Minimally invasive glaucoma surgery: Comparison of iStent with iStent inject in primary open angle glaucoma.

IMPORTANCE: Minimally invasive glaucoma surgery has gained significant traction in recent years. This study evaluates the first- and second-generation trabecular micro-bypass stents "iStent" and "iStent inject". BACKGROUND: To evaluate and compare the effect of a single iStent and double iStent inject in primary open angle glaucoma. DESIGN: Prospective comparative case series. PARTICIPANTS: Primary open angle glaucoma patients undergoing trabecular micro-bypass stent insertion combined with cataract surgery. METHODS: Baseline demographic information, preoperative, intraoperative and postoperative outcomes including intraocular pressure (IOP), visual acuity, reliance on glaucoma medication and complications were collected and analysed. MAIN OUTCOME MEASURES: Primary, secondary and tertiary outcome measures were consecutively defined as an IOP of ≤18 mmHg with zero medications, an IOP of ≤18 mmHg with reduced medications or a 20% reduction in IOP with or without medication. RESULTS: The study comprised 145 eyes in the iStent and 100 eyes in the iStent inject group. At 12 months, 56.0% of the iStent and 51.3% of the iStent inject eyes had achieved primary success and 63.1% and 57.7% secondary success. The mean postoperative IOP was 16.6 mmHg in iStent and 16.9 mmHg in iStent inject. Survival analysis demonstrated a greater incidence of failure in the iStent inject beyond 5 months. CONCLUSIONS AND RELEVANCE: Both trabecular micro-bypass stents in this study were effective in reducing IOP and the burden of medication when combined with cataract surgery. There was no statistically significant difference between the two groups across our outcome measures although the iStent inject required earlier recommencement of medications for optimal IOP control.

Bleb-associated endophthalmitis: Proportion, presentation, management and outcomes in Victoria, Australia.

IMPORTANCE: Bleb-associated endophthalmitis is a potentially vision-threatening complication of trabeculectomy. With improvements in surgical technique and changing patterns of intraoperative antimetabolite use, a re-evaluation of the incidence of bleb-associated endophthalmitis is warranted. BACKGROUND: To investigate changes in the incidence, presentation, management and outcomes of bleb-associated endophthalmitis between 1997 and 2015 in Victoria, Australia. DESIGN: A retrospective cohort analysis. PARTICIPANTS: Consecutive cases of bleb-associated endophthalmitis managed at the Royal Victorian Eye and Ear Hospital (RVEEH) between 1997 and 2015. METHODS: Medical record review of consecutive cases of bleb-associated endophthalmitis and statistical analysis were performed. MAIN OUTCOME MEASURES: Visual acuity, including loss of light perception, intraocular pressure, and need for further surgery. RESULTS: Sixty-seven eyes with bleb-associated endophthalmitis (BAE) were identified. Of these, 41 had trabeculectomy performed in Victoria during the study period, over which time 11 129 trabeculectomies were performed. The proportion of BAE was stable over time (0.4%). The mean age at presentation was 73.7 ± 12.1 years old and the majority of patients were Caucasian (79.1%). The mean duration between glaucoma filtration surgery and the development of bleb-associated endophthalmitis was 3 years (Interquartile Range = 0.4-6.0 years). The cultures were positive in 71.6% of cases. Approximately 1 in 8 patients required enucleation. The final visual acuity was poor with a Snellen Visual Acuity (VA) of 6/60 or worse in two-thirds of patients. CONCLUSIONS AND RELEVANCE: Bleb-associated endophthalmitis is an uncommon complication following glaucoma filtration surgery. The proportion has remained stable over time. Visual outcomes remain poor.

Minimally invasive glaucoma surgery as primary stand-alone surgery for glaucoma.

