Treatment of open-angle glaucoma and ocular hypertension with preservative-free tafluprost/timolol fixed-dose combination therapy: 6 case reports and clinical outcomes.

BACKGROUND: Treatment of open angle glaucoma (OAG) and/or ocular hypertension (OHT) focuses on achievement of target intraocular pressure (IOP), with the objective of slowing disease progression. However, ocular surface health is an important consideration in the optimization of treatment. We report 6 patient cases in which enhanced IOP control was achieved following appropriate management of ocular surface inflammation and a therapeutic switch to the preservative-free (PF) tafluprost (0.0015%)/timolol (0.5%) fixed-dose combination (FC). CASE PRESENTATION: Six patient cases, aged 48-74 years, presented with OAG or OHT. Each patient had signs and symptoms of ocular surface disease (OSD). Cases 1-3 were each receiving maximal medical therapy for OAG; regimens comprising prostaglandin analogue (PGA), ß-blocker, carbonic anhydrase inhibitor (CAI) and α-2 agonist agents (including treatments containing preservative agent). Cases 1 and 2 reported IOP values ≥23 mmHg in each eye, and wide IOP fluctuations were identified when reviewing patient data concerning case 3 (11-20 mmHg). Maximal therapy was ceased and PF tafluprost/timolol FC was initiated, after which the signs and symptoms of OSD were improved and IOP was reduced (≤18 mmHg for cases 1-3) and stabilized. Cases 4 and 5 were diagnosed with OAG and case 6 had OHT. Each had symptoms and signs of OSD and were treated with a preserved PGA monotherapy (latanoprost 0.005% or bimatoprost 0.03%). At presentation, IOP was 24 mmHg in both eyes (case 4), ≥18 mmHg (case 5) and ≥ 22 mmHg (case 6). Following a switch to the PF tafluprost/timolol FC, OSD symptoms were improved and IOP was 14 mmHg (both eyes; case 4), ≤14 mmHg (case 5) and 16 mmHg (both eyes; case 6). CONCLUSIONS: In addition to IOP-lowering efficacy, approaches to the management of OAG and OHT should consider the impact of treatment tolerability and the susceptibility of these patients to OSD. The presence of ocular surface inflammation appears to be detrimental to adherence and therefore to the effectiveness of topical medications. Addressing OSD through the use of PF FC formations, such as the PF tafluprost/timolol FC, reduces exposure to potentially toxic agents and facilitates improvements in IOP control.

Agreement between central corneal thickness measured using Pentacam, ultrasound pachymetry, specular microscopy and optic biometer Lenstar LS 900 and the influence of intraocular pressure.

PURPOSE: To compare central corneal thickness (CCT) values obtained by Lenstar (LE), Pentacam (PC), specular microscopy (SM) and ultrasound pachymetry (UP) in healthy corneas and study their influence on intraocular pressure (IOP) readings determined by Goldmann applanation tonometry (GAT). METHODS: CCT was measured in 76 healthy subjects by LE, PC, SM and UP. We established Lin's concordance correlation coefficient (ρ-C) between different techniques. The influence of CCT on GAT was established through univariate linear regression models, IOP being the dependent variable. RESULTS: The highest ρ-C was found between LE and SM at 0.94 (95% CI: 0.91-0.96) and between LE and UP at 0.95 (95% CI: 0.94-0.97). IOP readings showed less variability when CCT was determined using LE (7.7%, B = 0.16; 95% CI: 0.004-0.28). CONCLUSIONS: Although CCT values obtained with UP, PC, SM and LE show good correlation, these methods are not completely interchangeable. The amount of IOP variation differs when CCT is determined using LE or SM.

Detection and characterisation of visual field defects using Octopus perimetry in congenital glaucoma.

