Negative Pressure Application via a Multi-Pressure Dial to Lower IOP in Patients with Suspected Glaucoma or Open Angle Glaucoma.

PRCIS: The multi-pressure dial applies localized periocular negative pressure to safely and effectively lower IOP and represents the first non-invasive, non-pharmacologic device for IOP reduction. OBJECTIVE: To evaluate the safety and effectiveness of the Multi-Pressure Dial (MPD) system, a device that applies periocular negative pressure to lower intraocular pressure (IOP). SETTING: 6 investigational sites, United States. DESIGN: Prospective, assessor-masked, randomized controlled trial. METHODS: Subjects with suspected glaucoma, ocular hypertension (OHTN), and open angle glaucoma (OAG) with baseline IOP ≥13 mmHg and ≤32 mmHg were enrolled. One eye of each subject was randomized to receive negative pressure application; the fellow eye served as a control. The study eye negative pressure setting was programmed for 60% of the baseline IOP. The primary effectiveness endpoint was the proportion of study eyes versus control eyes achieving an IOP reduction ≥20% at Day 90. Secondary endpoints included the proportion of eyes achieving an IOP reduction ≥25% at Day 90 as well as the proportion of eyes achieving an IOP reduction ≥20% at Days 30 and 60. RESULTS: 116 eyes of 58 subjects completed the study. At the Day 90 visit, 89.7% ( n =52) of study eyes versus 3.4% ( n =2) of control eyes achieved an IOP reduction ≥20% ( P <0.001). At Day 90, 77.6% ( n =45) of study eyes achieved a ≥25% IOP reduction compared to 1.7% ( n =1) of control eyes ( P <0.001). The most commonly reported adverse events were lid (17.2% study eye, 7.8% control eye) and periorbital edema (14.1% study eye, 10.9% control eye). CONCLUSIONS: This trial demonstrates that the MPD safely and effectively lowers IOP in a group of patients that included glaucoma suspects, OHTN, and patients with OAG.

Cell-Specific Expression of Human SIRT1 by Gene Therapy Reduces Retinal Ganglion Cell Loss Induced by Elevated Intraocular Pressure.

SIRT1 prevents retinal ganglion cell (RGC) loss in several acute and subacute optic neuropathy models following pharmacologic activation or genetic overexpression. We hypothesized that adeno-associated virus (AAV)-mediated overexpression of SIRT1 in RGCs in a chronic ocular hypertension model can reduce RGC loss, thereby preserving visual function by sustained therapeutic effect. A control vector AAV-eGFP and therapeutic vector AAV-SIRT1 were constructed and optimized for transduction efficiency. A magnetic microbead mouse model of ocular hypertension was optimized to induce a time-dependent and chronic loss of visual function and RGC degeneration. Mice received intravitreal injection of control or therapeutic AAV in which a codon-optimized human SIRT1 expression is driven by a RGC selective promoter. Intraocular pressure (IOP) was measured, and visual function was examined by optokinetic response (OKR) weekly for 49 days following microbead injection. Visual function, RGC survival, and axon numbers were compared among control and therapeutic AAV-treated animals. AAV-eGFP and AAV-SIRT1 showed transduction efficiency of ~ 40%. AAV-SIRT1 maintains the transduction of SIRT1 over time and is selectively expressed in RGCs. Intravitreal injections of AAV-SIRT1 in a glaucoma model preserved visual function, increased RGC survival, and reduced axonal degeneration compared with the control construct. Over-expression of SIRT1 through AAV-mediated gene transduction indicates a RGC-selective component of neuroprotection in multiple models of acute optic nerve degeneration. Results here show a neuroprotective effect of RGC-selective gene therapy in a chronic glaucoma model characterized by sustained elevation of IOP and subsequent RGC loss. Results suggest that this strategy may be an effective therapeutic approach for treating glaucoma, and warrants evaluation for the treatment of other chronic neurodegenerative diseases.

Optic Disc Drusen in Patients With Ocular Hypertension: A Case Series and Review of the Literature.

BACKGROUND: The identification of glaucomatous optic neuropathy in the setting of optic disc drusen (ODD) is a challenge, and the decision of whether to offer treatment in the form of intraocular pressure (IOP) reduction is controversial. Here, we present a series of patients with coexisting ocular hypertension and ODD to evaluate clinical features, treatment options, and progression of optic neuropathy. In addition, a review of the literature on ODD with elevated IOP is provided. METHODS: Six patients with ODD and a history of ocular hypertension are presented. Components of the examination and imaging modalities used to establish the diagnosis of ODD were recorded and a description of ocular hypertension history, glaucoma testing, and the potential treatment of IOP were also provided. RESULTS: In this series, 4 of 6 patients with concurrent ocular hypertension and ODD showed progression of optic neuropathy as assessed by visual field or retinal nerve fiber layer thickness. Of the 2 patients who did not show evidence of progression, 1 was treated with IOP-lowering medications and 1 was observed off treatment. Of the 4 patients who showed evidence of progression, all 4 were initially treated with IOP-lowering medications and 2 ultimately went on to have trabeculectomy surgery. In the patients with progressive optic neuropathy, lowering the IOP seemed to halt the progression suggesting there was a pressure-sensitive component. CONCLUSIONS: Distinguishing changes to the optic nerve, particularly the structural changes at the lamina cribrosa of true glaucomatous optic neuropathy in the setting of ODD, is a challenge. Careful consideration of risk factors including age, presenting features, progression indicators, and management goals is to be accounted for in the decision to offer treatment. We see the presence ODD in the patients with ocular hypertension as an additional risk for progressive changes to the nerve fiber layer and visual field that needs to be considered when determining whether to initiate therapy. Our data suggest that treatment of IOP in the patients with ocular hypertension with ODD and evidence of progression reduces the risk of further progression. Further work is needed to determine whether progression of optic neuropathy in the setting of coexisting ODD and ocular hypertension is related mechanistically to predominantly an ODD-type process, a glaucomatous process, or a combination thereof.

