Trabecular Procedures Combined with Cataract Surgery for Open-Angle Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To determine the intraocular pressure (IOP) reduction of various trabecular procedures (a form of minimally invasive glaucoma surgery [MIGS]) combined with cataract surgery compared with cataract surgery alone, to compare the safety of the various trabecular procedures, and to highlight patient characteristics that may favor one trabecular procedure over another. METHODS: A search of English-language peer-reviewed literature in the PubMed database was initially conducted in February 2021 and updated in April 2023. This yielded 279 articles. Twenty studies met initial inclusion and exclusion criteria and were assessed for quality by the panel methodologist. Of these, 10 were rated level I, 3 were rated level II, and 7 were rated level III. Only the 10 level I randomized controlled trials (RCTs) were included in this assessment, and all were subject to potential industry-sponsorship bias. RESULTS: The current analysis focuses on the amount of IOP reduction (in studies that involved medication washout) and on IOP reduction with concurrent medication reduction (in studies that did not involve medication washout). Based on studies that performed a medication washout, adding a trabecular procedure to cataract surgery provided an additional 1.6 to 2.3 mmHg IOP reduction in subjects with hypertensive, mild to moderate open-angle glaucoma (OAG) at 2 years over cataract surgery alone, which itself provided approximately 5.4 to 7.6 mmHg IOP reduction. In other words, adding a trabecular procedure provided an additional 3.8% to 8.9% IOP reduction over cataract surgery alone, which itself provided 21% to 28% IOP reduction. There was no clear benefit of one trabecular procedure over another. Patient-specific considerations that can guide procedure selection include uveitis predisposition, bleeding risk, metal allergy, and narrowing of Schlemm's canal. There are no level I data on the efficacy of trabecular procedures in subjects with pretreatment IOP of 21 mmHg or less. CONCLUSIONS: Trabecular procedures combined with cataract surgery provide an additional mild IOP reduction over cataract surgery alone in hypertensive OAG subjects. Additional research should standardize outcome definitions, avoid industry sponsorship bias, and study the efficacy of these procedures in normotensive OAG. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Aqueous Shunts with Extraocular Reservoir for Open-Angle Adult Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To evaluate the recently published literature on the efficacy and safety of the use of aqueous shunts with extraocular reservoir for the management of adult open-angle glaucomas (OAGs). METHODS: A search of peer-reviewed literature was last conducted in April 2023 of the PubMed database and included only articles published since the last aqueous shunt Ophthalmic Technology Assessment, which assessed articles published before 2008. The abstracts of these 419 articles were examined, and 58 studies were selected for full-text analysis. After inclusion and exclusion criteria were applied, 28 articles were selected and assigned ratings by the panel methodologist according to the level of evidence. Twenty-five articles were rated level I and 3 articles were rated level II. There were no level III articles. RESULTS: Implantation of aqueous shunts with extraocular reservoir can lower intraocular pressure (IOP) by between one-third and one-half of baseline IOP, depending on whether it is undertaken as the primary or secondary glaucoma surgery. Success rates for aqueous shunts were found to be better than for trabeculectomies in eyes with prior incisional surgery. Conversely, in eyes without prior incisional surgery, implantation of aqueous shunts was found to have an overall lower success rate as the primary glaucoma procedure compared with trabeculectomy. Although both valved and nonvalved aqueous shunts with extraocular reservoir were effective, the nonvalved device generally achieved slightly lower long-term IOPs with fewer glaucoma medications and less need for additional glaucoma surgery. Both devices slow the rates of visual field progression with efficacy comparable with that of trabeculectomy. Early aqueous humor suppression after aqueous shunt implantation is recommended for the management of the postoperative hypertensive phase and long-term IOP control. No strong evidence supports the routine use of mitomycin C with aqueous shunt implantation for OAG. CONCLUSIONS: Implantation of aqueous shunts with extraocular reservoir, including valved or nonvalved devices, has been shown to be an effective strategy to lower IOP. Strong level I evidence supports the use of aqueous shunts with extraocular reservoir by clinicians for the management of adult OAG. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the current published literature for high-quality studies on the use of selective laser trabeculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment titled, "Laser Trabeculoplasty for Open-Angle Glaucoma," published in November 2011. METHODS: Literature searches in the PubMed database in March 2020, September 2021, August 2022, and March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and 30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a level II rating to 11 studies. RESULTS: Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term efficacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power settings for SLT. CONCLUSIONS: Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication, or an additional therapy with glaucoma medications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Central Visual Field Testing in Early Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To evaluate the current published literature on the utility of the 10-2 visual field (VF) testing strategy for the evaluation and management of early glaucoma, defined here as mean deviation (MD) better than -6 decibels (dB). METHODS: A search of the peer-reviewed literature was last conducted in June 2023 in the PubMed database. Abstracts of 986 articles were examined to exclude reviews and non-English-language articles. After inclusion and exclusion criteria were applied, 26 articles were selected, and the panel methodologist rated them for strength of evidence. Thirteen articles were rated level I, and 8 articles were rated level II. The 5 level III articles were excluded. Data from the 21 included articles were abstracted and reviewed. RESULTS: The central 12 locations on the 24-2 VF test grid lie within the central 10 degrees covered by the 10-2 VF test. In early glaucoma, defects detected within the central 10 degrees generally agree between the 2 tests. Defects within the central 10 degrees of the 24-2 VF test can predict defects on the 10-2 VF test, although the 24-2 may miss defects detected on the 10-2 VF test. In addition, results from the 10-2 VF test show better association with findings from OCT scans of the macular ganglion cell complex. Modifications of the 24-2 test that include extra test locations within the central 10 degrees improve detection of central defects found on 10-2 VF testing. CONCLUSIONS: Evidence to date does not support routine testing using 10-2 VF for patients with early glaucoma. However, early 10-2 VF testing may provide sufficient additional information for some patients, particularly those with a repeatable defect within the central 12 locations of the standard 24-2 VF test or who have inner retinal layer thinning on OCT scans of the macula. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Corneal Hysteresis for the Diagnosis of Glaucoma and Assessment of Progression Risk: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the current published literature on the utility of corneal hysteresis (CH) to assist the clinician in the diagnosis of glaucoma or in the assessment of risk for disease progression in existing glaucoma patients. METHODS: Searches of the peer-reviewed literature in the PubMed database were performed through July 2022. The abstracts of 423 identified articles were examined to exclude reviews and non-English articles. After inclusion and exclusion criteria were applied, 19 articles were selected, and the panel methodologist rated them for level of evidence. Eight articles were rated level I, and 5 articles were rated level II. The 6 articles rated level III were excluded. RESULTS: Corneal hysteresis is lower in patients with primary open-angle glaucoma, primary angle-closure glaucoma, pseudoexfoliative glaucoma, and pseudoexfoliation syndrome compared with normal subjects. Interpretation of low CH in patients with high intraocular pressure (IOP) or on topical hypotensive medications is complicated by the influence of these parameters on CH measurements. However, CH is also lower in treatment-naïve, normal-tension glaucoma patients compared with normal subjects who have a similar IOP. In addition, lower CH is associated with an increased risk of progression of glaucoma based on visual fields or structural markers in open-angle glaucoma patients, including those with apparently well-controlled IOP. CONCLUSIONS: Corneal hysteresis is lower in glaucoma patients compared with normal subjects, and lower CH is associated with an increased risk of disease progression. However, a causal relationship remains to be demonstrated. Nevertheless, measurement of CH complements current structural and functional assessments in determining disease risk in glaucoma suspects and patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Does the ISNT rule apply to the radial peripapillary capillary vessel density in OCT angiography?

