Iris stromal cell nuclei deform to more elongated shapes during pharmacologically-induced miosis and mydriasis.

Nuclear shape alteration in ocular tissues, which can be used as a metric for overall cell deformation, may also lead to changes in gene expression and protein synthesis that could affect the biomechanics of the tissue extracellular matrix. The biomechanics of iris tissue is of particular interest in the study of primary angle-closure glaucoma. As the first step towards understanding the mutual role of the biomechanics and deformation of the iris on the activity of its constituent stromal cells, we conducted an ex-vivo study in freshly excised porcine eyes. Iris deformation was achieved by activating the constituent smooth muscles of the iris. Pupillary responses were initiated by inducing miosis and mydriasis, and the irides were placed in a fixative, bisected, and sliced into thin sections in a nasal and temporal horizontal orientation. The tissue sections were stained with DAPI for nucleus, and z-stacks were acquired using confocal microscopy. Images were analyzed to determine the nuclear aspect ratio (NAR) using both three-dimensional (3D) reconstructions of the nuclear surfaces as well as projections of the same 3D reconstruction into flat two-dimensional (2D) shapes. We observed that regardless of the calculation method (i.e., one that employed 3D surface reconstructions versus one that employed 2D projected images) the NAR increased in both the miosis group and the mydriasis group. Three-dimensional quantifications showed that NAR increased from 2.52 ± 0.96 in control group to 2.80 ± 0.81 and 2.74 ± 0.94 in the mydriasis and miosis groups, respectively. Notwithstanding the relative convenience in calculating the NAR using the 2D projected images, the 3D reconstructions were found to generate more physiologically realistic values and, thus, can be used in the development of future computational models to study primary angle-closure glaucoma. Since the iris undergoes large deformations in response to ambient light, this study suggests that the iris stromal cells are subjected to a biomechanically active micro-environment during their in-vivo physiological function.

Standalone XEN45 Gel Stent implantation versus combined XEN45-phacoemulsification in the treatment of open angle glaucoma-a systematic review and meta-analysis.

PURPOSE: The XEN45 Gel Stent is currently the only FDA-approved sub-conjunctival minimally invasive glaucoma surgery (MIGS) procedure. It has been used worldwide either as a standalone implantation procedure or in combination with phacoemulsification surgery. Concomitant phacoemulsification is understood to influence outcomes of traditional subconjunctival filtering surgery. However, the comparative efficacy between standalone XEN45 Gel Sent implantation ("Standalone XEN45") and combined XEN-phacoemulsification surgery ("XEN45-Phaco") remains unclear. This study aims to appraise current literature to compare the efficacy of Standalone XEN45 and XEN45-Phaco in open-angle glaucoma. METHODS: A comprehensive search of PubMed, CINAHL, CENTRAL databases was performed with the terms "Xen surgery" followed by selective vetting. Pilot, cohort, observational studies and randomised controlled trials that included at least 10 patients undergoing either Standalone XEN45 or XEN45-Phaco surgeries for the treatment of open-angle glaucoma were deemed eligible for inclusion after independent assessment by 2 authors. The search workflow was reported according to the PRISMA guidelines. Data was pooled using random-effects model. A meta-analysis of continuous outcome and proportions was performed using the meta routine in R v3.2.1. RESULTS: Ten studies were included. There was a statistically significant difference in IOP reduction favouring Standalone XEN45 at post-operative day 1, week 1, months 1, 3 and 6. There was a statistically significant difference in decrease in IOP-lowering medications favouring Standalone XEN45 at post-operative week 1 and month 1. CONCLUSION: Standalone XEN45 has superior IOP-lowering outcomes compared to XEN45-Phaco in the early post-operative period, up to 6 months after surgery.

Using Enhanced Depth Imaging Optical Coherence Tomography-Derived Parameters to Discriminate between Eyes with and without Glaucoma: A Cross-Sectional Comparative Study.