Recently, many new devices and procedures have been developed to lower intraocular pressure in a less invasive and purportedly safer manner than traditional glaucoma surgery. These new devices might encourage an earlier transition to surgery and reduce the long-term commitment to topical glaucoma medications with their associated compliance and intolerance issues. Although often seen as an adjunct to cataract surgery, a growing body of evidence suggests that primary minimally invasive glaucoma surgery may be a viable initial treatment option. New studies have shown that primary ab interno trabeculectomy (Trabectome, NeoMedix Inc., Tustin, CA, USA), trabecular micro-bypass stent insertion (iStent and iStent Inject, Glaukos Corporation, Laguna Hills, CA, USA), canalicular scaffolding (Hydrus, Invantis Inc., Irvine CA, USA), the ab interno gel Implant (XEN, Allergan, Dublin, Ireland) or supraciliary stenting (CyPass Micro-Stent, Alcon, Fort Worth, TX, USA) may lower the lowering intraocular pressure and/or topical medication burden in phakic or pseudophakic patients with glaucoma. This effect seems to last at least 12 months but reliable cost-effectiveness and quality of life indicators have not yet been established by investigator-initiated randomized trials of sufficient size and duration.

Toward zero effective phacoemulsification time using femtosecond laser pretreatment.

OBJECTIVE: To compare effective phacoemulsification time after femtosecond laser pretreatment with conventional phacoemulsification and the associated effect on visual outcomes and endothelial cell loss. DESIGN: Prospective, consecutive, single-surgeon case-control study. CONTROLS: Controls underwent phacoemulsification cataract extraction plus insertion of an intraocular lens (IOL). Cases underwent pretreatment with the femtosecond laser followed by phacoemulsification cataract extraction and IOL insertion. METHODS: Two hundred one eyes underwent cataract surgery between April 2012 and July 2012. Data collected included patient demographics, preoperative characteristics, femtosecond lens fragmentation method, effective phacoemulsification time (EPT), intraoperative complications, and postoperative outcomes. MAIN OUTCOME MEASURES: Effective phacoemulsification time, intraoperative complications, corneal endothelial cell loss, as well as postoperative best-corrected visual acuity, intraocular pressure, and refractive outcomes. RESULTS: Patient demographics were similar between groups. There was no difference between baseline cataract grades (2.59 ± 0.71 vs. 2.52 ± 0.72, not significant). One hundred percent of cases pretreated with the femtosecond laser had complete capsulotomy. Mean EPT was reduced by 83.6% in the femtosecond pretreatment group (P<0.0001) when compared with controls, with 30% having 0 EPT (P<0.0001). Effective phacoemulsification time was reduced 28.6% within the femtosecond group using improved lens fragmentation algorithms, and a further 72.8% reduction was achieved with a 20-gauge phacoemulsification tip. Overall, there was a 96.2% reduction in EPT between controls and the optimized femtosecond pretreatment group. This was associated with a 36.1% reduction in endothelial cell loss in the femtosecond group. Visual and refractive outcomes were similar to those of conventional cataract surgery. CONCLUSIONS: Femtosecond laser pretreatment results in a significant reduction in effective phacoemulsification time, including the possibility of 0 EPT. Further reductions may be achieved using optimization of lens fragmentation patterns and surgical technique. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Connexin43 mimetic peptide reduces vascular leak and retinal ganglion cell death following retinal ischaemia.