PURPOSE: To investigate the applicability of ISNT (inferior ≥ superior ≥ nasal ≥ temporal), IST (inferior ≥ superior ≥ temporal), and T min (temporal quadrant with the minimum value) rules to the peripapillary nerve fiber layer (NFL) thickness and radial peripapillary capillary (RPC) vessel density (VD) using Optical Coherence Tomography (OCT) and OCT angiography (OCT-A). MATERIALS AND METHODS: This cross-sectional study included 134 eyes of 74 healthy individuals. NFL thickness and RPC VD were measured in all four quadrants using OCT and OCT-A in order to determine the number of eyes that obey the ISNT, IST, and T min rules. RESULTS: Mean age was 48.8 ± 15.5 (range 25-82) years. The ISNT rule was valid in 52 eyes (38.81%) on OCT and only 12 eyes (8.95%) on OCT-A scans. The IST rule was followed by 83 (61.94%) and 37 (27.61%) eyes on OCT and OCT-A scans respectively. The T min rule was valid in 86 eyes (64.18%) in OCT scans and in 26 eyes (19.4%) in OCT-A scans. CONCLUSION: The topography of the RPC network does not obey the ISNT rule in healthy eyes. The ISNT rule and its variants were found to be more relevant in OCT NFL thickness measurements compared to OCT-A RPC VD measurements.