INTRODUCTION: New technologies have been developed in order to decrease interpersonal influence and subjectivity during the glaucoma diagnosis process. Enhanced depth imaging spectral-domain OCT (EDI OCT) has turned up as a favorable tool for deep optic nerve head (ONH) structures assessment. OBJECTIVE: A prospective cross-sectional study was conducted to compare the diagnostic performance of different EDI OCT-derived parameters to discriminate between eyes with and without glaucoma. MATERIAL AND METHODS: The following ONH parameters were measured: lamina cribrosa (LC) thickness and area; prelaminar neural tissue (PLNT) thickness and area; average Bruch's membrane opening - minimum rim width (BMO-MRW), superior BMO-MRW, and inferior BMO-MRW. Peripapillary retinal nerve fiber layer (pRNFL) thickness was also obtained. RESULTS: Seventy-three participants were included. There were no significant differences between AUCs for average BMO-MRW (0.995), PLNT area (0.968), and average pRNFL thickness (0.975; p ≥ 0.089). However, AUCs for each of these 3 parameters were significantly larger than LC area AUC (0.701; p ≤ 0.001). Sensitivities at 80% specificity were: PLNT area = 92.3%, average BMO-MRW = 97.4%, and average pRNFL thickness = 94.9%. CONCLUSIONS: Comparing the diagnostic performance of different EDI OCT ONH parameters to discriminate between eyes with and without glaucoma, we found better results for neural tissue-based indexes (BMO-MRW and PLNT area) compared to laminar parameters. In this specific population, these neural tissue-based parameters (including PLNT area, which was investigated by the first time in the present study) had a diagnostic performance comparable to that of the conventional pRNFL thickness protocol.

Exercise-Induced Changes in Ocular Blood Flow Parameters in Primary Open-Angle Glaucoma Patients.

PURPOSE: To evaluate exercise-induced changes in ocular blood flow (OBF) parameters in primary open-angle glaucoma (POAG) patients. METHODS: A prospective observational study was carried out, in which medically treated patients with POAG were enrolled. Following inclusion, all patients performed a 40-min cycloergometry in a standardized fashion. The following parameters were measured and compared immediately before and 1 and 30 min after the exercise: intraocular pressure (IOP; Goldman applanation tonometry), mean arterial pressure (MAP), ocular pulse amplitude (OPA; assessed by dynamic contour tonometry), and ocular perfusion pressure (OPP; 2/3 MAP - IOP). In addition, we investigated possible factors associated with OBF parameter changes immediately after exercise. RESULTS: A total of 30 eyes (30 patients; mean age was 62.9 ± 1.7 years) were included. Most patients were women (53%), and median visual field mean deviation index was -3.5 dB. Both MAP (mean change, 21%) and IOP (mean change, 17.3%) increased significantly immediately after the workout (p < 0.01), persisting higher than baseline following 30 min (p < 0.01%). Regarding OBF parameters, both OPA (mean change, 58.8%) and OPP (mean change, 21.7%) increased significantly immediately after the workout and persisted higher than baseline 30 min after the workout (p < 0.01). Regression analysis revealed that only age was significantly associated with OPA variation (R2 0.14; p < 0.05). No significant associations were found for OPP (p ≥ 0.19). CONCLUSION: Aerobic exercise leads to a significant short-time increase in OBF parameters in patients with POAG. Even though IOP seems to present a modest elevation, it is accompanied by a significant increase in MAP, leading to higher OBF measurements. Exercise-induced short-term changes and its possible implications for glaucoma prognosis deserve further investigation.

Structure-function relationships in glaucoma using enhanced depth imaging optical coherence tomography-derived parameters: a cross-sectional observational study.

BACKGROUND: To investigate structural and functional correlations in glaucoma patients using enhanced depth imaging spectral-domain optical coherence tomography (EDI OCT)-derived parameters. METHODS: We prospectively enrolled healthy participants and glaucomatous patients with a wide range of disease stages. All participants underwent visual field (VF) testing (SITA - Standard 24-2; Carl Zeiss Meditec, Dublin, CA) and EDI OCT imaging (Spectralis; Heidelberg Engineering Co., Heidelberg, Germany). The following optic nerve head parameters were measured on serial vertical EDI OCT B-scans by two experienced examiners masked to patients clinical data: lamina cribrosa (LC) thickness and area, prelaminar neural tissue thickness and area, anterior LC depth, Bruch's membrane opening (BMO) and average, superior, and inferior BMO-minimum rim width (BMO-MRW). Only good quality images were considered, and whenever both eyes were eligible, one was randomly selected for analysis. Scatter plots were constructed to investigate correlations between each anatomic parameter and patient's VF status (based on VF index [VFI] values). RESULTS: A total of 73 eyes of 73 patients were included. All EDI OCT parameters evaluated differed significantly between glaucomatous and control eyes (P ≤ 0.045). A secondary analysis, in which glaucomatous patients were divided according to VF mean deviation index values into 3 groups (mild [G1; > - 6 dB], moderate [G2; - 6 to - 12 dB] and advanced [G3; <- 12 dB] glaucoma), revealed that average BMO-MRW was the EDI OCT parameter that presented more significant differences between the different stages of glaucoma. Significant structure-function correlations were found between VFI values and prelaminar neural tissue area (R2 = 0.20, P = 0.017), average BMO-MRW (R2 = 0.35, P ≤ 0.001), superior BMO-MRW (R2 = 0.21, P = 0.012), and inferior BMO-MRW (R2 = 0.27, P = 0.002). No significant correlations were found for LC area and anterior LC depth (P ≥ 0.452). CONCLUSIONS: Evaluating the distribution pattern and structure-function correlations of different laminar and prelaminar EDI OCT-derived parameters in glaucomatous patients, we found better results for neural tissue-based indexes (compared to LC-derived parameters). The diagnostic utility of each parameter deserves further investigations.