Persistência da vasculatura fetal diagnosticada pela ultrassonografia ­ Relato de caso / Vasculature persistence fetal diagnosed by ultrasound ­ case report

Contexto: A persistência da vasculatura fetal é uma malformação ocular rara em adultos, habitualmente unilateral, sendo uma condição não hereditária, com poucas manifestações sistêmicas e neurológicas. Descrição do caso: Homem de 45 anos queixando-se de dor no olho esquerdo, com pressão intraocular de 56 mmHg. A ultrassonografia do olho esquerdo demonstra aumento da ecogenicidade do cristalino inferindo catarata e redução da amplitude da câmara anterior, membrana posterior hiperecogênica no interior da câmara vítrea com intensa vascularização com fluxo arterial ao estudo com Doppler, caracterizando a persistência da vasculatura fetal. O paciente recebeu tratamento por três dias. Com a redução da pressão intraocular após esse período, realizou a cirurgia combinada de facoemulsificação com implante de lio e implante de tubo de Ahmed. Após o procedimento cirúrgico, o paciente não voltou a apresentar a sintomatologia. Discussão: Clinicamente, há duas condições de doença, dependendo da porção atingida do vítreo primário ­ as formas anterior e posterior. A persistência da vasculatura fetal não tratada frequentemente progride para phthisis bulbi ou enucleação devido a uma hemorragia intraocular recorrente e secundária ao glaucoma. Os esforços cirúrgicos têm o intuito de preservar a visão. Conclusão: Relatamos um caso de persistência da vasculatura fetal diagnosticado pela ultrassonografia e tratado cirurgicamente com sucesso devido ao alívio dos sintomas em olho esquerdo sem percepção luminosa.

Incidence and Risk Factors of Glaucoma Following Pediatric Cataract Surgery With Primary Implantation.

PURPOSE: To determine the incidence and risk factors for glaucoma after pediatric cataract surgery with intraocular lens (IOL) implantation. DESIGN: Retrospective, consecutive case series. METHODS: In this single-center study, we reviewed 136 children (199 eyes) who underwent pediatric cataract surgery before 1 year of age with a minimum of 1 year of follow-up. The intervention used was pediatric cataract surgery with IOL implantation, and the primary outcome measure was the presence or absence of secondary glaucoma. RESULTS: The mean age at surgery was 148 ± 93 days (range 30-359 days) with a mean follow-up of 6.3 ± 3.6 years (range 1.1-12.8 years). Glaucoma developed in 31 eyes (16%) with 5- and 10-year incidence rates of 12% and 28%, respectively. The incidence of glaucoma seemed to be bimodal, with a first peak occurring after a mean delay of 2.5 months (range 1.6-4.1 months) and a second peak occurring after a mean delay of 5.7 years (range 2.6-11.7 years). Younger age at surgery, shorter axial length, longer follow-up, use of trypan blue, reintervention, and bilateral surgery were associatied with a higher incidence of glaucoma. Multivariate analysis including the aforementioned variables indentified longer follow-up (odds ratio [OR] = 1.3 [95% confidence interval {CI} 1.1-1.6], P = .001), reintervention (OR = 4.1 [95% CI 1.2-13.4], P = 0.02), and the use of trypan blue (OR = 4.1 [95% CI 1.3-13.1], P = .02) as predictors for the development of glaucoma. CONCLUSION: Glaucoma is a common complication after pediatric cataract surgery. It seemed to have a bimodal incidence. Risk factors for glaucoma development were reintervention, the use of trypan blue, and a long follow-up.

Glaucoma Care of Prison Inmates at an Academic Hospital.