Reproducibility and agreement of four anterior segment-optical coherence tomography devices for anterior chamber angle measurements.

PURPOSE: To compare the reproducibility and agreement of anterior chamber angle (ACA) parameters and metrics obtained by four different anterior segment-optical coherence tomography (AS-OCT) devices. METHODS: In this prospective study, 30 eyes from 15 normal subjects underwent anterior segment angle scanning using the Spectralis, Cirrus, and Optovue spectral domain optical coherence tomography (SD-OCT), as well as the Visante time-domain optical coherence tomography (TD-OCT). For each eye, the scan line was performed perpendicularly on the inferior (270°) angle, and the inferior ACA image was acquired 2 times. Inter-instrument and intra-instrument, as well as inter-observer and intra-observer reproducibility of anterior chamber angle metrics, Schwalbe's line (SL) to scleral spur (SS) distance (TM-Span), angle opening distance (AOD), and trabecular iris space area (TISA) measurements, were evaluated by intraclass correlation coefficients (ICCs) and Bland-Altman plots with limits of agreement (LoA). RESULTS: For this cohort of 30 eyes of 15 normal subjects, the mean TM-Span, AOD, and TISA were 0.966 ± 0.198 mm, 0.750 ± 0.205 mm, and 0.286 ± 0.090 mm2 from the Spectralis; 0.929 ± 0.113 mm, 0.717 ± 0.120 mm, and 0.267 ± 0.095 mm2 from the Cirrus; 0.923 ± 0.191 mm, 0.683 ± 0.161 mm, and 0.265 ± 0.072 mm2 from the Optovue; and 0.970 ± 0.070 mm, 0.705 ± 0.150 mm, and 0.279 ± 0.065 mm2 from the Visante. The intra-instrument (ICCs > 0.838), intra-grader (ICCs > 0.910), and inter-grader (ICCs > 0.869) agreement were good. Agreement between the four instruments was also good with ICCs from 0.901 to 0.967 for TM-Span, 0.887 to 0.941 for AOD, and 0.923 to 0.961 for TISA. CONCLUSIONS: Consistent and reproducible ACA measurements could be obtained from multiple AS-OCT devices including both SD- and TD-OCT instruments. These findings have relevance when considering multiple imaging devices in future studies.

Clinical results of ab interno trabeculotomy using the trabectome in patients with uveitic glaucoma.

IMPORTANCE: To evaluate the safety and efficacy of ab interno trabeculotomy (AIT) (trabecular ablation) with the trabectome in patients with uveitic glaucoma. BACKGROUND: Traditional glaucoma filtration surgeries in the uveitic patient population come with a higher risk of complications such as failure and hypotony. DESIGN: Retrospective observational cohort study. PARTICIPANTS: All patients diagnosed with uveitic glaucoma were included in this study. Patients were excluded if they have less than 12 months of follow-up. METHODS: All patients who received AIT alone or combined with phacoemulsification. MAIN OUTCOME MEASURES: Major outcomes include intraocular pressure (IOP), number of glaucoma medications and secondary glaucoma surgery, if any. Kaplan-Meier method was used for survival analysis and success was defined as IOP ≤21 mmHg, at least 20% IOP reduction from baseline for any two consecutive visits after 3 months, no additional glaucoma medications, and no secondary glaucoma surgery. RESULTS: A total of 45 eyes, 45 patients, with an average age of 52 years were included in the study. The majority were Japanese (40%) and underwent AIT alone (71%). IOP was reduced from 29.2 ± 8.0 to 16.7 ± 4.6 mmHg at 12 months (P < .01*), while the number of glaucoma medications was reduced from 4.0 ± 1.0 to 2.5 ± 1.6 (P < .01*). Survival rate at 12 months was 91%. Six cases required secondary glaucoma surgery and no other serious complication were reported. CONCLUSIONS AND RELEVANCE: The trabectome AIT procedure appears to be effective in reducing IOP in uveitic glaucoma patients. Although no statistically significant difference was found in the number of glaucoma medications, a decreasing trend was found.

