% respectively. BCVA improved up to 1 year in paediatric group, with continued improvement in adults up to 3 years. SSOCT measured bleb height was 0.88 ± 0.37 and 1.32 ± 0.49mm in children versus adults (p = 0.006) and wall thickness, 0.35 ± 0.22 and 0.58 ± 0.24mm respectively, p = 0.008. CONCLUSION: Bleb-sparing epithelial exchange is an equally safe and effective technique with good long-term success in both paediatric and adult dysfunctional blebs.

Cogan-Reese syndrome with Iris cyst: A novel presentation.

PURPOSE: To report an atypical case of Cogan-Reese syndrome associated with iris cyst in a young adult male. METHODS: Slit-lamp biomicroscopic examination, swept-source anterior segment optical coherence tomography (ASOCT) and ultrasound bio-microscopy (UBM) were done to evaluate and characterize the nature of the iris cyst. Gonioscopy, specular microscopy and confocal microscopy were attempted, but unsuccessful due to the large corneal opacity. RESULTS: On slit-lamp biomicroscopy, a large nasal corneal opacity with overlying band-shaped keratopathy was noted, with history suggestive of a trivial non-penetrating trauma and likely healed corneal ulcer. Through the temporal clear cornea, the iris displayed altered pattern with overlying shiny membrane and multiple, small, discrete, hyperpigmented, irregular nodules suggestive of Cogan-Reese syndrome. On the nasal side, an iris cyst with typical 'stuck-on appearance' onto the endothelium was visible. ASOCT and UBM failed to show any evidence of epithelial downgrowth or Descemet membrane disintegrity, ruling out the possibility of a post-traumatic implantation iris cyst. CONCLUSION: The occurrence of iris cyst in this case of Cogan-Reese syndrome is unique, and could be related to the disease pathogenesis, or a rare co-incidental finding.

Changes in Intraocular Pressure and Angle Status After Phacoemulsification in Primary Angle Closure Hypertension.

PURPOSE: To study the change in intraocular pressure (IOP) and angle status after phacoemulsification in a cohort of primary angle closure hypertension (PACHT) patients. SETTING: Tertiary Eye Care, India. DESIGN: Prospective interventional case-series. METHODS: Case-series of 18 eyes of 18 patients. Preoperative biometry including axial length, anterior chamber depth (ACD), lens thickness, and central corneal thickness were studied. Preoperative and postoperative IOP, number of topical glaucoma medications, angle swept source optical coherence tomography (SS-OCT) parameters of nasal and temporal angle opening distance, trabecular iris space area, scleral spur angle, lens vault and circumferential iridotrabecular contact (ITC) were studied and their correlations derived. RESULTS: The mean preoperative IOP, 31±6 mm Hg, decreased to 14±1 mm Hg at 6-months postoperative period, P<0.001, a fall by 58±14%. The number of glaucoma medications reduced from 4(3-5) to 2(1-3), P<0.001. All SS-OCT studied parameters denoted significant angle widening postsurgery. The ITC% reduced from 52(16-100) to 19(0-97), P<0.001. The preoperative ITC showed moderate to strong correlation with all preoperative nasal and temporal angle parameters. It also showed moderate positive correlation with percentage fall in IOP at 1-month postoperative period. The preoperative ACD showed significant negative correlation with preoperative and postoperative ITC. CONCLUSIONS: PACHT patients benefit significantly from cataract surgery with marked angle widening, IOP reduction and a decrease in the number of glaucoma medications. The SS-OCT derived circumferential iridotrabecular contact index can be used as the single best parameter to indicate the preoperative angle status and predict postoperative change in IOP, as against the numerous single section measured angle parameters.

Hook and flip technique: for phacoemulsification in non-rotating nuclei and posterior polar cataracts.

PURPOSE: We put forward a physical levitation method to hook and flip the chopped nuclear fragments that could not be solely drawn by vacuum during phacoemulsification, due to various reasons such as a non-rotating nuclei or posterior polar cataracts where hydrodissection was unsuccessful or contra-indicated, respectively. METHOD: A Sinskey hook is insinuated through the crack of the divided nuclei into a plane behind the nuclear pie to 'hook and flip' the chopped piece, heading it towards the phacoemulsification probe. This simple step disassembles the nuclear chunk, thereby creating space to facilitate the dismantling of the rest of the fragments. The remnant epinuclear cushion guards the posterior capsule, mitigating the chances of serious intra-operative complications. RESULT: We have employed this technique in 17 eyes during similar situations. No specific intra-operative complications were observed; all surgeries were uneventful. A Sinskey hook utilised for this step ensures safety and familiarity, none encountered posterior capsular rent. This technique not only eases the surgery, but also decreases the anticipated intra-operative and post-operative complications. CONCLUSION: 'Hook and flip technique' thus proves useful whenever dismantling difficulties are encountered during phacoemulsification.

One-step management of post-traumatic triple dialysis using two rings.

PURPOSE: To report a case that presented with post blunt trauma cataract, zonular dialysis, cyclodialysis and iridodialysis and its successful single-sitting management. METHODS: After lens aspiration, a capsular tension ring and multipiece intraocular lens were placed in the bag to support the zonules, a single eyelet Cionni ring was fixed in the sulcus to provide endocyclotamponade, and iridodialysis repair was done using the 'stroke and dock technique'. RESULT: Successful centration of the intraocular lens, closure of the cleft and apposition of the iris root to its base were achieved at the end of the surgery. CONCLUSION: A single-sitting surgery correcting all the three dialysis can curtail the burden of repeated surgeries and their complications, providing early visual recovery and cost-effectivity.

Single-suture single-knot ab interno cyclopexy for extensive posttraumatic cyclodialysis: Modified sewing machine technique.

We describe a modified sewing machine technique that is ab interno and minimally invasive. The single-suture, single-knot endocyclopexy (internal suture fixation) is performed to correct cyclodialysis. This inside-out technique is an alternative to existing standard cleft repair procedures, such as external direct/indirect cyclopexy and endocyclotamponade (internal mechanical tamponade using extraneous agents). Results in 1 case indicate that the modified technique can be used as a primary procedure and in eyes in which previous cyclopexy failed.