Importance: Glaucoma care for prison inmates is underrepresented in the literature even though managing the treatment of such patients may provide unique challenges. Objectives: To evaluate the glaucoma profile of prison inmates treated at an academic ophthalmology center and to report on the medical and surgical management and follow-up metrics. Design, Setting, and Participants: This retrospective cohort study assessed data from 82 incarcerated patients treated at the glaucoma clinic, an academic referral center at the University of Illinois at Chicago, between January 2013 and December 2017. Main Outcomes and Measures: Diagnosis, glaucoma severity, medical and surgical interventions, and patient-reported medication adherence were recorded for each visit. Recommended and actual follow-up times were recorded and compared. Data analyses were conducted from January 2013 to December 2018. Results: In total, 82 patients (161 eyes) had 375 visits during the study period. All patients were male and ranged from 20 to 75 years of age (mean [SD] age, 50.8 [11.9] years). Most participants were black patients (65 [79.3%]). The most common diagnoses were primary open-angle glaucoma (POAG; 53 eyes [32.9%]) and POAG suspect (52 eyes [32.3%]). Glaucoma severity ranged from mild (25 of 77 eyes [32.5%]) to advanced (41 of 77 eyes [53.2%]). Overall, 59 patients (73.2%) were treated medically with up to 4 topical agents (40.0%). Of those treated, 70.0% of patients (95% CI, 57.7%-81.2%) reported medication nonadherence during at least 1 visit. Medication nonadherence was more common among those taking 4 different topical medications (21 of 24 [87.5%]) compared with others taking fewer medications (20 of 35 [57.1%]), for a difference of 30.4% (95% CI, 7.0%-53.6%; P = .02), and among those with advanced disease (22 of 26 [84.6%]) compared with glaucoma suspect (6 of 13 [46.2%]), for a difference of 38.4% (95% CI, 9.3%-67.5%; P = .02). Nineteen office procedures, including laser peripheral iridotomy and laser trabeculoplasty, were performed on 14 eyes. Seventeen incisional glaucoma procedures were performed on 15 eyes, including glaucoma drainage device implant (11 procedures [64.7%]) and trabeculectomy (3 procedures [17.6%]). Only 26.6% of return office visits (95% CI, 21.3%-32.3%) occurred within the recommended follow-up time frame. Furthermore, 93 patients (34.8%; 95% CI, 28.2%-40.0%) were seen more than 1 month after the recommended follow-up. Conclusions and Relevance: Despite incarceration in prison, where medication administration and appointment attendance are theoretically controlled, the results of this study suggested that substantial medication and follow-up nonadherence exists among inmates.

Current management of uveitis-associated ocular hypertension and glaucoma.

Glaucoma secondary to ocular inflammation is potentially blinding and requires aggressive multifaceted management. The pathogenesis is related to the intraocular pressure elevation secondary to compromised aqueous humor outflow by inflammatory cells, chemical mediators released into the aqueous, and to the uveitic therapy itself (corticosteroid induced). The management of uveitic glaucoma needs a careful combination between anti-inflammatory therapy and appropriate intraocular pressure-lowering drugs to prevent worsening of condition and long-term visual loss. Although there have been novel medications that have emerged in the management of glaucoma and uveitis, around 30% of uveitic glaucoma eyes do not respond to maximal medical therapy and require surgical intervention. Studied procedures include laser therapy, filtration surgery, and glaucoma drainage devices, as well as recent surgical techniques for intraocular pressure control such as minimally invasive glaucoma surgery and angle-based procedures. We review and update the medical and surgical management of uveitic glaucoma.

Incidence and Management of Glaucoma or Glaucoma Suspect in the First Year After Pediatric Lensectomy.

Importance: Glaucoma can occur following cataract removal in children, and determining the risk for and factors associated with glaucoma and glaucoma suspect in a large cohort of children after lensectomy can guide clinical practice. Objective: To estimate the incidence of glaucoma and glaucoma suspect and describe its management in the first year following lensectomy in children before 13 years of age. Design, Setting, and Participants: A multicenter clinical research registry containing data for 1361 eyes of 994 children who underwent unilateral or bilateral lensectomy between June 2012 and July 2015 at 1 of 61 sites in the United States (n = 57), Canada (n = 3), and the United Kingdom (n = 1). Patients were eligible for inclusion in the study if they were enrolled in the registry within 45 days after lensectomy and had at least 1 office visit between 6 and 18 months after lensectomy. Patient data were reviewed, and glaucoma and glaucoma suspect were diagnosed by investigators using standardized criteria. Statistical analysis was performed between June 2017 and August 2019. Exposures: Clinical care 6 to 18 months after lensectomy. Main Outcomes and Measures: Incidence risk using standardized definitions of glaucoma and glaucoma suspect after lensectomy. Results: Among 702 patients included in this cohort study, 353 (50.3%) were male and 427 (60.8%) were white; mean age at lensectomy was 3.4 years (range, 0.04-12.9 years). After lensectomy, glaucoma or glaucoma suspect was diagnosed in 66 of 970 eyes (adjusted overall incidence risk, 6.3%; 95% CI, 4.8%-8.3%). Glaucoma was diagnosed in 52 of the 66 eyes, and glaucoma suspect was diagnosed in the other 14 eyes. Mean age at lensectomy in these 66 eyes was 1.9 years (range, 0.07-11.2 years), and 40 of the 66 (60.6%) were eyes of female patients. Glaucoma surgery was performed in 23 of the 66 eyes (34.8%) at a median of 3.3 months (range, 0.9-14.8 months) after lensectomy. The incidence risk of glaucoma or glaucoma suspect was 15.7% (99% CI, 10.1%-24.5%) for 256 eyes of infants 3 months or younger at lensectomy vs 3.4% (99% CI, 1.9%-6.2%) for 714 eyes of infants older than 3 months (relative risk, 4.57; 99% CI, 2.19-9.57; P < .001) and 11.2% (99% CI, 7.6%-16.7%) for 438 aphakic eyes vs 2.6% (99% CI, 1.2%-5.6%) for 532 pseudophakic eyes (relative risk, 4.29; 99% CI, 1.84-10.01; P < .001). No association was observed between risk of developing glaucoma or glaucoma suspect and any of the following variables: sex, race/ethnicity, laterality of lensectomy, performance of anterior vitrectomy, prelensectomy presence of anterior segment abnormality, or intraoperative complications. Conclusions and Relevance: This study found that glaucoma or glaucoma suspect developed in a small number of eyes in the first year after lensectomy and may be associated with aphakia and younger age at lensectomy. Frequent monitoring for signs of glaucoma following lensectomy is warranted, especially in infants 3 months or younger at lensectomy and in children with aphakia after lensectomy.