Assessment of Corneal Changes Associated with Topical Antiglaucoma Therapy Using in vivo Confocal Microscopy.

PURPOSE: Ocular surface disease (OSD) is highly prevalent in eyes treated with chronic, topical antiglaucoma (A/G) therapy. The purpose of this study was to utilize in vivo confocal microscopy (IVCM) to evaluate the corneal morphology, including characteristics of corneal epithelial cells, presence of epithelial dendritic cells (DCs), and characteristics of subbasal nerve plexus, of eyes under topical A/G therapy versus normal eyes. METHODS: Central corneal images were prospectively captured from 30 eyes of 16 patients under topical A/G therapy (>6 months) and 20 normal control eyes, using IVCM (HRT 3 RCM, Heidelberg, Germany). Demographic data were collected, as well as information on the types and duration of A/G therapy. In addition, OSD index (OSDI) score, tear film breakup time, Schirmer 1 test results, density of epithelial wing cells (WCs) and basal cells (BCs), subbasal nerve features (density, tortuosity, and reflectivity), and presence of DCs were all assessed and recorded by trained Doheny Image Reading Center graders. RESULTS: IVCM findings of 30 glaucomatous eyes and 20 normal control eyes were analyzed. The mean OSDI score was 8.72 in controls and 32.06 in patients under A/G therapy (p = 0.002). Nerve fiber density, nerve fiber reflectivity, and BC density were all decreased in the A/G group (1,789.07 ± 785.70 µm/frame, 2.79 ± 0.83, 6,457.67 ± 692.55 cells/mm2, respectively) as compared to controls (2,815.981 ± 563.77 µm/frame, 3.52 ± 0.50, 7,854.13 ± 1,073.69 cells/mm2, respectively) (p < 0.05), whereas the decrease in WC density was statistically nonsignificant (p = 0.5). Nerve tortuosity and DC density were both significantly greater in the A/G eyes (3.00 ± 0.57, 71.24 ± 61.74 cells/mm2, respectively) compared to controls (2.10 ± 0.42, 34.08 ± 11.70 cells/mm2, respectively) (p < 0.05). Tear film breakup time and Schirmer 1 test results were significantly lower in the A/G group as compared to controls (p < 0.001). CONCLUSIONS: Using IVCM, our study identified significant microstructural alterations in the corneas of eyes treated with topical A/G therapy. In addition, our study also revealed that glaucoma patients treated with topical A/G therapy report significantly higher OSDI scores compared to controls. Thus, IVCM may be a useful tool in providing structural parameters to correlate with the functional OSDI assessments in the evaluation of ocular surface toxicity associated with topical A/G therapy.

Potential applications of optical coherence tomography angiography in glaucoma.

PURPOSE OF REVIEW: Optical coherence tomography angiography (OCTA) is a novel, noninvasive imaging modality that allows assessment of the retinal and choroidal vasculature. The scope of this review is to summarize recent studies using OCTA in glaucoma and highlight potential applications of this new technology in the field of glaucoma. RECENT FINDINGS: OCTA studies have shown that retinal vascular changes may not develop solely as a result of advanced glaucoma damage. OCTA-derived measurements have provided evidence for lower retinal vascular densities at the optic nerve head, peripapillary and macula in preperimetric-glaucoma and early-glaucoma, as well as, in more advanced glaucoma, in comparison to with normal eyes. SUMMARY: OCTA is a novel imaging modality that has already started to expand our knowledge base regarding the role of ocular blood flow in glaucoma. Future studies will better elucidate the role of OCTA-derived measurements in clinical practice, research, and clinical trials in glaucoma.