Intraocular Pressure Spikes within First Postoperative Hours following Standard Trabeculectomy: Incidence and Associated Factors.

PURPOSE: To evaluate the incidence of intraocular pressure (IOP) spikes within the first postoperative hours following trabeculectomy (TRAB) and to determine possible associated factors. METHODS: An observational study was carried out. We enrolled consecutive patients undergoing standard TRAB with mitomycin C. They were examined twice within the first few postoperative hours (hours 1-2 and 4-6) and 3 times after TRAB (on days 1, 7, and 30). Demographic and ocular data were collected. Main outcome measurements were postoperative IOP values at each time point and the frequency of IOP spikes, defined as IOP ≥25 mm Hg. RESULTS: A total of 40 eyes of 40 patients were included (mean age 59.62 ± 13.37 years). Although IOP was significantly reduced to 11.14 ± 7.99 mm Hg at hours 1-2 (p < 0.01) and to 11.52 ± 7.30 mm Hg at hours 4-6 (p < 0.01), IOP spikes were documented in 3 patients (7.5%). In the group of patients with IOP spikes, we noted that there was a high incidence of black patients and that the surgeries had been performed by fellow surgeons. CONCLUSION: Although the majority of the cases (92.5% of the patients) did not present IOP spikes, 7.5% of our patients presented the event. In selected cases, such as those with advanced disease, fixation threat, and of black race, IOP should be monitored during the first few postoperative hours for the identification and adequate management of potential IOP spikes, preventing undesirable outcomes.

Appropriate Objective Functions for Quantifying Iris Mechanical Properties Using Inverse Finite Element Modeling.

Quantifying the mechanical properties of the iris is important, as it provides insight into the pathophysiology of glaucoma. Recent ex vivo studies have shown that the mechanical properties of the iris are different in glaucomatous eyes as compared to normal ones. Notwithstanding the importance of the ex vivo studies, such measurements are severely limited for diagnosis and preclude development of treatment strategies. With the advent of detailed imaging modalities, it is possible to determine the in vivo mechanical properties using inverse finite element (FE) modeling. An inverse modeling approach requires an appropriate objective function for reliable estimation of parameters. In the case of the iris, numerous measurements such as iris chord length (CL) and iris concavity (CV) are made routinely in clinical practice. In this study, we have evaluated five different objective functions chosen based on the iris biometrics (in the presence and absence of clinical measurement errors) to determine the appropriate criterion for inverse modeling. Our results showed that in the absence of experimental measurement error, a combination of iris CL and CV can be used as the objective function. However, with the addition of measurement errors, the objective functions that employ a large number of local displacement values provide more reliable outcomes.

Neurophthalmological conditions mimicking glaucomatous optic neuropathy: analysis of the most common causes of misdiagnosis.