[Whether lowering intraocular pressure is needed for thyroid associated ophthalmopathy with intraocular hypertension].

Patients with thyroid associated ophthalmopathy often have elevated intraocular pressure. Patients and doctors are often confused about whether intraocular hypertension in thyroid associated ophthalmopathy needs to be lowered. There are several theories on the possible causes of this kind of increased intraocular pressure: restriction and compression of the globe by fibrotic and enlarged rectus muscles, increased episcleral venous pressure resulting from orbital congestion and venous outflow obstruction, and increased resistance to trabecular outflow. In addition, the patient's eye position and the device for measuring intraocular pressure also have great impacts on the accuracy of intraocular pressure measurement. At the same time, there are very few patients with thyroid associated ophthalmopathy combined with primary glaucoma. Therefore, whether patients with elevated intraocular pressure need to be treated depends on the specific clinical manifestations of the thyroid associated ophthalmopathy. Intraocular pressure of most patients can be lowered by active treatment for thyroid associated ophthalmopathy; antiglaucoma medical therapy may be necessary for patients whose intraocular pressure cannot be lowered; only very few cases of glaucoma require antiglaucoma drugs or surgery. (Chin J Ophthalmol, 2019, 55:811-813).

Comparison of Biomechanically Corrected Intraocular Pressure Obtained by Corvis ST and Goldmann Applanation Tonometry in Patients With Open-angle Glaucoma and Ocular Hypertension.

PRECIS: Biomechanically corrected intraocular pressure (bIOP) measurements provided by the new Corvis ST (CST) were higher than measurements obtained with Goldman applanation tonometry (GAT) in eyes with ocular hypertension (OHT) or open-angle glaucoma (OAG). PURPOSE: To compare bIOP obtained with a new version of CST with GAT measurements in patients with OAG and OHT, and to identify factors affecting IOP measurement differences between these methods. METHODS: A total of 122 eyes with OAG or OHT were enrolled. Sixty eyes were treated with prostaglandin analogs (PGA) and 62 eyes with selective laser trabeculoplasty (SLT). IOP was measured with CST, followed by GAT. Central corneal thickness (CCT) was measured with ultrasound pachymetry. Measurements obtained with these 2 approaches were compared. RESULTS: The overall mean IOP was 15.2±3.0 mm Hg and 14.1±3.2 mm Hg with the CST and GAT, respectively (r=0.74; P<0.0001). There was a 1.17 mm Hg bias between tonometers, with 95% limits of agreement of -2.66 to 5.01 mm Hg. According to multivariate regression analysis, differences between bIOP and GAT-IOP were associated with CCT (P=0.001) and age (P=0.007) in the PGA group, but only with CCT in the SLT group (P=0.002). bIOP and GAT-IOP values were influenced by age (PGA: P=0.014; SLT: P=0.006) and CCT (PGA: P=0.007; SLT: P=0.032), respectively. CONCLUSIONS: BIOP values were higher and less affected by CCT than GAT-IOP values in eyes with OAG and OHT. However, these measurements may not be interchangeable in the clinic.

Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT.