Comparison of Noncontact Specular and Confocal Microscopy for Evaluation of Corneal Endothelium.

PURPOSE: To compare endothelial cell analysis obtained by noncontact specular and confocal microscopy, using the Konan NSP-9900 and Nidek ConfoScan4 systems, respectively. METHODS: Three groups including 70 healthy eyes, 49 eyes with Fuchs endothelial corneal dystrophy (FECD), and 78 eyes with glaucoma were examined with both the Konan NSP-9900 specular microscope and the Nidek ConfocScan4 confocal microscope. Certified graders at the Doheny Image Reading Center compared corneal endothelial images from both instruments side by side to assess image quality. Endothelial cell density (ECD) measurements were calculated and compared using three different modalities: (1) each instrument's fully automated analysis; (2) each instrument's semiautomatic analysis with grader input; and (3) manual grading methods by certified grader. RESULTS: All normal eyes yielded gradable endothelial images, and most but not all glaucomatous eyes yielded images with high enough image quality to allow grading. In addition, in corneas with severe FECD, poor image quality precluded ECD grading by specular microscopy in 20 eyes (40.8%) but in only 4 (8.2%) confocal images from the same eyes. For the gradable images, the ECD values obtained using the manual grading method from either device were comparable with no statistically significant difference (P>0.05) between specular and confocal devices. Machine-generated ECD values were significantly different from manual results, measuring greater in all cases with specular microscopy. Machine-generated ECD values from confocal microscopy also differed significantly from manual determinations, but not in a consistent direction. Semiautomatic methods for both instruments obtained clinically acceptable ECD values. CONCLUSIONS: Automatic machine-generated ECD measurements differed significantly from manual assessments of corneal endothelium by both specular and confocal microscopy, suggesting that automated results should be used with caution. But ECD values derived manually were comparable between the two devices in both normal and glaucomatous eyes, suggesting that manually graded images from the two instruments can be used interchangeably for reliable ECD measurements. Because of a higher proportion of gradable images, confocal microscopy may be superior to specular microscopy for ECD measurements in FECD.

Corneal features in ocular graft-versus-host disease by in vivo confocal microscopy.

PURPOSE: The purpose of our study was to determine the morphological features of the corneal epithelial layers, sub-basal nerve plexus and anterior stroma in patients with ocular graft-versus-host disease (oGVHD) compared to non-GVHD dry eyes and normal controls, using in vivo confocal microscopy (IVCM). METHODS: IVCM was used to capture central cornea images from eight volunteers with normal healthy eyes, ten patients with non-GVHD dry eye syndrome (DES) and 15 patients with clinically diagnosed oGVHD, in a cross-sectional study. Morphological changes of the corneal epithelial layers and anterior stroma, characteristics of corneal nerves and presence of dendritic cells (DCs) were then evaluated. RESULTS: IVCM images obtained from 66 eyes were analyzed. The density of superficial epithelial cells was 636.07 ± 101.05 cells/mm2 in the oGVHD group, 827 ± 99.62 cells/mm2 in the DES group and 1277.2 ± 121.42 cells/mm2 in the control group (P < 0.001). The density of wing cells was 4499.79 ± 976.36 cells/mm2 in the oGVHD group, 4662.85 ± 319.72 cells/mm2 in DES group and 6556.38 ± 503.99 cells/mm2 in the control group (p < 0.001). The density of basal cells was 7850.93 ± 723.51 cells/mm2 in the oGVHD group, 8570 ± 913.32 cells/mm2 in DES group and 9759.8 ± 251.99 cells/mm2 in the control group (p < 0.01). The density of nerve fibers was 11.22 ± 5.46 mm/mm2 in the oGVHD group, 14.50 ± 4.27 mm/mm2 in DES group and 19.56 ± 4.75 mm/mm2 in the control group (p < 0.01). The DC density was 67.88 ± 71.82 cells/mm2 in the oGVHD group, 40.06 ± 31.95 cells/mm2 in the DES group and 29.45 ± 8.1 cells/mm2 in the control group (P > 0.05). Visible networks of activated keratocytes were seen in the anterior stroma of eyes with oGVHD and DES, but not in normal controls. CONCLUSIONS: IVCM revealed distinct microstructural changes in the corneas of patients with oGVHD and DES, similar between the two groups. Our findings suggest implications for use of IVCM to evaluate and monitor patients with dry eyes associated or not with GVHD.