PURPOSE: To detect and characterise visual field (VF) defects using static Octopus perimetry in patients with primary congenital glaucoma (PCG) and to determine VF quality and time duration. MATERIAL AND METHODS: Eighty-eight eyes of 70 patients diagnosed with PCG were included. Assessments were performed using an Octopus 900 and each eye was assessed with the tendency-oriented perimetry (G-TOP) algorithm. Quantitative VF data were collected: quality data (false positive and negative response, and time duration) and results of mean deviation (MD) and square root of loss variance (sLV). Qualitative data were collected: the presence of diffuse and localized defects, the affected hemifield and grade of defects using the Aulhorn and Karmeyer classification. Correlations between perimetric results and clinical variables were analysed. RESULTS: Median age was 11 (8-17) years. 65.9% (58/88) of PCG eyes showed VF defects. Diffuse defects were observed in 10/58 eyes (16.94%) (mean MD = 23.92 [SD: 2.52]) dB) and localized defects in 48/58 eyes (82.75%). The most frequent defect was spot-like/stroke-like/incipient paracentral scotoma (n = 15), nasal step (n = 8), adding arcuate defect (n = 2), half ring-shaped (n = 13) and concentric defect with a central island (n = 9). And the most frequent affected visual hemifield was inferior hemifield. Mean test duration was 2 min 12 s (SD: 21.6 s). MD and sLV values were correlated with best corrected visual acuity (BCVA), cup to disc ratio and number of antiglaucoma surgeries (all P < .001). CONCLUSION: A high number of diffuse and localized defects were identified using Octopus perimetry in PCG patients. The most frequent defect was paracentral scotoma and inferior hemifield was the most affected.

Analysis of the influence of corneal properties and densitometry on applanation and rebound tonometry in primary open angle glaucoma.

PURPOSE: To evaluate the influence of corneal densitometry on portable applanation (Perkins) and rebound (iCare ic100 and PRO) tonometry. A secondary goal was to assess if there was a relationship between various corneal properties and the severity of primary open angle glaucoma (POAG). MATERIAL AND METHODS: Seventy-five eyes of 75 patients with primary open angle glaucoma were studied, divided by severity into 3 groups: 25 mild, 25 moderate and 25 advanced. Intraocular pressure (IOP) was measured 3 times in each participant with a Perkins applanation tonometer (PAT), a handheld version of the Goldman applanation tonometer (GAT), an iCare PRO and an iCare ic100. Mean values were then calculated. Corneal topography with the Pentacam HR (Oculus, Wetzlar, Germany) was also performed in all individuals. RESULTS: Mean age and sex were comparable in all groups, as were densitometry values (P>0.05). The mean visual field defect (MD) was 2.85 (±1.23) dB in the mild glaucoma group, 8.26 (±1.90) dB in the moderate group and 15.66 (±3.46) dB in the advanced group. Three multivariate regression analyses were performed. The first and second calculations assessed the effect of IOP obtained with iCare ic100 and PAT as dependent variables with age, sex, CCT and mean keratometry (Km) within the glaucoma subgroups and the global sample. The third analysis was carried out to assess the relationship between corneal densitometry as the dependant variable and the aforementioned corneal parameters among the glaucoma groups. In the first multivariate regression analysis, a statistically significant correlation was found between ic100 rebound tonometry and CCT in the POAG global sample (coef. 0.117; IC [-0.21-(-0.01)]; P=0.025). No statistically significant correlation was found in the subgroup analyses. In the second multivariate analysis, no significant correlation was found between PAT and CCT, Km, age or sex (P>0.05). In the third analysis, densitometry was correlated with age in all glaucoma subgroups (P<0.001) and with CCT in the moderate glaucoma subgroup (coef. -0.037; IC [-0.67-(-0.01)]; P=0.021). Tonometry appeared to be minimally influenced by corneal densitometry, with a mild positive linear correlation seen (R=0.03). IOP values were similar with 3 of the tonometers: PAT 16.07 (±3.18) mmHg, PRO 16.27 (±3.42) mmHg and ic100 15.17 (±4.28) mmHg. There was, however, a significant underestimation of IOP with ic100 (-0.89mmHg) compared to PAT (P=0.007). CONCLUSION: Corneal densitometry did not show significant differences between glaucoma severity groups. A positive correlation was seen with CCT and both corneal densitometry and age. No correlation was found with keratometry or severity of glaucoma. The influence of corneal densitometry on IOP measurements appears weak, with little clinical relevance identified.

Dependence of corneal hysteresis on non-central corneal thickness in healthy subjects.

OBJECTIVE: To evaluate the dependence of corneal hysteresis (CH) on non-central corneal thickness. METHODS: Cross-sectional study of 1561 eyes of 1561 healthy volunteers with IOP less than 21mmHg, open angles on gonioscopy and no prior eye surgeries or local or systemic diseases. Pentacam-Scheimpflug technology was employed to segment the cornea into 6 circular zones centered on the apex (zones 1-6) and to determine the mean corneal thickness of these areas. CH was measured with ORA. Univariate and multivariate linear regression models adjusted for age and sex were created to model the dependence of CH on corneal thickness in zones 1 to 6. RESULTS: In the univariate linear regression models, we found that CH was dependent on mean corneal thickness of zone 1 (B=0,004; R2=0.95%; P<0.001), zone 2 (B=0,004; R2=0.57%; P=0.002), zone 4 (B=0,005; R2=1.50%; P<0.001) and zone 6 (B=0,003; R2=0.92%; P<0.001). Similar results were obtained in the multivariate model (R2=3.46%; P<0.001). CONCLUSION: This study suggests a significant dependence of CH on non-central corneal thickness. The model of corneal thickness segmentation into circular zones centered on the corneal apex is able to explain 3.47% of the variation in CH measurements.