Connexin43 gap junction protein is expressed in astrocytes and the vascular endothelium in the central nervous system. It is upregulated following central nervous system injury and is recognized as playing an important role in modulating the extent of damage. Studies that have transiently blocked connexin43 in spinal cord injury and central nervous system epileptic models have reported neuronal rescue. The purpose of this study was to investigate neuronal rescue following retinal ischaemia-reperfusion by transiently blocking connexin43 activity using a connexin43 mimetic peptide. A further aim was to evaluate the effect of transiently blocking connexin43 on vascular permeability as this is known to increase following central nervous system ischaemia. Adult male Wistar rats were exposed to 60 min of retinal ischaemia. Treatment groups consisted of no treatment, connexin43 mimetic peptide and scrambled peptide. Retinas were then evaluated at 1-2, 4, 8 and 24 h, and 7 and 21 days post-ischaemia. Evans blue dye leak from retinal blood vessels was used to assess vascular leakage. Blood vessel integrity was examined using isolectin-B4 labelling. Connexin43 levels and astrocyte activation (glial fibrillary acidic protein) were assessed using immunohistochemistry and western blot analysis. Retinal whole mounts and retinal ganglion cell counts were used to quantify neurodegeneration. An in vitro cell culture model of endothelial cell ischaemia was used to assess the effect of connexin43 mimetic peptide on endothelial cell survival and connexin43 hemichannel opening using propidium iodide dye uptake. We found that retinal ischaemia-reperfusion induced significant vascular leakage and disruption at 1-2, 4 and 24 h following injury with a peak at 4 h. Connexin43 immunoreactivity was significantly increased at 1-2, 4, 8 and 24 h post ischaemia-reperfusion injury co-localizing with activated astrocytes, Muller cells and vascular endothelial cells. Connexin43 mimetic peptide significantly reduced dye leak at 4 and 24 h. In vitro studies on endothelial cells demonstrate that endothelial cell death following hypoxia can be mediated directly by opening of connexin43 hemichannels in endothelial cells. Blocking connexin43 mediated vascular leakage using a connexin43 mimetic peptide led to increased retinal ganglion cell survival at 7 and 21 days to levels of uninjured retinas. Treatment with scrambled peptide did not result in retinal ganglion cell rescue. Pharmacological targeting of connexin43 gap junction protein by transiently blocking gap junction hemichannels following injury provides new opportunities for treatment of central nervous system ischaemia.

Femtosecond laser-assisted cataract surgery compared with conventional cataract surgery.

BACKGROUND: To investigate the safety and efficacy of the Catalys (Optimedica, Santa Clara, CA, USA) femtosecond laser-assisted cataract surgery system compared with conventional phacoemulsification cataract extraction. DESIGN: Prospective, consecutive, parallel cohort study. PARTICIPANTS: The first 200 eyes undergoing conventional cataract surgery to the first 200 eyes undergoing femtosecond laser-assisted cataract surgery between April and July 2012. METHODS: Femtosecond laser-assisted cataract surgery involved anterior capsulotomy and lens fragmentation based on optical coherence tomography-guided treatment mapping. Conventional cataract surgery involved manual continuous curvilinear capsulorhexis. Both procedures were completed by standard phacoemulsification and insertion of an intraocular lens. MAIN OUTCOME MEASURES: Effective phacoemulsification time and intraoperative complication rates. RESULTS: Patient demographics were similar between both groups. There was no statistically significant difference in intraoperative complications between femtosecond laser-assisted cataract surgery and conventional surgery. There was one posterior capsule rupture in both groups (0.5%; not significant). One hundred per cent of cases treated with the femtosecond laser had a complete capsulotomy. Vacuum time decreased with experience. Effective phacoemulsification time was reduced by 70% in the femtosecond group (P < 0.0001). Twenty-six cases in the femtosecond group versus one case in the conventional group had 0 effective phacoemulsification time (P < 0.0001). CONCLUSION: Femtosecond laser-assisted cataract surgery appears to be as safe as conventional cataract surgery in the short term and results in significantly lower effective phacoemulsification time. Although it may allow for greater efficiency and decreased postoperative complications, further research is needed into long-term safety aspects such as corneal endothelial cell loss.

Patient satisfaction with topical ocular hypotensives.

BACKGROUND: The aim of this study is to assess patient satisfaction, convenience of use, ease of administration, side effects and treatment burden of topical ocular hypotensives. DESIGN: Prospective, observational cohort. PARTICIPANTS: Two thousand five hundred and forty-one patients with glaucoma or ocular hypertension. METHODS: The Treatment Impact Patient Satisfaction Scale (TIPSS) was administered by mail to all patients with glaucoma or ocular hypertension registered with Glaucoma New Zealand during a 3-month study period. The questionnaire assessed patient demographics; topical ocular hypotensive use including number of medications, frequency of administration, ease of use, class of medication, and presence/severity of side effects; impact on quality of life; and patient satisfaction. Univariate and multivariate analyses were performed to identify determinants of patient satisfaction. MAIN OUTCOME MEASURES: Patient satisfaction. RESULTS: Almost 80% of respondents were either 'very satisfied' or 'satisfied' with topical ocular hypotensives. Factors that were predictive of patient satisfaction included satisfaction with frequency of eye drop use {odds ratio (OR) 2.4 (95% confidence interval [CI] 1.8-3.1); P < 0.001}, subjective convenience (OR 2.6 [95% CI 2.0-3.4]; P < 0.001) and ease of administration (OR 2.5 [95% CI 2.0-3.3]; P < 0.001). Male gender was associated with lower satisfaction (OR 0.6 [95% CI 0.5-0.9]; P = 0.01). Factors that were not predictive of patient satisfaction included age, duration of eye drop use, class of medication and the presence of side effects. CONCLUSIONS: Patients with glaucoma and ocular hypotension are satisfied with topical ocular hypotensives. Efforts to improve patient satisfaction should focus on convenience and ease of administration.