BACKGROUND: To analyze the most common neurophthalmological conditions that may mimic glaucomatous optic neuropathy and to determine which most often lead to misdiagnosis when evaluated by a glaucoma specialist. METHODS: We reviewed the charts of consecutive patients with optic neuropathies caused by neurophthalmological conditions screened in a single Eye Clinic within a period of 24 months. Within these enrolled patients, we selected the eyes whose fundoscopic appearance could resemble glaucoma based in pre-defined criteria (vertical cup-to-disc ratio ≥0.6, asymmetry of the cup-to-disc ratio ≥0.2 between eyes, presence of localized retinal nerve fiber layer and/or neuroretinal rim defects, and disc haemorrhages). Then, color fundus photographs and Humphrey Visual Field tests (HVF) of these eyes were mixed with tests from 21 consecutive glaucomatous patients (42 eyes with normal tension glaucoma). These images were mixed randomly and a masked glaucoma specialist was asked to distinguish if each set of exams was from a patient with glaucoma or with a neurophthalmologic condition. RESULTS: Among the 101 eyes (68 patients) enrolled with neurophthalmological diseases, 16 (15.8%) were classified as conditions that could mimic glaucoma. The most common diagnoses were ischemic optic neuropathy (25%), compressive optic neuropathy (18.7%) and hereditary optic neuropathy (18.7%). Based on the analysis of fundus photographs and HVF tests, 25% of these were misdiagnosed as glaucoma (two ischemic optic neuropathies and two congenital optic disc anomalies). Conversely, 11.9% of the glaucomatous neuropathies were misdiagnosed as neurophthalmological disorders. Overall, the glaucoma specialist correctly diagnosed 84.5% of the eyes. CONCLUSIONS: Some neurophthalmological disorders can mimic glaucoma. In our study, isquemic and compressive optic neuropathies were the ones that most often did so. Almost one quarter of the eyes were misdiagnosed when evaluated by a glaucoma specialist, which can lead to inadequate management and influence the prognosis of these patients.

Influence of Vitreomacular Adhesion on Anti-Vascular Endothelial Growth Factor Treatment for Neovascular Age-Related Macular Degeneration.

PURPOSE: To investigate the effect of vitreomacular adhesion (VMA) on the outcome of antiangiogenic treatment for neovascular age-related macular degeneration (AMD). METHODS: Ninety-nine eyes of 83 patients were used in our cohort study. We prospectively evaluated best corrected visual acuity (BCVA) and central retinal thickness (CRT) in patients with neovascular AMD at baseline and 1, 2, 3, 6, and 12 months after treatment with anti-vascular endothelial growth factor (anti-VEGF) agents. All patients were stratified by spectral domain optical coherence tomography into 2 groups (i.e., VMA[+] and VMA[-]) according to the presence or absence of VMA, and the response to treatment was evaluated. RESULTS: Fifty-four eyes (54.5%) were included in the VMA(-) group and 45 eyes (45.5%) comprised the VMA(+) group. In paired comparisons of mean BCVA between baseline and each follow-up visit (1, 2, 3, 6, and 12 months), the VMA(-) group showed statistically significant improvement at 1, 2, and 3 months compared to baseline, and BCVA significantly improved only at 3 months in the VMA(+) group. For both groups, paired comparisons of CRT showed a statistically significant decrease when data obtained at 1, 2, 3, 6, and 12 months were compared to baseline values (p < 0.05). CONCLUSIONS: Posterior VMA is associated with a worse short-term outcome in patients with neovascular AMD treated with anti-VEGF agents.

Analysis of neuroretinal rim distribution and vascular pattern in eyes with presumed large physiological cupping: a comparative study.

BACKGROUND: To investigate possible differences in neuroretinal rim distribution, vascular pattern, and peripapillary region appearance between eyes with presumed large physiological optic disc cupping (pLPC) and eyes with minimal optic disc excavation. METHODS: We prospectively enrolled consecutive subjects with pLPC and individuals with minimal excavation (optic disc excavation within normal limits; control group). All eyes had normal visual fields and untreated intraocular pressure (IOP) <21 mmHg. Eyes with pLPC required vertical cup-to-disc ratio (VCDR) ≥ 0.6 and ≥ 30 months of follow-up with no evidence of glaucomatous neuropathy. For controls, VCDR was limited to ≤ 0.5. We compared ocular signs and characteristics related to the neuroretinal rim distribution, vascular pattern, peripapillary region appearance and disc size between groups. Whenever both eyes were eligible, one was randomly selected for analysis. RESULTS: A total of 74 patients (mean age, 45.6 ± 14.9 years) with pLPC and 45 controls (mean age, 44.8 ± 11.6 years) were enrolled (p = 0.76). Median disc size and VCDR was significantly larger in eyes with pLPC compared to controls (p < 0.01). The proportion of eyes with violation of the ISNT rule, laminar dot sign, nasal shifting of the central vessels, nasal excavation and baring of circumlinear vessel was significantly greater in the eyes with pLPC compared to controls (p < 0.01). There were no significant differences regarding the proportions of eyes with peripapillary atrophy between groups (p < 0.09). Finally, disc size was significantly associated with VCDR (r(2) = 0.47, p < 0.01), with an increase of 0.21 in VCDR for each 1 mm(2) in disc area. CONCLUSION: Compared to normal controls, eyes with pLPC may present a higher proportion of optic nerve head findings frequently observed in glaucomatous eyes. This seems to be explained in part by the larger discs found in these eyes. We believe care should be taken while classifying them as glaucomatous or not based solely on these characteristics.