Implantation of a second glaucoma drainage device.

PURPOSE: To evaluate success rates in controlling intraocular pressure (IOP) after implantation of a second glaucoma drainage device (GDD) with a Baerveldt glaucoma implant in patients with refractory glaucoma, with a secondary aim of reducing the need for postoperative glaucoma medications. MATERIAL AND METHODS: This retrospective, noncomparative, interventional study included patients undergoing a second GDD for uncontrolled glaucoma from a tertiary care glaucoma service. Data were obtained from the medical records for the preoperative period and after the 1st, 15th, and 30th day, 3, 6, and 12 months, and then yearly until the last postoperative visit. Visual acuity, IOP, and number of glaucoma medications (NGM) from the follow-up visits were compared to baseline. Success and failure criteria were analyzed based on IOP level or need of glaucoma medications. RESULTS: Forty-nine patients were studied, with a mean follow-up time of 25 ± 21 months. The mean preoperative IOP was 23.7 ± 8.2 mmHg, and decreased to 14.8 ± 4.0 mmHg after 1 year, 14.4 ± 3.9 mmHg after 2 years, and 16.6 ± 8.5 mmHg after 3 years. The mean preoperative NGM was 3.4 ± 1.3, and decreased to 2.0 ± 1.8 after 1 year, 2.5 ± 1.6 after 2 years, and 2.8 ± 2.0 after 3 years. Absolute success was 9% after 1 year for a postoperative IOP between 5 and 18 mmHg, and 76% for a postoperative IOP between 5 and 21 mmHg. The qualified success was 88% at the first and second years and 83% at the third year. CONCLUSION: With up to 3 years of follow-up, a second glaucoma drainage device was successful in reducing IOP to below 21 mmHg, but not as successful below 18 mmHg. The success rate is improved with the use of glaucoma medications with up to 3 years of follow-up.

Effects of diurnal, lighting, and angle-of-incidence variation on anterior segment optical coherence tomography (AS-OCT) angle metrics.

BACKGROUND: First reported study to assess the effect of diurnal variation on anterior chamber angle measurements, as well as, to re-test the effects of lighting and angle-of-incidence variation on anterior chamber angle (ACA) measurements acquired by time-domain anterior segment optical coherence tomography (AS-OCT). METHODS: A total of 30 eyes from 15 healthy, normal subjects underwent anterior chamber imaging using a Visante time-domain AS-OCT according to an IRB-approved protocol. For each eye, the inferior angle was imaged twice in the morning (8 am - 10 am) and then again in the afternoon (3 pm - 5 pm), under light meter-controlled conditions with ambient room lighting 'ON' and lights 'OFF', and at 5° angle of incidence increments. The ACA metrics measured for each eye were: angle opening distance (AOD, measured 500 and 750 µm anterior from scleral spur), the trabecular-iris-space area (TISA, measured 500 and 750 µm anterior from scleral spur), and scleral spur angle. Measurements were performed by masked, certified Reading Center graders using the Visante's Internal Measurement Tool. Differences in measurements between morning and afternoon, lighting variations, and angle of incidence were compared. RESULTS: Mean age of the participants was 31.2 years (range 23-58). Anterior chamber angle metrics did not differ significantly from morning to afternoon imaging, or when the angle of incidence was offset by 5° in either direction away from the inferior angle 6 o'clock position. (p-value 0.13-0.93). Angle metrics at the inferior corneal limbus, 6 o'clock position (IC270), with room lighting 'OFF', showed a significant decrease (p < 0.05) compared to room lighting 'ON'. CONCLUSIONS: There does not appear to be significant diurnal variation in AS-OCT parameters in normal individuals, but lighting conditions need to be strictly controlled since variation in lighting led to significant variability in AS-OCT parameters. No changes in ACA parameters were noted by varying the angle-of-incidence, which gives confidence in being able to perform longitudinal studies in approximately the same area (plus/minus 5° of original scan location).