Genetic Testing of Inherited Retinal Disease in Australian Private Tertiary Ophthalmology Practice.

Background: To assess the prevalence of genetic testing for inherited retinal diseases (IRDs) in a tertiary practice setting. Methods: Single-centre retrospective analysis of patients with diagnosed or suspected IRD. Results: Four hundred and sixty-four patient records were analysed. Patients had received care for different IRDs grouped as follows: panretinal pigmentary retinopathies (283, 61%), macular dystrophies (136, 29.3%), stationary diseases (23, 5%), hereditary vitreoretinopathies (14, 3%), and other IRDs (8, 1.7%). The suspected pattern of inheritance of patients' IRD was predominantly autosomal recessive (205, 44.2%). Genetic testing was performed with the corresponding results available for 44 patients (9.5%). Diagnostic yield was 65.9% for the results received. Genetic test results were available mostly for younger patients (13.1% for <45 years vs 6.2% ≥45 years of age, p = 0.01) and those who received greater than 12 months of care (16% for ≥12 months vs 4% for <12 months, p < 0.01). For patients without genetic testing results, reasons include awaiting a geneticist consultation (17.9%), awaiting test results (4.5%), or patient refusal (8.4%). Most clinical records (69.2%) did not document genetic testing status. Conclusion: Genetic testing is increasingly being utilised in the work-up for patients with IRD worldwide. This large Australian private practice IRD cohort shows a low uptake of testing (around 10%), reflecting historical management patterns and accessibility of genetic counselling and testing. The results show that younger patients and those with a longer duration of care were more likely to have received genetic testing. As the importance of IRD genetic testing continues to increase, we expect to see a change in patient management within the Australian private ophthalmology system and testing rates to increase. Further research is required to identify and address clinician and patient barriers to improving genetic testing rates for IRD.

Acute primary angle closure attack does not cause an increased cup-to-disc ratio.

PURPOSE: To determine if an increased cup-to-disc ratio (CDR) and retinal nerve fiber layer (RNFL) loss occur after acute primary angle closure (APAC). DESIGN: Prospective, observational case series. PARTICIPANTS: Twenty participants with unilateral APAC provided 20 affected eyes and 20 fellow eyes (controls) for analysis. METHODS: After initial presentation, participants attended 3 further assessments over a 12-month period (visit 2, within 2 weeks; visit 3, 2-3 months; and visit 4, 6-12 months), in which they underwent the following investigations: Heidelberg Retinal Tomography (Heidelberg Engineering, Dossenheim, Germany), optical coherence tomography of the RNFL and macula, and automated perimetry. MAIN OUTCOME MEASURES: Cup-to-disc ratio, optic cup area, neuroretinal rim area, RNFL thickness, macular thickness, and volume. RESULTS: There was no change from visits 2 to 4 in CDR (0.46 ± 0.17 vs. 0.47 ± 0.20; P = 0.94), neuroretinal rim area (1.64 ± 0.55 vs. 1.64 ± 0.57; P = 0.96), or other optic nerve head parameters analyzed in eyes with APAC. The mean overall RNFL thickness decreased from 106.6 ± 17.9 µm to 92.9 ± 18.3 µm between visits 2 and 3 (P<0.01) in affected eyes. The superior quadrant RNFL thickness decreased from 134.8 ± 25.9 µm to 113 ± 25.7 µm (P<0.01), and the inferior quadrant RNFL thickness decreased from 139.1 ± 28.4 µm to 115.6 ± 24.9 µm (P<0.01). There was no significant change in macular thickness or volume. CONCLUSIONS: This study demonstrated that an increase in CDR does not occur after APAC that is treated promptly, although RNFL loss does occur.