BACKGROUND: Newly diagnosed open-angle glaucoma (OAG) and ocular hypertension (OHT) are habitually treated with intraocular pressure (IOP)-lowering eyedrops. Selective laser trabeculoplasty (SLT) is a safe alternative to drops and is rarely used as first-line treatment. OBJECTIVES: To compare health-related quality of life (HRQoL) in newly diagnosed, treatment-naive patients with OAG or OHT, treated with two treatment pathways: topical IOP-lowering medication from the outset (Medicine-1st) or primary SLT followed by topical medications as required (Laser-1st). We also compared the clinical effectiveness and cost-effectiveness of the two pathways. DESIGN: A 36-month pragmatic, unmasked, multicentre randomised controlled trial. SETTINGS: Six collaborating specialist glaucoma clinics across the UK. PARTICIPANTS: Newly diagnosed patients with OAG or OHT in one or both eyes who were aged ≥ 18 years and able to provide informed consent and read and understand English. Patients needed to qualify for treatment, be able to perform a reliable visual field (VF) test and have visual acuity of at least 6 out of 36 in the study eye. Patients with VF loss mean deviation worse than -12 dB in the better eye or -15 dB in the worse eye were excluded. Patients were also excluded if they had congenital, early childhood or secondary glaucoma or ocular comorbidities; if they had any previous ocular surgery except phacoemulsification, at least 1 year prior to recruitment or any active treatment for ophthalmic conditions; if they were pregnant; or if they were unable to use topical medical therapy or had contraindications to SLT. INTERVENTIONS: SLT according to a predefined protocol compared with IOP-lowering eyedrops, as per national guidelines. MAIN OUTCOME MEASURES: The primary outcome was HRQoL at 3 years [as measured using the EuroQol-5 Dimensions, five-level version (EQ-5D-5L) questionnaire]. Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness and safety. RESULTS: Of the 718 patients enrolled, 356 were randomised to Laser-1st (initial SLT followed by routine medical treatment) and 362 to Medicine-1st (routine medical treatment only). A total of 652 (91%) patients returned the primary outcome questionnaire at 36 months. The EQ-5D-5L score was not significantly different between the two arms [adjusted mean difference (Laser-1st - Medicine-1st) 0.01, 95% confidence interval (CI) -0.01 to 0.03; p = 0.23] at 36 months. Over 36 months, the proportion of visits at which IOP was within the target range was higher in the Laser-1st arm (93.0%, 95% CI 91.9% to 94.0%) than in the Medicine-1st arm (91.3%, 95% CI 89.9% to 92.5%), with IOP-lowering glaucoma surgery required in 0 and 11 patients, respectively. There was a 97% probability of Laser-1st being more cost-effective than Medicine-1st for the NHS, at a willingness to pay for a quality-adjusted life-year of £20,000, with a reduction in ophthalmology costs of £458 per patient (95% of bootstrap iterations between -£585 and -£345). LIMITATION: An unmasked design, although a limitation, was essential to capture any treatment effects on patients' perception. The EQ-5D-5L questionnaire is a generic tool used in multiple settings and may not have been the most sensitive tool to investigate HRQoL. CONCLUSIONS: Compared with medication, SLT provided a stable, drop-free IOP control to 74.2% of patients for at least 3 years, with a reduced need for surgery, lower cost and comparable HRQoL. Based on the evidence, SLT seems to be the most cost-effective first-line treatment option for OAG and OHT, also providing better clinical outcomes. FUTURE WORK: Longitudinal research into the clinical efficacy of SLT as a first-line treatment will specify the long-term differences of disease progression, treatment intensity and ocular surgery rates between the two pathways. TRIAL REGISTRATION: Current Controlled Trials ISRCTN32038223. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 31. See the NIHR Journals Library website for further project information.

Glaucoma is an eye condition in which the optic nerve becomes damaged and, if left untreated, will lead to loss of vision. Ocular hypertension (OHT) is the medical name for high pressure in the eye that increases the risk of getting glaucoma. Lowering the eye pressure is the only known way to prevent glaucoma from getting worse. Before this trial, the standard initial treatment of these conditions was the prescription of eyedrops to lower the pressure in the eye. An alternative is a laser therapy that is known to reduce the eye pressure. This study investigated if starting treatment of glaucoma or OHT with laser therapy (using eyedrops later, if needed) affected the patients' quality of life (QoL) more or less than starting treatment with eyedrops alone. The study also investigated if initial treatment with laser and initial treatment with eyedrops are equally good at controlling eye pressure and are equally safe and how much they cost the NHS. Patients were randomly assigned to starting treatment with either laser or eyedrops and the two groups were then compared. The study found that for the first 3 years QoL was similar regardless of treatment. However, three-quarters of patients initially treated with laser did not need any eyedrops to control their eye pressure for 3 years. Patients initially treated with laser were less likely to require cataract surgery, and none needed any glaucoma surgery in the first 3 years. In contrast, among those patients treated with eyedrops, glaucoma surgery was required in 11 eyes (out of 622 eyes). Initial treatment with laser was cheaper than initial treatment with eyedrops. The results of this study suggest that laser is an efficient, safe and cheaper alternative to eyedrops, and that three-quarters of the patients initially treated with laser do not need any eyedrops for the first 3 years of treatment.

A Pilot Study on the Effect of Alternate Nostril Breathing and Foot Reflexology on Intraocular Pressure in Ocular Hypertension.