Endoscopic cyclophotocoagulation versus second glaucoma drainage device after prior aqueous tube shunt surgery.

BACKGROUND: To evaluate the efficacy in controlling intraocular pressure (IOP) with endoscopic cyclophotocoagulation (ECP) versus implantation of a second glaucoma drainage device (GDD-2) in the treatment of uncontrolled glaucoma with a prior aqueous tube shunt. DESIGN: A nonrandomized retrospective chart review. PARTICIPANTS: Patients with refractory glaucoma following a failed initial tube shunt (Baerveldt Glaucoma Implant 350), who underwent ECP or GDD-2 with Baerveldt Glaucoma Implant as a second surgery. Twenty-five eyes underwent ECP, and 48 eyes received a GDD-2. METHODS: ECP or second tube-shunt surgery. MAIN OUTCOME MEASURES: Reduction in IOP and antiglaucoma medications, and Kaplan-Meier survival with success defined as lOP ≥ 5 mmHg and ≤ 21 mmHg and ≥ 20% reduction from preoperative IOP. Secondary outcome measures were visual acuity and the presence of any postoperative complications. RESULTS: Both ECP and GDD-2 significantly lowered IOP (Student's t test) and number of antiglaucoma medications (Wilcoxon paired signed rank test). There were no significant differences in postoperative IOP (Student's t test) or antiglaucoma medications (Mann Whitney test) between ECP and GDD-2 at 6 and 12 months. There was also no difference in the Kaplan-Meier survival outcomes between the two groups. CONCLUSION: Both ECP and GDD-2 are both effective as second surgeries for refractory glaucoma that has failed a prior aqueous shunt.

Identification of anterior chamber angle parameters with a portable SD-OCT device compared to a non-portable SD-OCT.

The aim of this study is to compare a portable spectral domain optical coherence tomography (SD-OCT) device with a non-portable SD-OCT for the identification of anterior chamber angle parameters based on location of Schwalbe's line (SL) and to measure their reproducibility. 99 eyes from 46 normal, healthy participants underwent imaging of the inferior iridocorneal angle with the iVue and Cirrus SD-OCT under well-controlled low-light conditions. SL-angle opening distance (SL-AOD) and SL-trabecular iris space area (SL-TISA) were measured by masked, certified graders at the Doheny Image Reading Center using customized Image J grading software. Inter- and intrainstrument, as well as inter- and intraobserver reproducibility of SL-AOD and SL-TISA measurements were evaluated with intraclass correlation coefficients (ICCs) and Bland-Altman plots with limits of agreement. The mean SL-AOD was 0.814 ± 0.315 mm with the iVue and 0.797 ± 0.294 mm with the Cirrus. The mean SL-TISA was 0.247 ± 0.112 mm2 with iVue and 0.259 ± 0.113 mm2 with Cirrus. Interinstrument correlation coefficients (r) were 0.93 (P < 0.0001), 0.92 (P < 0.0001), and 0.92 (P < 0.0001) for SL_AOD and SL_TISA, respectively. Intraclass correlation coefficient showing the degree of agreement among SL-AOD and SL-TISA was 0.923 (95 % confidence interval 0.885-0.948) and 0.921 (95 % confidence interval 0.883-0.947) for both devices. The agreement for intrainstrument (ICCs > 0.95), intragrader (ICCs > 0.93), and intergrader (ICCs > 0.96) was excellent. Excellent agreement between the two devices was also documented with Bland-Altman analysis. Both instruments provide consistent and reproducible measurements of anterior chamber angle metrics.

Clinical results of ab interno trabeculotomy using the Trabectome in patients with pigmentary glaucoma compared to primary open angle glaucoma.