Health economic evaluation in ophthalmology.

Health economic evaluation is the application of economic theories, tools and concepts to healthcare. In the setting of limited resources, increasing demand and a growing array of intervention options, economic evaluation provides a framework for measuring, valuing and comparing the costs and benefits of different healthcare interventions. This review provides an overview of the concepts and methods of economic evaluation, illustrated with examples in ophthalmology. Types of economic evaluation include cost-minimisation, cost-benefit, cost-effectiveness, cost-utility and economic modelling. Topics including utility measures, the quality-adjusted lifeyear, discounting, perspective and timeframe are discussed. Health economic evaluation is important to understand the costs and value of interventions in ophthalmology and to inform health policy as well as guide clinical decision-making.

Primary Needling of the Ab Interno Gelatin Microstent Reduces Postoperative Needling and Follow-up Requirements.

PURPOSE: To evaluate the effect of primary needling at the time of ab interno gelatin microstent insertion on postoperative needling rates. DESIGN: Retrospective, interventional cohort study. PARTICIPANTS: Eighty-six eyes of 74 patients with no prior incisional surgery. METHODS: Consecutive eyes with open-angle glaucoma refractory to medical treatment that underwent ab interno gelatin microstent insertion (XEN; Allergan Inc.) with or without primary needling. MAIN OUTCOME MEASURES: Primary outcome measure was the proportion of eyes requiring postoperative needling. Secondary outcome measures included the mean reduction in intraocular pressure (IOP), topical glaucoma medication use, complications, reoperations, and number of follow-up clinic visits over 12 months. RESULTS: Fifty-one eyes (42 patients, median age 74 years) underwent XEN surgery with primary needling at the time of surgery, and 35 eyes (32 patients, median age 73 years) underwent XEN surgery without routine primary needling. Eyes that received routine primary needling had an 84.8% lower rate of postoperative needling (3.9% vs. 25.7%, P = 0.003) and required fewer postoperative clinic visits (P = 0.043). Median IOP was 18.0 mmHg (interquartile range [IQR], 13.0-23.0) on 3.0 (IQR, 2.0-3.0) classes of topical medications at baseline. At 12 months, the median IOP was 11.0 mmHg (IQR, 9.0-14.0) in the primary needling group and 11 mmHg (IQR, 10.0-14.0) when primary needling was not routinely performed. Both groups demonstrated a high safety profile. In total, 5 eyes required further glaucoma surgery with insertion of a glaucoma drainage device. CONCLUSIONS: Primary needling at the time of XEN gel stent insertion is associated with a significant reduction in the need for postoperative needling and postoperative clinic visits. This modification provides a predictable postoperative course with a significant and sustained reduction in both IOP and glaucoma medication requirements with less intense postoperative management.

Standalone iStent Trabecular Micro-bypass Glaucoma Surgery: A Systematic Review and Meta-Analysis.