The purpose of this study is to investigate the effects of alternate nostril breathing (ANB) and foot reflexology (FR) on lower intraocular pressure (IOP) in patients with ocular hypertension (OHTN). This prospective pilot study recruited 11 patients from 2014 to 2016 from Temple opthamology outpatient clinic. Patients had OHTN with ages of 48-78 years. Patients were excluded if they currently performed ANB or FR, were unable to perform the task, had previous eye surgery or laser, were receiving other complementary and alternative medicine for OHTN, or were unable to complete drug washout period. After a 30-day drug washout, patients were randomly assigned to complete either ANB or FR for 5 min. After instruction, patients completed either ANB or FR, and completed the alternate task 2 weeks later. IOP was measured before the task, immediately after the task, and then every 30 min for 2 h. Decrease in IOP compared with baseline IOP was significant for ANB and FR at all time points. Baseline IOP was 25.86 ± 3.19 mmHg for ANB and 25.41 ± 3.54 mmHg for FR (N = 22 eyes). There was only one significant difference between IOP for the right and left eyes for FR at 120 min. Otherwise, there was no difference between eyes for both ANB and FR. There was a significant decrease in IOP at 30 min post task with IOP decrease of 1.98 ± 1.70 mmHg for ANB and 3.59 ± 1.89 mmHg for FR (both p < 0.0001) and at 60 min post task with IOP decrease of 2.39 ± 2.05 mmHg for ANB and 3.86 ± 1.89 mmHg for FR (both p < 0.0001). The decrease in IOP at 90 and 120 min post task was less but remained significant (p < 0.0001). Both FR and ANB had a small but significant IOP lowering effect. These alternative therapies could serve as possible adjunctive treatments for lowering IOP.

Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial.

BACKGROUND: Primary open angle glaucoma and ocular hypertension are habitually treated with eye drops that lower intraocular pressure. Selective laser trabeculoplasty is a safe alternative but is rarely used as first-line treatment. We compared the two. METHODS: In this observer-masked, randomised controlled trial treatment-naive patients with open angle glaucoma or ocular hypertension and no ocular comorbidities were recruited between 2012 and 2014 at six UK hospitals. They were randomly allocated (web-based randomisation) to initial selective laser trabeculoplasty or to eye drops. An objective target intraocular pressure was set according to glaucoma severity. The primary outcome was health-related quality of life (HRQoL) at 3 years (assessed by EQ-5D). Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness, and safety. Analysis was by intention to treat. This study is registered at controlled-trials.com (ISRCTN32038223). FINDINGS: Of 718 patients enrolled, 356 were randomised to the selective laser trabeculoplasty and 362 to the eye drops group. 652 (91%) returned the primary outcome questionnaire at 36 months. Average EQ-5D score was 0·89 (SD 0·18) in the selective laser trabeculoplasty group versus 0·90 (SD 0·16) in the eye drops group, with no significant difference (difference 0·01, 95% CI -0·01 to 0·03; p=0·23). At 36 months, 74·2% (95% CI 69·3-78·6) of patients in the selective laser trabeculoplasty group required no drops to maintain intraocular pressure at target. Eyes of patients in the selective laser trabeculoplasty group were within target intracoluar pressure at more visits (93·0%) than in the eye drops group (91·3%), with glaucoma surgery to lower intraocular pressure required in none versus 11 patients. Over 36 months, from an ophthalmology cost perspective, there was a 97% probability of selective laser trabeculoplasty as first treatment being more cost-effective than eye drops first at a willingness to pay of £20 000 per quality-adjusted life-year gained. INTERPRETATION: Selective laser trabeculoplasty should be offered as a first-line treatment for open angle glaucoma and ocular hypertension, supporting a change in clinical practice. FUNDING: National Institute for Health Research, Health and Technology Assessment Programme.

Ab interno trabecular bypass surgery with iStent for open-angle glaucoma.