Clinical Outcomes of MicroPulse Transscleral Laser Therapy with the Revised P3 Delivery Device.

Aim: To evaluate the success and safety of MicroPulse transscleral laser therapy (TLT) on intraocular pressure (IOP) reduction in adults with uncontrolled glaucoma using different total treatment durations, sweep velocities, and a number of sweeps utilizing the revised MicroPulse P3 delivery device. Materials and methods: A single-center Institutional Review Board (IRB) approved multiple cohort studies of MicroPulse TLT with the revised MicroPulse P3 delivery device, which was conducted in 61 eyes from 40 adults with uncontrolled glaucoma. Eyes that received 50-second (GI, GII, and GIII) and 60-second (GIV, GV, and GVI) treatment applications between May and October 2020 were reviewed. Each hemisphere received a total of five, four, or three sweeps. The patient's IOP and glaucoma medications were monitored over 12 months follow-up. Qualified success was defined as an IOP of ≤21 mm Hg and/or reduction of ≥20% from baseline at 12 months, with no secondary glaucoma reinterventions. Complete success was defined as meeting the above criteria with no increase in glaucoma medications at 12 months. All eyes requiring a glaucoma surgical intervention were considered a failure. Results: Qualified success was achieved in 83.6% of eyes, while complete success was achieved in 75.4% of eyes. In eyes receiving 50-second applications of five, four, or three sweeps (GI, GII, and GIII), 70, 90, and 91% achieved qualified success, respectively; in eyes receiving 60-second applications of five, four, or three sweeps (GIV, GV, and GVI), 78, 82, and 90% achieved qualified success, respectively. Within each subgroup, mean IOP reductions ranged from 32.8 to 49.4% and were statistically significant (p < 0.008). The failure rate was 16.4%, and at least one eye failed in each subgroup. Conclusions: MicroPulse TLT with the revised MicroPulse P3 delivery device and relatively low total energy levels is safe and effective at lowering IOP. Efficacy appears to increase with longer treatment durations and slower sweep velocities, but statistical differences between age and clinical differences between baseline IOP measurements limit comparison between subgroups. Clinical significance: There is a lack of literature evaluating the safety and IOP-lowering success of the revised MicroPulse P3 delivery device using different total treatment durations, sweep velocities, and number of sweeps. How to cite this article: Checo LA, Dorairaj S, Wagner IV, et al. Clinical Outcomes of MicroPulse Transscleral Laser Therapy with the Revised P3 Delivery Device. J Curr Glaucoma Pract 2024;18(1):10-15.

Comparison of Peripapillary Choroidal Thickness Between Primary Open-angle Glaucoma, Normal Tension Glaucoma, and Normal Eyes: A Systematic Review and Meta-analysis.