PRECIS: Standalone trabecular micro-bypass glaucoma surgery with the iStent devices is associated with clinically relevant reductions in intraocular pressure (IOP) sustained over a reasonably long-term while simultaneously reducing medication burden and a relatively favorable safety profile. PURPOSE: While there is a relatively large body of evidence supporting the implantation of the iStent trabecular micro-bypass devices during phacoemulsification in patients with open-angle glaucoma (OAG), its efficacy as a standalone procedure has been less widely reported. The aims of this study were to systematically identify and quantitatively evaluate the efficacy of iStent devices (iStent and iStent inject) when performed independently of cataract surgery in patients with OAG. METHODS: A systematic review of the literature was undertaken in August 2019 to identify studies of standalone trabecular micro-bypass glaucoma surgery with iStent devices in patients with OAG. All randomized trials were considered and nonrandomized studies that included at least 6 months of follow-up or more than 10 eyes. Key efficacy analyses included postoperative IOP and medication use, which were used to evaluate weighted mean differences from baseline, and the proportion of eyes free of ocular medication. Postoperative adverse events were descriptively summarized. RESULTS: A total of 13 studies were identified including 4 randomized controlled trials and 9 nonrandomized or single-arm studies providing data for 778 eyes. In eyes implanted with iStent devices, a weighted mean IOP reduction of 31.1% was observed at 6 to 12 months. In studies reporting longer-term outcomes (36 to 48 mo or 60 mo), the weighted mean IOP reduction was 30.4% and 32.9%, respectively. The pooled weighted mean reduction in IOP from baseline across all studies at 6 to 12 months and 36 to 60 months poststent implantation was 7.01 mm Hg (95% confidence interval: 5.91, 8.11) and 6.59 mm Hg (95% confidence interval: 5.55, 7.63), respectively. Medication burden was reduced by ~1.0 medication at 6 to 18 months and 1.2 medications at 36 to 60 months. Adverse events reported in more than 5% of participants were progression of pre-existing cataract/cataract surgery and loss of best-corrected visual acuity but these rates were no different to those reported in comparator medical therapy study arms. CONCLUSIONS: The results from these studies support the independent effect of the iStent trabecular bypass devices on IOP and medication burden over a duration of follow-up of up to 5 years.

Understanding the mechanism of the water drinking test: the role of fluid challenge volume in patients with medically controlled primary open angle glaucoma.

BACKGROUND: To determine whether a 500-mL fluid challenge produces a different intraocular pressure (IOP) response profile compared with a 1000-mL water drinking test (WDT). METHODS: Prospective, observer-masked, cross-over, observational study. Patients with primary open angle glaucoma were recruited from a private specialist glaucoma practice. One eye of each patient was included. Subjects were randomized to receive either a 500-mL or 1000-mL fluid challenge. Baseline IOP was recorded with a Goldmann applanation tonometer and then every 15 min for 1 h. A second WDT with the alternate volume of water was performed after a minimum washout period of 24 h. Primary statistical analysis was performed using a two-way anova repeated measures of variance with a Bonferroni post-hoc test. RESULTS: Fifteen patients were included in this study. The mean patient age was 67.0 +/- 10.2 (SD) years, and 60% of patients were female. There was no statistically significant difference in baseline IOP between the 500-mL and 1000-mL WDTs (P = 0.11). Both fluid challenge volumes produced a statistically significant rise in IOP from baseline at 15, 30 and 45 min after water ingestion. However the mean maximum increase in IOP was less in the 500-mL WDT (3.3 +/- 1.8 mmHg [23.9%]) compared with the 1000-mL WDT (4.9 +/- 2.3 mmHg [32.5%]; P = 0.0095). CONCLUSION: The 500-mL WDT may provide an alternative for patients who are unable to tolerate drinking 1000 mL of water. However, because the maximum IOP obtained is less, a 500-mL WDT cannot be used to directly estimate peak diurnal pressure.

Phosphodiesterase inhibitors and the eye.

Phosphodiesterase type 5 (PDE5) inhibitors are effective oral treatments for erectile dysfunction and have become one of the most widely prescribed medications worldwide. The mechanism of action is to reduce the degradation of cyclic GMP (cGMP) potentiating the effect of nitric oxide in the corpus cavernosum and allowing erectile function to occur by consequent relaxation of penile smooth muscle. Because of the presence of PDE5 in choroidal and retinal vessels these medications increase choroidal blood flow and cause vasodilation of the retinal vasculature. The most common symptoms are a blue tinge to vision and an increased sensitivity to light. There have been reports of non-arteritic anterior ischaemic optic neuropathy and serous macular detachment in users of PDE5 inhibitors, although a causal relationship has not been conclusively shown. Despite the role of cGMP in the production and drainage of aqueous humour these medications do not appear to alter intraocular pressure and are safe in patients with glaucoma. All PDE5 inhibitors weakly inhibit PDE6 located in rod and cone photoreceptors resulting in mild and transient visual symptoms that correlate with plasma concentrations. Psychophysical tests reveal no effect on visual acuity, visual fields or contrast sensitivity; however, some studies show a mild and reversible impairment of blue-green colour discrimination. PDE5 inhibitors transiently alter retinal function on electroretinogram testing but do not appear to be retinotoxic. Despite the role of cyclic nucleotides in tear production there is no detrimental effect on tear film quality. Based on the available evidence PDE5 inhibitors have a good ocular safety profile.