BACKGROUND: Glaucoma is a leading cause of irreversible blindness worldwide. In early stages, glaucoma results in progressive loss of peripheral (side) vision; in later stages, it results in loss of central vision leading to blindness. Elevated intraocular pressure (IOP) is the only known modifiable risk factor for glaucoma. Minimally invasive glaucoma surgical (MIGS) techniques, such as ab interno trabecular bypass surgery with iStent (Glaukos Corporation, Laguna Hills, CA, USA), have been introduced as a new treatment modality for glaucoma. However, the effectiveness of MIGS on keeping people 'drop-free' (i.e. not having to use eye drops to control IOP) and other outcomes is uncertain. OBJECTIVES: To assess the effectiveness and safety of ab interno trabecular bypass surgery with iStent (or iStent inject) for open-angle glaucoma in comparison to conventional medical, laser, or surgical treatment. SEARCH METHODS: Cochrane Eyes and Vision's Information Specialist searched the following databases on 17 August 2018: the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register; 2018, Issue 7), MEDLINE Ovid, Embase Ovid, the ISRCTN registry, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We applied no date or language restrictions. We searched the reference lists of reports from included studies. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that had compared iStent or iStent inject to medical therapy, laser treatment, conventional glaucoma surgery (trabeculectomy), or other MIGS procedures. We included RCTs that had compared iStent or iStent inject in combination with phacoemulsification to phacoemulsification alone. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently screened search results, assessed risk of bias, and extracted data from reports of included RCTs using an electronic data collection form. MAIN RESULTS: We included seven RCTs (765 eyes of 764 participants; range per study 33 to 239 participants) that evaluated iStent in people with open-angle glaucoma. We also identified 13 studies that are ongoing or awaiting publications of results. Most participants in the included studies were women (417/764 (55%) participants) and older age (age range: 49 to 89 years). We assessed most trials at unclear or high risk of bias: four trials did not clearly report the method of generating the random sequence or concealing allocation; five were unmasked, open-label studies, which we assessed at high risk of bias for performance and detection bias. All seven trials were funded by the Glaukos Corporation. We graded the certainty of evidence as very low.Four RCTs compared iStent in combination with phacoemulsification to phacoemulsification alone. The summary estimate which we derived from two of the four RCTs suggested that participants in the iStent in combination with phacoemulsification group were 1.38 times more likely to be drop-free between six and 18 months than those in the phacoemulsification alone group (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.18 to 1.63, I2 = 67%). Data from two RCTs also suggested that iStent in combination with phacoemulsification compared to phacoemulsification alone may have offered a small reduction in number of IOP-lowering drops (mean difference (MD) -0.42 drops, 95% CI -0.60 to -0.23). It is uncertain whether there was any difference in terms of mean reduction in IOP from baseline (no meta-analysis).Two RCTs compared treatment with iStent to medical therapy; one of the two trials used the iStent inject. We determined the two trials to be clinically and methodologically heterogeneous and did not conduct a meta-analysis; however, the investigators of both trials reported that over 90% of participants in the treatment groups were drop-free compared to no participants in the medical therapy groups at six to 18 months.One RCT compared treatment with one versus two versus three iStents. There was no difference in terms of participants who were drop-free at 36 months or less; however, at longer follow-up (i.e. at 42 months) participants in the one iStent treatment were less likely to be drop-free than those in the two iStent (RR 0.51, 95% CI 0.34 to 0.75) or three iStent (RR 0.49, 95% CI 0.34 to 0.73) treatment groups. The study did not report the mean change in number of IOP-lowering drops.The type and timing of complications reported varied by RCTs. Similar proportions of participants who underwent treatment with iStent in combination with phacoemulsification and who underwent phacoemulsification alone needed secondary glaucoma surgery. None of RCTs reported findings related to quality of life. AUTHORS' CONCLUSIONS: There is very low-quality evidence that treatment with iStent may result in higher proportions of participants who are drop-free or achieving better IOP control, in the short, medium, or long-term. Results from the 13 studies with results not yet available may clarify the benefits of treatment of people with iStent. Additionally, future MIGS studies should consider measuring quality of life and outcomes that reflect people's ability to perform vision-dependent activities.

The Effect of Therapeutic IOP-lowering Interventions on the 24-hour Ocular Dimensional Profile Recorded With a Sensing Contact Lens.

PRéCIS:: The 24-hour ocular dimensional profile recorded by a contact lens sensor was affected by intraocular pressure lowering interventions. Among different treatments, incisional surgery had the most significant effect. PURPOSE: We investigated the effect of different intraocular pressure (IOP)-lowering interventions on contact lens sensor (CLS) parameters and their relationship with Goldmann applanation tonometry (GAT)-measured IOP reduction. METHODS: Data from reliable CLS recordings performed before and after IOP-lowering interventions were analyzed. Three interventions were evaluated: topical medications, laser trabeculoplasty, and incisional surgery. A set of 115 different CLS parameters were derived from 24-hour curves. We compared before versus after values for each parameter. In addition, linear regression was performed using the percentage change of each CLS parameter as the outcome variable and the type of IOP-lowering procedure as the predictor after adjusting age and race. Finally, we investigated the relationship between changes in CLS parameters and GAT IOP with the Spearman rank correlation coefficient. RESULTS: A total of 182 eyes of 182 patients were included in the analyses: 60 (33%) topical medications, 69 (38%) laser, and 53 (29%) surgery. The mean GAT IOP change was 3.6±6.5 mm Hg (P<0.001). Overall, more CLS parameters had a significant change after surgery than in the other groups (surgery>laser=drug). Linear regression showed that, for 20 CLS parameters, surgery was the most predictive of greatest percentage change in CLS signals. In all, 11 (9.5%) of the CLS parameters were significantly correlated with GAT changes. CONCLUSIONS: Incisional glaucoma surgery had a more pronounced effect on GAT and CLS parameters than laser and drugs. The CLS can detect changes in patterns resulting from IOP-lowering interventions beyond daytime GAT IOP. This device could potentially be used to assess treatment efficacy in glaucoma.