TOPIC: To investigate differences in peripapillary choroidal thickness (PPCT) between primary open-angle glaucoma (POAG), normal tension glaucoma (NTG), and healthy eyes, additionally comparing differences between POAG and NTG eyes. CLINICAL RELEVANCE: Peripapillary choroidal thickness is a well-established OCT parameter in eyes with glaucoma and other ocular pathologies. The relationship between PPCT and glaucoma, if better understood, may facilitate the development of PPCT as a potential diagnostic and monitoring metric for glaucoma. In particular, there has yet to be a synthesis that directly compares PPCT between POAG eyes and NTG eyes. METHODS: A comprehensive literature search was performed on PubMed, EMBASE, and Cochrane Library, identifying studies from inception to December 2022. We included studies that measured PPCT using OCT in POAG, NTG, and healthy eyes. Mean difference (MD) among groups was calculated. Statistical analysis was performed using R version 4.2.0. Risk of bias of included studies was assessed using the Newcastle Ottawa Scale (NOS). RESULTS: Eighteen studies were included in this meta-analysis, with a pooled total of 935 healthy control eyes, 446 NTG eyes, and 934 POAG eyes. There was a significant reduction of PPCT in POAG eyes compared with healthy eyes [MD = -16.32; 95% confidence interval (CI) (-27.55 to -5.09)]. Reduction in PPCT was also significant in NTG eyes compared with healthy eyes [MD = -34.96; 95% CI (-49.97 to -19.95)]. NTG eyes had significantly reduced PPCT compared with POAG eyes [MD = -26.64; 95% CI (-49.00 to -4.28)]. CONCLUSIONS: Glaucomatous eyes appear to have significantly reduced PPCT compared with normal healthy eyes. In addition, PPCT in NTG eyes appear significantly thinner compared with that in POAG eyes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Recent Updates on the Diagnosis and Management of Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the Western world, with a higher prevalence among Europeans and North Americans than that in Africans, Hispanics, and Asians. Advanced AMD is categorized as atrophic (dry) or exudative (wet/neovascular age-related macular degeneration [nAMD]). Dry AMD is characterized by progressive geographic atrophy of the retinal pigment epithelium and outer retinal layers, whereas nAMD is characterized by new vessels that invade the subretinal and/or subretinal pigment epithelium spaces. Existing treatments delay the onset of advanced AMD and reverses vision loss for a couple of years before atrophy usually decreases central visual acuity. We searched PubMed and Medline databases from January 1, 1980, to December 1, 2023, using the following search terms: macular degeneration, choroidal neovascularization, geographic atrophy, drusen, age-related maculopathy, AMD, ARMD, and anti-VEGF. Relevant articles in English (or English translations) were retrieved and reviewed. Bibliographies of the identified manuscripts were also reviewed to identify relevant studies. Age-related macular degeneration most commonly affects people older than 55 years. Visual prognosis varies, with advanced lesions (nAMD and geographic atrophy) leading to rapid, progressive loss of central vision and contrast sensitivity. Although AMD is not a life-threatening disease, reduced vision profoundly compromises quality of life and necessitates living assistance for many patients. Over the past 2 decades, advances in prevention (vitamin supplementation) and therapy (antivascular endothelial growth factor and complement inhibitor drugs) have reduced vision loss and blindness. Further research is needed to decrease the incidence of blindness in patients with advanced disease.

Complications Following XEN45 Gel Stent and Glaucoma Drainage Device Implantation During Glaucoma Fellowship.

Purpose XEN45 Gel Stent and glaucoma drainage device (GDD) implantation is safe and effective for glaucoma treatment and should be taught during glaucoma fellowship training. However, complications may still occur, with potentially sight-threatening consequences. The purpose of this study is to describe the management of complications following a series of XEN45 Gel Stent and GDD surgeries performed over the course of glaucoma fellowship training. Methods This is a retrospective case series of XEN45 Gel Stent surgeries performed on 16 eyes and GDD surgeries performed on seven eyes. Patient demographics, disease characteristics, and complications are reviewed. The intra- and postoperative course of five select cases with complications are described in detail. Results The most frequent complications following XEN45 implantation were transient hypotony (10 eyes, 63%), reduced visual acuity (VA) (five eyes, 31%), choroidal effusion (three eyes, 19%), hyphema (two eyes, 13%), and intraocular pressure (IOP) spike (two eyes, 13%). Thirteen eyes (81%) required bleb needling, and three eyes (19%) required XEN45 replacement. Complications following GDD implantation included hypotony (three eyes, 43%), reduced VA (two eyes, 29%), choroidal effusion (two eyes, 29%), IOP spike (two eyes, 29%), implant exposure (two eyes, 29%), and shallow anterior chamber (one eye, 14%). Three eyes (43%) required revision or explantation with a secondary glaucoma surgery. One choroidal effusion following XEN45 surgery and one following GDD surgery were hemorrhagic choroidal effusions requiring surgical drainage. Conclusion Significant and potentially sight-threatening complications may occur following XEN45 Gel Stent and GDD implantation performed over the course of fellowship training. Glaucoma fellows should be ably equipped to recognize, diagnose, and manage these complications both intra- and postoperatively.

Applications of Artificial Intelligence in Cataract Surgery: A Review.

Cataract surgery is one of the most performed procedures worldwide, and cataracts are rising in prevalence in our aging population. With the increasing utilization of artificial intelligence (AI) in the medical field, we aimed to understand the extent of present AI applications in ophthalmic microsurgery, specifically cataract surgery. We conducted a literature search on PubMed and Google Scholar using keywords related to the application of AI in cataract surgery and included relevant articles published since 2010 in our review. The literature search yielded information on AI mechanisms such as machine learning (ML), deep learning (DL), and convolutional neural networks (CNN) as they are being incorporated into pre-operative, intraoperative, and post-operative stages of cataract surgery. AI is currently integrated in the pre-operative stage of cataract surgery to calculate intraocular lens (IOL) power and diagnose cataracts with slit-lamp microscopy and retinal imaging. During the intraoperative stage, AI has been applied to risk calculation, tracking surgical workflow, multimodal imaging data analysis, and instrument location via the use of "smart instruments". AI is also involved in predicting post-operative complications, such as posterior capsular opacification and intraocular lens dislocation, and organizing follow-up patient care. Challenges such as limited imaging dataset availability, unstandardized deep learning analysis metrics, and lack of generalizability to novel datasets currently present obstacles to the enhanced application of AI in cataract surgery. Upon addressing these barriers in upcoming research, AI stands to improve cataract screening accessibility, junior physician training, and identification of surgical complications through future applications of AI in cataract surgery.