Non-arteritic anterior ischaemic optic neuropathy: a review and update.

Non-arteritic anterior ischaemic optic neuropathy (NAION) is the most common acute optic neuropathy in people aged 50 years and older. The condition is caused by infarction of the laminar or retrolaminar portion of the optic nerve head supplied by the short posterior ciliary arteries (SPCAs). The underlying aetiology and pathophysiology is poorly elucidated. Factors that have been implicated include nocturnal hypotension, impaired autoregulation of the microvascular supply, vasculopathic occlusion, and venous insufficiency. These factors are thought to result in axonal oedema causing a compartment syndrome in a structurally crowded optic disc leading to axonal degeneration and loss of retinal ganglion cells via apoptosis. Clinically NAION is characterised by sudden, usually painless, loss of vision in one or both eyes. Examination findings include decreased visual acuity, a visual field defect, decreased colour vision, a relative afferent pupillary defect, and optic disc swelling. Despite significant research, treatment options for NAION remain limited.

The Safety and Efficacy of Supraciliary Stenting Following Failed Glaucoma Surgery.

PURPOSE: To evaluate the safety and efficacy of supraciliary stenting following failed glaucoma surgery. DESIGN: Interventional case series. METHODS: Setting: Moorfields Eye Hospital, London, United Kingdom. STUDY POPULATION: Twenty eyes from 20 patients with glaucoma refractory to prior glaucoma surgery. INTERVENTION: Ab interno microstent (CyPass Micro-Stent; Alcon, Fort Worth, Texas, USA) implantation into the supraciliary space. MAIN OUTCOME MEASURES: Outcome measures included the occurrence of ocular adverse events, mean intraocular pressure (IOP) change, and glaucoma medication use through 12 months. RESULTS: Mean baseline IOP was 22.5 ± 8.0 mm Hg and number of medications was 2.7 ± 1.0. The majority of patients had undergone either prior trabeculectomy or aqueous shunt surgery. There were no serious intraoperative complications or major adverse events following supraciliary stenting. The most common adverse events included transient hyphema (3/20, 15%), transient IOP > 30 mm Hg (4/20, 20%), and transient IOP < 6 mm Hg (4/20, 20%). At 12 months, mean IOP was 14.9 ± 4.3 mm Hg-a 33.7% reduction (P = .01). Mean medication usage decreased 56% to 1.2 ± 1.5 at 12 months (P = .01). Two patients (10%) required subsequent aqueous shunt insertion. CONCLUSION: Ab interno supraciliary stenting has a favorable safety profile and provides an effective approach to controlling IOP and reducing medication burden in eyes in which previous glaucoma surgery has failed.

Ab Interno Gel Implant-associated Bleb-related Infection.

PURPOSE: To examine the presentation and management of 3 cases of bleb-related infection following ab interno gel implant surgery, so as to add to the growing understanding of complications associated with the emerging landscape of newer, minimally invasive glaucoma surgical procedures, and how they are best managed. DESIGN: Multicenter retrospective interventional case series. METHODS: Consecutive cases of bleb-related infection following ab interno gel implant surgery from 2 university-affiliated hospitals were included. Risk factors, visual outcomes, intraocular pressure, and subsequent management were analyzed. RESULTS: We report 3 cases of late bleb-related infection occurring after ab interno gelatin stent insertion (8, 7, and 24 months after surgery). One case had blebitis only; the other 2 had bleb-related endophthalmitis. All cases responded rapidly to management of their infections according to standard bleb-related infection protocol, recovering to within 2 lines of their previous visual acuity (6/9, 6/12, and 6/18). Explantation of the devices was not required. CONCLUSIONS: Bleb-related infections after ab interno gel implant insertion can occur. If infection is treated appropriately, good clinical outcomes are possible.