La uveítis y el glaucoma, un reto para el oftalmólogo / Uveitis and glaucoma, a challenge for ophthalmologists

La incidencia y la prevalencia de las uveítis varía alrededor del mundo, así como los agentes causales y el grupo de edad más afectado. De forma general, pueden asociarse a gran número de complicaciones oculares que originan marcada disminución de la visión, a veces de modo irreversible, e incluso pueden llevar a la ceguera de uno o de ambos ojos. Existe una asociación frecuente entre uveítis y glaucoma. La incidencia de glaucoma secundario a uveítis oscila sobre el 10 por ciento, con fluctuaciones relacionadas con su origen y la edad de presentación. Una parte de las uveítis cursa con hipertensión ocular más o menos marcada durante o después del proceso inflamatorio, lo que constituye un reto para el oftalmólogo, quien debe tratar simultáneamente dos entidades con terapéuticas prácticamente antagónicas. El tratamiento de la inflamación ocular está bien establecido; la hipertensión ocular debe ser tratada sobre la base de las características y el origen de cada entidad. Realizamos una revisión del tema por su importancia, así como de los elementos a tener en cuenta para un mejor resultado del tratamiento en estos pacientes. Se utilizó la plataforma Infomed, específicamente la Biblioteca Virtual de Salud(AU)

The incidence and prevalence of uveitis vary around the world, and so do its causative agents and most affected age group. In general terms, these may be associated to a large number of ocular complications which cause marked, at times irreversible vision reduction, and may even lead to vision loss in one or both eyes. An association is often found between uveitis and glaucoma. The incidence of glaucoma secondary to uveitis ranges around 10 percent, with fluctuations related to its origin and presentation age. A form of uveitis develops with more or less marked ocular hypertension during or after the inflammation process. This is a challenge for ophthalmologists, who should treat two conditions simultaneously with practically opposite therapies. The treatment for ocular inflammation is well established, whereas ocular hypertension should be treated according to the characteristics and origin of each condition. Due to its importance, we conducted a review of the topic, as well as of the elements to be borne in mind to obtain better treatment results. Use was made of the platform Infomed, specifically the Virtual Health Library(AU)

Pressure-induced stromal keratopathy after laser in situ keratomileusis: Acute and late-onset presentations.

We present a series of 4 cases of pressure-induced stromal keratopathy after laser in situ keratomileusis (LASIK). Four patients (5 eyes) with previous LASIK presented for poor visual acuity and ocular pain because of ocular hypertension. At examination, all cases revealed corneal haze and a space filled with fluid between the surgical flap and the residual stroma. All cases were managed with topical hypotensive treatment and one of them was also treated with a valve drainage device. Topical steroids restriction was indicated in all cases. Intraocular pressure (IOP) was normalized in all cases with subsequent interface fluid resolution and significant improvement of vision in most cases. Early recognition and appropriate treatment for pressure-induced stromal keratopathy is essential to avoid complications associated with prolonged elevated IOP. It is extremely important to measure the IOP in the peripheral cornea because IOP in the central cornea can be incorrectly measured with the characteristic interface fluid developed in this entity.

Neuroprotection of Transplanting Human Umbilical Cord Mesenchymal Stem Cells in a Microbead Induced Ocular Hypertension Rat Model.

PURPOSE: The purpose of this study is to investigate the potential therapeutic benefits of intravitreally transplanted human umbilical cord mesenchymal stem cells (UC-MSCs) in an animal model of microbead-injection-induced ocular hypertension (OHT). METHODS: UC-MSCs were isolated from human umbilical cords and then cultured. The OHT model was induced via intracameral injection of polystyrene microbeads in Sprague-Dawley adult rat eyes. Fifty-four healthy adult rats were randomly divided into three groups: normal control, OHT model treated with intravitreal transplantation of UC-MSCs, or phosphate-buffered saline (PBS). Two days after OHT was induced, either 5 µl 105 UC-MSCs suspension or PBS was injected into the vitreous cavity of rats. UC-MSCs localization and integration were examined via immunohistochemistry. Neuroprotection was quantified by counting retinal ganglion cells (RGCs) and axons 2 weeks following transplantation. The expression levels of glial-derived neurotrophic factor (GDNF), brain-derived neurotrophic factor (BDNF), and glial fibrillary acidic protein (GFAP) were assessed via immunohistochemistry and Western blot. Functional recovery was assessed 2 weeks after transplantation via scotopic threshold response (STR) electroretinography. RESULTS: Elevated IOP levels were sustained at least 3 weeks after intracameral microbead injection and the number of ß-III-tubulin+ RGCs significantly declined compared to PBS-injected eyes. UC-MSCs survived for at least 2 weeks after intravitreal transplantation and predominantly located in the vitreous cavity. A fraction of cells migrated into the ganglion cell layer of host retina, but without differentiation. Intravitreal UC-MSC transplantation resulted in increased number of RGCs, axons, and increased expression of GDNF and BDNF but decreased expression of GFAP. Intravitreal delivery of UC-MSCs significantly improved the recovery of the positive STR. CONCLUSIONS: Intravitreal transplantation of UC-MSCs revealed the neuroprotection in the microbead-injection induced OHT. The effects could be related to the secretion of tropic factors (BDNF and GDNF) and the modulation of glial cell activation.