Although barriers remain for the generalizability and standardization of artificial intelligence in cataract surgery, there are growing applications improving efficiency, data analysis, safety, training, and patient outcomes in pre-operative, intraoperative, and post-operative stages.

Racial Disparities in Microinvasive Glaucoma Surgery for Management of Primary Open-Angle Glaucoma: A Propensity Matched Cohort Study: Racial Disparities in MIGS for the Management of POAG.

PURPOSE: To evaluate racial/ethnic differences in the use of microinvasive glaucoma surgery (MIGS) for the management of mild-moderate primary open-angle glaucoma (POAG) in the United States. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with a diagnosis of mild or moderate POAG, as defined by current procedural terminology (CPT) codes, were included. The experimental group comprised African American (AA) patients and the control group consisted of patients without an AA designation in the TriNetX database. METHODS: Propensity scoring was used to match cohorts for age at diagnosis, Charlson Comorbidity Index, sex, nicotine dependence, glaucoma medications, family history of POAG, Body Mass Index, and weight. Outcome was incidence of MIGS over 1 year of follow up. Odds ratios were calculated between cohorts MAIN OUTCOME MEASURE: Incidence of MIGS over 1 year of follow-up post-POAG diagnosis. RESULTS: 63,418 POAG patients were included (50% AA, 50% non-AA). AA patients were found to undergo MIGS at a significantly lower rate (1,268 of 31,709) compared to non-AA patients (1,508 of 31,709) (OR 0.834, 95% CI: 0.773 - 0.900). CONCLUSION: Although POAG is understood to be more prevalent among African Americans, these patients display lower utilization of MIGS, suggesting a possible nationwide racial disparity in the management of POAG.

Delayed Corneal Healing After the Use of Topical Ophthalmic Anesthetics.

Topical anesthetics for control of pain from corneal abrasions can cause drug-related toxicity that delays corneal healing. This report documents three cases where topical anesthetic drops were prescribed in the emergency department for pain control, after which patients developed persistent ocular pain, epithelial toxicity with impaired healing, and significant loss of vision. On consultation with the ophthalmology service, each patient was instructed to discontinue the topical anesthetic drops but to continue topical antibiotics. Soon thereafter, symptoms resolved, and the corneas healed within 72 hours. This report emphasizes the harm that can result from injudicious and/or unmonitored use of topical anesthetics for corneal abrasions. We advise emergency medicine and primary care providers against providing topical anesthetics to patients with corneal abrasions.

36-Month Outcomes of Standalone Kahook Dual Blade Goniotomy Compared with Ab-Interno Closed Conjunctiva Xen Gel Stent Implantation.

Purpose: To compare the safety and effectiveness of standalone Kahook Dual Blade (KDB) excisional goniotomy to standalone ab-interno Xen gel stent implantation in eyes with moderate-to-severe open-angle glaucoma (OAG). Methods: A single-center, retrospective study including eyes with moderate-to-severe OAG undergoing standalone KDB goniotomy or Xen gel stent implantation was conducted. Intraocular pressure (IOP), the number of antiglaucoma medications taken daily, and best-corrected visual acuity (BCVA) were recorded at baseline and for up to 36-months. Primary outcomes assessed included changes from baseline in IOP and the number of antiglaucoma medications taken. Intergroup comparisons were conducted using independent-samples Student's t-tests. The incidence of intraoperative and postoperative adverse events and the need for glaucoma surgical re-interventions were also recorded. Results: Eyes receiving standalone KDB (n=26) or Xen gel stent (n=45) surgery were analyzed. The baseline mean IOP and number of antiglaucoma medications in both groups were as follows: KDB: 23.2 ± 6.0 mmHg, 2.2 ± 1.4 medications; Xen: 22.7 ± 8.8 mmHg, 3.0 ± 1.0 medications. At 36 months, IOP was reduced to 16.6 ± 5.4 mmHg in KDB eyes (n=23, -23.5%; p=0.0004) and 15.3 ± 5.6 mmHg in Xen gel stent eyes (n=15, -22.1%; p=0.006), while number of antiglaucoma medications was reduced to 1.1 ± 0.7 (-30.8%; p=0.0005) and 2.2 ± 1.4 (-25.6%; p=0.01), respectively. Three eyes (11.5%) in the KDB group and 19 eyes (42.2%) in the Xen gel stent group required additional surgery before month 36 due to refractory high IOP. Conclusion: Both KDB goniotomy and Xen gel stent implantation significantly lowered the IOP and antiglaucoma medication burden in patients with moderate-to-severe OAG. While the Xen gel stent is frequently used to treat moderate-to-severe OAG patients with uncontrolled IOP, standalone KDB goniotomy may be equally effective as a long-term intervention, reducing the need for subsequent glaucoma surgery.