BACKGROUND: To evaluate outcomes of Trabectome on pigmentary glaucoma (PG) patients compared to matched controls with primary open angle glaucoma (POAG). DESIGN: Prospective comparison study PARTICIPANTS: A total of 101 POAG cases were matched with 101 PG cases. METHODS: Data of the patients diagnosed with PG or POAG was obtained from Trabectome Study Group Database. A one-to-one exact matching was performed between POAG and pigmentary cases based on type of surgery, baseline IOP and baseline number of glaucoma medications. IOP and number of glaucoma medications were compared between groups by Wilcoxon test. Success was defined as IOP ≤ 21 mmHg, at least 20% IOP reduction from baseline for two consecutive visits after 3 months and no secondary surgery. MAIN OUTCOME MEASURES: Success rate after Trabectome surgery in PG patients. RESULTS: Baseline IOP for PG is 24.4 ± 7.7 mmHg and 24.2 ± 7.5 mmHg for POAG (P = 1.0), while baseline number of glaucoma medications was 2.8 ± 1.2 mmHg for PG and 2.8 ± 1.2 mmHg for POAG (P = 1.0). Postoperative IOP values at 12 months were 17.1 ± 5.0 for PG cases and 15.9 ± 4.2 mmHg for POAG cases. Postoperative number of glaucoma medications at 12 month was 2.1 ± 1.4 in PG cases and 2.4 ± 1.3 in POAG cases. There was no statistically significant difference between groups in IOP or number of medications at any time point. Survival rate at 12 months was 92% and 86% in PG and POAG, respectively (P = 0.47). Six PG cases and nine POAG cases required secondary surgery. CONCLUSION: Trabectome provides similar outcomes to PG patients and POAG patients.

Effects of light variation on Schwalbe's line-based anterior chamber angle metrics measured with cirrus spectral domain optical coherence tomography.

BACKGROUND: Evaluate the impact of variations in ambient lighting conditions on the reproducibility/reliability of Schwalbe's Line (SL)-based anterior chamber angle (ACA) metrics using spectral domain optical coherence tomography (SD-OCT). DESIGN: Images were taken at Doheny Eye Centers-UCLA clinic, which were randomized, masked and graded twice by dual reading centre graders. PARTICIPANTS: Twenty-five normal/healthy participants with open angles METHODS: Inferior angles were imaged using Cirrus SD-OCT under five light levels (foot-candles (fc) measured at camera-eye interface with Sper light-meter) with the instrument's corneal illumination function set to default level of 50 (CIdef) and low 5 (CIlow). Each eye was imaged 20 times, totaling 500 assessments. MAIN OUTCOME MEASURES: SL-angle-opening-distance (SL-AOD) and SL-trabecular-iris-space-area (SL-TISA) measured using custom ImageJ software. Intra-/inter-grader variability analyses were completed using Statistical-Package-for-Social-Science and Bland-Altman plots demonstrated limits of agreement for comparisons. RESULTS: Light level demonstrated a linear relationship with angle size, thus differences from highest to lowest light levels were compared. Decreasing light from 1.0 → 0.0fc at CIdef decreased SL-AOD from 394 µm +/- 137 µm → 356 µm +/- 137 µm (mean percent difference (MPD) = 10.71%,P < 0.001) and SL-TISA from 297 µm(2) +/- 114 µm(2) → 261 µm(2) +/- 109 µm(2) (MPD = 13.7%, P < 0.001). Decreasing from 1.0 → 0.0fc at CIlow decreased SL-AOD from 366 µm +/- 136 µm → 329 µm +/- 122 µm (MPD = 10.9%, P < 0.001) and SL-TISA from 271 µm(2) +/- 113 µm(2) → 234 µm(2) +/- 98 µm(2) (MPD = 15.8%, P < 0.001). There was 7.9/11.4% (both P < 0.001) difference for SL-AOD/SL-TISA between CIdef → CIlow at 1.0fc, and 7.7/9.4% (both P < 0.001) difference at 0.0fc. Intra-/inter-grader results showed high reproducibility for all metrics (MPD = 0.33-4.4%; CV = 0.96-1.36; PCC = 0.93-0.95(P < 0.001); R2 = 0.94-0.98). Bland-Altman plots did not demonstrate bias, with repeat-ability and agreement among measurements. CONCLUSIONS: Using Cirrus SD-OCT, we found that SL-based ACA morphometrics are exquisitely sensitive to changes in ambient illumination and also corneal illumination by the OCT instrument. Consistently imaging in the darkest room possible is recommended (≤0.2 fce).