Posterior chamber implantation of a Preserflo Microshunt in a patient with a compromised endothelium.

The objective of the present case is to describe a variation in the Preserflo Microshunt surgical technique, placing it in the posterior chamber to minimise the risk of endothelial cell loss in cases with a compromised endothelium. The patient was a 72-year-old pseudophakic woman, with granular dystrophy and a primary diagnosis of open-angle glaucoma presenting with a progressive visual field defect and an IOP of 26 mmHg with maximal medical therapy. The cornea had incipient stromal folds with an endothelial count of 700 cells/mm2. A Preserflo Microshunt was implanted in the posterior chamber to minimise the possibility of further damage to the corneal endothelium. Six months after surgery, the implant remains functional. The IOP is 9 mmHg without medications. As far as we know, this is the first Preserflo implanted in the posterior chamber described in the literature.

Comparision of intraocular pressure measured using the new icare 200™ rebound tonometer and the Perkins™ applanation tonometer in healthy subjects and in patients with primary congenital glaucoma. / Comparación entre el tonómetro de rebote IC200 y el tonómetro de aplanación Perkins en sujetos sanos y pacientes con glaucoma congénito.

OBJECTIVE: To compare intraocular pressure (IOP) measurements obtained using the Icare 200™ (IC200) rebound tonometer and the hand-held version of the Goldmann Applanation Tonometer (Perkins™ tonometer, GAT) in patients with primary congenital glaucoma (PCG) and in healthy subjects. MATERIAL AND METHODS: A total of 42 eyes of healthy subjects (G1) and 40 patients with PCG (G2) were analysed. The following clinical data were collected: gender, age, Cup/Disc ratio, central corneal thickness (CCT). IOP was determined in the examination room using the IC200 and GAT tonometers, in the same order. Agreement between both tonometers was determined using the intraclass correlation coefficient (ICC) and Bland-Altman plot. A linear regression analysis was used to establish the IOP was affected by the studied variables. RESULTS: Mean IOP between both tonometers (IC200 minus GAT) was: G1=15.91 (2.57) mmHg vs. 15.06 (2.12) mmHg (mean difference, MD=0.84 (0.50) mmHg; P<.101) and G2=20.10 (6.37) vs.19.12 (5.62) (MD=0.98 (1.36); P=.474). Excellent agreement was found between IC200 and GAT in both groups (ICC=G1: 0.875 (95% CI; 0.768-0.933; P<.001); G2: 0.924 (95% CI; 0.852-0.961; P<.001), and there was a statistically significant correlation between the IOP difference measured with IC200 and GAT and CCT in G1 (B=0.021; 95% CI; 0.005-0.037; P=.008), but was not statistically significant in G2. CONCLUSION: There was excellent agreement between the IC200 and GAT tonometers, both in healthy subjects and PCG, with a trend to overestimate IOP when measured with IC200. There was no influence by CCT on IOP measurements in patients with PGC.

Structure-function relationship in a series of glaucoma cases.

PURPOSE: To map retinal sensitivity and peripapillary retinal nerve fiber layer (RNFL) thickness, as measured by standard automated perimetry (SAP) and optical coherence tomography (OCT) respectively, in patients with various stages of primary open-angle glaucoma (POAG). METHODS: Ninety patients with POAG were prospectively selected for SAP and for OCT RNFL thickness measurements. Factorial analysis performed independently for each hemifield was used to identify groups of related SAP visual field points. Pearson correlation coefficients were determined between visual field regions and peripapillary RNFL sectors and these data used to construct structure-function correlation maps for the various disease stages. RESULTS: Factorial analysis identified 4 factors or visual field regions for the inferior hemifield and 5 for the superior hemifield. For all patients and the subset of patients with advanced POAG, the strongest correlation was detected between the superior hemifield and the inferior RNFL sectors, while higher correlations for incipient and moderate disease stages were observed between the inferior hemifield and the superior RNFL sectors. CONCLUSIONS: In these patients, functional and structural damage can be mapped such that each zone of related SAP points correlates with one or several peripapillary RNFL zones. Such maps could improve our understanding of structure-function relationships in glaucoma.