36-Month Outcomes of Ahmed ClearPath® Glaucoma Drainage Device in Severe Primary Open Angle Glaucoma.

Purpose: To evaluate the safety and effectiveness of the Ahmed ClearPath® (ACP) 250 mm2 glaucoma drainage device (GDD) in managing refractory primary open-angle glaucoma (POAG). Patients and Methods: This was a retrospective case series focused on adult patients diagnosed with severe POAG who underwent implantation of an ACP GDD. Over a 36-month follow-up period, data on intraocular pressure (IOP), the number of glaucoma medications, and complications were recorded. The primary objectives were to assess the reductions from baseline in both IOP and medication usage, through 36 months. Secondary objectives included the proportion of eyes achieving an IOP reduction of ≥ 20% from baseline at 36 months. Intraoperative and postoperative complications were also assessed. Results: Twelve eyes from 11 patients (mean age: 71.3 ± 14.1 years) met the inclusion criteria and were included in the study. All patients had severe POAG (n=11), with the majority being Caucasian (n=8) and female (n=10). The mean (standard deviation) IOP and number of glaucoma medications at baseline were 29 (7.6) mmHg and 3 (0.9), respectively. At 36 months, mean IOP was reduced to 10.6 (5.5) mmHg (-61.8%; p= 0.0008) and mean number of medications was reduced to 0.9 (0.9) (-71.4%; p=0.0005), with 88.9% of eyes achieving an IOP reduction by ≥20%. No vision threatening complications were observed. Conclusion: To our knowledge this is the first study to report 36-month outcomes of the novel ACP device in the treatment of refractory POAG. The safety profile and efficacy of the ACP was found to be comparable to that of other commonly utilized GDD models.

Clinical Outcomes of Excisional Goniotomy with the Kahook Dual Blade: 6-Year Results.

INTRODUCTION: This study aims to evaluate the long-term clinical outcomes of excisional goniotomy with the Kahook Dual Blade (KDB) in the management of various types of glaucoma. METHODS: This was a retrospective, noncomparative chart review of 90 eyes of 53 patients with glaucoma that underwent standalone KDB goniotomy (KDB-alone group) or KDB goniotomy with concomitant phacoemulsification (KDB-phaco group) between October 2015 and October 2017. Surgical success was defined as an intraocular pressure (IOP) reduction by ≥ 20% at the last follow-up with no surgical reinterventions required and a final IOP ≥ 4 mmHg and ≤ 21 mmHg. We also report on changes from baseline in IOP, number of glaucoma medications, best-corrected visual acuity (BCVA), and visual field parameters, for up to 72 months. RESULTS: At 72 months, mean (standard deviation [SD]) IOP was reduced from 17.5 (5.7) to 13.6 (3.0) mmHg (P < 0.0001) in the KDB-phaco group and from 23.3 (5.9) to 15.1 (6.2) mmHg (P = 0.0593) in the KDB-alone group. The mean (SD) number of glaucoma medications was reduced from 1.3 (1.0) to 0.8 (0.9) (P < 0.0001) in the KDB-phaco group and from 1.2 (1.0) to 0.7 (0.8) (P = 0.3409) in the KDB-alone group. During the 72-month follow-up, surgical success was achieved in 24 of the 52 available eyes (46.2%). Four eyes underwent a glaucoma surgical reintervention by 72 months. CONCLUSIONS: Excisional goniotomy with the KDB effectively lowered the IOP (by an average of 28.0% from baseline) and maintained or further reduced glaucoma medication burdens (by an average of 30.8% from baseline) under an excellent safety profile, independent of phacoemulsification status. The procedure exhibited favorable success for up to 6 years, providing valuable insights into its long-term efficacy as a glaucoma treatment.