Multimodal imaging in optic nerve melanocytoma: Optical coherence tomography angiography and other findings.

PURPOSE: To evaluate optical coherence tomography (OCT), fundus autofluorescence (FAF) imaging and optical coherence tomography angiography (OCTA) as diagnostic tools in optic disc melanocytoma (ODM) and study the differences in peripapillary and macular vascular density in eyes with ODM using OCTA. METHODS: Patients with ODM were enrolled in this case series. Each patient underwent evaluation of best-corrected visual acuity, slit-lamp biomicroscopy, fundus examination, fundus photography, standard visual field testing, spectral domain OCT, ultrasound B-scan examination, FAF, fluorescein angiography and OCTA. RESULTS: Eight patients (three males and five females) with ODM (9 eyes) were enrolled. The largest ODM presented a nodular appearance with a hyper-reflective tumor surface and a posterior optical shadow on OCT. FAF images showed hypoautofluorescence of the tumor with well-defined outlines. Analysis of optic nerve vascular area showed decreased values in the radial peripapillary capillary plexus (3 of 5) and the outer retinal plexus (4 of 5) in the eyes with ODM. In contrast, the ODM eyes had a higher macular vascular area in the deep capillary plexus in 4 of 6 patients. CONCLUSIONS: ODM may be associated with changes in peripapillary and macular perfusion, with an increase in peripapillary vascularization being a possible risk factor for growth. OCTA might be a helpful objective method in the analysis of changes in flow in patients with ODM.

Corneal densitometry and topography in patients with primary congenital glaucoma.

OBJECTIVE: To compare corneal densitometry and topography variables in patients with primary congenital glaucoma (PCG) and healthy subjects. MATERIAL AND METHODS: Cross sectional study, consecutive recruitment with gender- and age-matched control group. Forty eyes of 40 patients in each group were studied with Pentacam corneal topography. The variables compared between the two groups were: intraocular pressure (IOP), visual acuity (VA) and Pentacam (Oculus, Wetzlar, Germany) corneal topography measurements: mean and maximum keratometry (Km, Kmax), cylinder (Cyl), anterior elevation apex (AEA), central anterior elevation (CAE), maximum anterior elevation (MAE), posterior elevation apex (PEA), central posterior elevation (CPE), maximum posterior elevation (MPE), pachymetry and anterior, mid-stromal and posterior corneal densitometry in the 0-2mm, 2-6mm, 6-10mm zones. RESULTS: Significant differences between patients and healthy controls were detected in the topographic variables MAE (P=0.002) and MPE (P<0.001), and in all the densitometry variables (anterior, mid-stromal, posterior for the 0-2mm, 2-6mm and 6-10mm zones) (P<0.001 each). In the PCG group, negative correlation was observed between VA and total densitometry (r=-0.49; P=0.004). CONCLUSION: Patients with PCG and healthy subjects display differences in corneal densitometry and topographic measurements. PCG patients show greater corneal density with an inverse relationship between visual acuity and higher elevation (anterior and posterior values).

Haab striae: Optical coherence tomographic analysis.

PURPOSE: To study Haab striae in adults with primary congenital glaucoma and describe them by anterior segment optical coherence tomography, as well as analyze their evolution over the patient's lifetime. MATERIAL AND METHODS: Three patients with primary congenital glaucoma were recruited, aged between 17 and 48 years old, with incidentally noted Haab striae on glaucoma consultation. They were studied by: slit lamp; anterior segment optical coherence tomography, Heidelberg Engineering Inc., Germany, (with anterior segment module) and Cirrus HD-OCT, Carl Zeiss Meditec, Dublin, California, USA (with 3D reconstruction); and specular biomicroscopy. The results obtained were contrasted with other studies performed in children. RESULTS: Rounded excrescences protruding towards the anterior chamber were found, as well as dense, irregular tissue between them. In addition, endothelial abnormalities (polymegathism and polymorphism) were found. These findings fit the evolution of those obtained in pediatric studies and remain stable in adult life. CONCLUSIONS: Through noninvasive methods such as optical coherence tomography and specular biomicroscopy, it is possible to make the diagnosis and follow up these patients. The findings suggest posterior corneal topographic changes; additional studies on this subject may be necessary.

Scheie's line as a first sign of pigment dispersion syndrome. / Línea de Scheie como primer signo de síndrome de dispersión pigmentaria.

A 50 year old woman was diagnosed with pigment dispersion syndrome (PDS) in the right eye and pigmentary glaucoma in the left eye in a routine medical examination. A line of pigment was observed in the vitreo-lenticular interface (Scheie's line) of the left eye and with an intraocular pressure of 26mmHg. The Scheie's line (SL) develops by the accumulation of detached iris pigment in PDS and accumulated in the ligament of Wieger that forms the vitreo-lenticular union. The SL is considered a pathognomonic sign of PDS.

The correlation between the thickness of the inner macular layers and the mean deviation of the visual field in children with primary congenital glaucoma. / Correlación entre el grosor de las capas internas de la retina y el defecto medio del campo visual en pacientes con glaucoma congénito primario.

PURPOSE: To analyse the association between the thickness of the circumpapillary retinal nerve fibre layer (cpRNFL) and the thickness of the inner macular layers with the mean deviation of the visual field (MD) in children with primary congenital glaucoma (PCG). MATERIAL AND METHODS: A total of 41 children with PGC were included in the study. They all had a complete ophthalmological examination, including visual acuity, intraocular pressure, funduscopy, Octopus™ visual field, as well as circumpapillar and macular spectral domain optical coherence tomography (SD-OCT). SD-OCT with automated segmentation was used to measure the thicknesses and volumes of the macular retinal nerve fibre layer (mRNFL), ganglion cell layer (GCL), and inner plexiform layer. RESULTS: The mean age was 11.2±3.86 years, and the mean MD was 8.85±6.76dB. The visual field was classified as normal in 46% of the patients, and 20% of the patients had a concentrical restriction of the visual field. A positive correlation was found between between the cup-to-disc ratio and the MD, r=0.51 (P=.004). The correlation between the MD and the cpRNFL was r=-0.63 (P<.001), and r=-0.69 (P<.001) with the GCL. CONCLUSIONS: Inner macular layers thickness and cpRNFL thickness show a good correlation with the mean deviation of the visual field in children with primary congenital glaucoma.

Angle-closure glaucoma after piggyback intraocular lens implantation.

PURPOSE: To report a case of angle closure glaucoma after piggyback intraocular lens implantation and its treatment. METHODS: The authors present the case of a 75-year-old woman who was seen in the emergency department with angle closure glaucoma. Two years before she had undergone piggyback intraocular lens (IOL) implantation in order to correct a refractive error after cataract surgery. Ultrasound biomicroscopy revealed a closed angle with synechiae in 360 degrees as well as the presence of two IOLs: one in the capsular bag and the other in the ciliary sulcus. Extraction of the anterior IOL was precluded due to the poor endothelial count. Peripheral iridotomy and trabeculectomy were ineffective to lower the intraocular pressure (IOP); the authors decided to implant with an Ahmed valve and to place the valve's tube between the two IOLs to protect the endothelium. RESULTS: After Ahmed valve implantation, IOP maintains stable around 10-12 mmHg without medical treatment. CONCLUSIONS: Ahmed valve implantation is a good option in angle closure glaucoma due to piggyback. The placement of the valve's tube between the two IOLs is a good option to protect corneal endothelium.

Agreement between slit lamp examination and optical coherence tomography in estimating cup-disc ratios.

PURPOSE: To compare optical coherence tomography (OCT) cup-disc ratio measurements with those estimated by two independent examiners using the slit lamp in an evaluation of the optic nerve head (ONH). METHODS: In 47 eyes each of 47 patients with glaucoma and 47 healthy subjects, the ONH was examined using the slit lamp with a 78 D lens. Two examiners subjectively determined the cup-disc area ratio (A-CDR), the horizontal cup-disc ratio (H-CDR), and the vertical cup-disc ratio (V-CDR). These measurements were compared to objective OCT readings obtained by a third examiner blind to the slit lamp results. RESULTS: For the three variables determined, correlation indices between the OCT readings and the two sets of slit lamp measurements were significantly higher for the glaucoma group than the control group. In the patients with glaucoma, the OCT tended to underestimate A-CDR and overestimate H-CDR. For both these variables, Bland-Altmann analysis revealed significant differences between the two methods that persisted across the whole range of CDRs examined. In contrast, differences in V-CDR varied with disc size. CONCLUSIONS: The OCT is a diagnostic tool that provides a complete automatic evaluation of the ONH. However, its measurements vary significantly from those obtained in subjective evaluations performed by experienced ophthalmologists.