Epithelial inclusion cyst secondary to glaucoma surgery: A case series.

Epithelial inclusion cysts (EIC) are a rare ocular disease and its physiopathology is not well-known. They consist on growths of ocular surface epithelial cells inside the anterior segment of the eye in the form of a cyst. To date several cases have been published in the literature, none of them related to glaucoma surgery. We describe two cases of EIC after glaucoma devices implantation. An 86 year-old male patient with primary open angle glaucoma develop an EIC in right eye three years after removal of PRESERFLO™ MicroShunt (Santen, Osaka, Japan) and a 9 year-old female patient with glaucoma secondary to uveitis for juvenile idiopathic arthritis develops an EIC under the tube of an Ahmed valve implant during postoperative period. EIC develop after ocular penetrating wounds and an inflammatory stimulus. They are benign proliferations, follow-up is necessary to detect space complications early, so less mutilating surgery is needed for removal.

Reproducibility of peripapillary, optic nerve head and macular vessel density by OCT-A according to glaucoma severity staging.

OBJECTIVE: To assess the reproducibility of peripapillary, optic nerve head (PP-ONH) and macular vessel density (VD) by Spectral Domain optical coherence tomography angiography (SD OCT-A) in glaucoma patients and healthy subjects. METHODS: Cross-sectional study assessing 63 eyes of 63 subjects, including 33 glaucoma patients and 30 healthy subjects. Glaucoma was classified in mild, moderate, or advanced. Two consecutive scans were acquired by Spectralis Module OCT-A (Heidelberg, Germany), and provided images of the superficial vascular complex (SVC), nerve fiber layer vascular plexus (NFLVP), superficial vascular plexus (SVP); deep vascular complex (DVC), intermediate capillary plexus (ICP) and deep capillary plexus (DCP). VD (%) was calculated by AngioTool. Intraclass correlation coefficients (ICCs) and coefficients of variation (CV) were calculated. RESULTS: Among PP-ONH VD, better ICC presented advanced (ICC 0.86-0.96) and moderate glaucoma (ICC 0.83-0.97) compared with mild glaucoma (0.64-0.86). For the macular VD reproducibility, ICC results for superficial retinal layers were better for mild glaucoma (0.94-0.96) followed by moderated (0.88-0.93) and advanced glaucoma (0.85-0.91), and for deeper retinal layers ICC was better for moderate glaucoma (0.95-0.96) followed by advanced (0.80-0.86) and mild glaucoma (0.74-0.91). CVs ranged from 2.2% to 10.94%. Among healthy subjects, ICCs for the PP-ONH VD measurements (0.91-0.99) and for the macular VD measurements (0.93-0.97) were excellent in all layers, with CVs from 1.65% to 10.33%. CONCLUSIONS: SD OCT-A used to quantify macular and PP-ONH VD showed excellent and good reproducibility in most layers of the retina, both in healthy subjects and in glaucoma patients regardless of the severity of the disease.

Peripapillary and optic nerve head vessel density of glaucoma and healthy subjects from Afro-Caribbean and European descent: A pilot study.

PURPOSE: To compare the peripapillary and optic nerve head vessel density (PP-ONH VD) between glaucoma patients (all, early, moderated, and advanced) and healthy subjects of Afro-Caribbean descent (AD) and European descent (ED). METHODS: This was a cross-sectional study. One eye was evaluated in 90 subjects, including 66 glaucoma patients and 24 healthy subjects, who underwent PP-ONH VD imaging using SPECTRALIS® Optical Coherence Tomography Angiography (OCT-A). We analysed the superficial vascular complex using the AngioTool version 0.6a software. The correlation between the PP-ONH VD and visual field mean deviation (MD) was evaluated using a scatter plot and Spearman's rho correlation coefficient. RESULTS: Among the healthy subjects, the AD group had a lower superficial PP-ONH VD [43.29±3.25% (mean±standard deviation)] than the ED group (46.06±1.75%) (P=0.016). Overall, superficial PP-ONH VD did not show any significant differences between the total AD and ED glaucoma patients or in the subgroup analyses (early/moderate/advanced) (AD: 32.73±6.70%, 37.11±5.72%, 32.48±5.73%, 27.76±4.74%, respectively; ED: 33.94±6.89%, 38.52±3.82%, 35.56±4.18%; 27.65±6.31%, respectively) (P>0.05 for all). A strong, statistically significant correlation was established between vessel density and mean deviation among AD and ED glaucoma patients (r=0.709 and r=0.704, respectively) (P<0.001 for both). CONCLUSION: This pilot study shows that healthy subjects of AD had lower peripapillary and optic nerve head superficial vessel density than healthy subjects of ED, but no significant differences were found between AD and ED glaucoma groups (all, early, moderate, or advanced).

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.

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.

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.

Ocular inflammatory signs observed in a cohort of Spanish patients with Behçet disease and ocular inflammation.

PURPOSE: To study the clinical characteristics of a cohort of Spanish patients diagnosed with Behcet disease and who also presented ocular inflammation. METHODS: Thirty cases of Behçet disease were studied retrospectively. The authors studied age distribution, distribution by sex, clinical course, laterality, type of uveitis, secondary glaucoma, corneal involvement, hypopyon, iris-lens synechiae, secondary cataract, cystoid macular edema (CME), and papillitis (optic neuritis). RESULTS: Fourteen of the patients were men and 16 were women (ratio 0.875:1). The mean age of the patients was 35.24 years (+/-10.917; 21-61 years). In 23 patients, the disease course was recurrent. In 9 patients, the disease manifested unilaterally. In 5 patients showing unilateral onset, the contralateral eye became affected. In 2 of the 30 patients, uveitis exclusively affected the anterior segment. In 8 patients, uveitis was solely posterior. There was one case of intermediate uveitis. The remaining 19 patients showed panuveitis. Three had focal chorioretinitis. One had diffuse chorioretinitis. Fifteen showed signs of diffuse vasculitis. Eight patients showed focal vasculitis. CONCLUSIONS: Women were slightly more affected than men, although the authors found no significant correlation between sex and the clinical variables examined. Apart from one unexpected case of intermediate uveitis, the observations are similar to those reported for other patient series.

Herpetic optic neuritis associated with herpetic keratitis.

PURPOSE: To report a case of herpetic optic neuritis associated with herpetic keratitis. METHODS: A 65 year old woman presented with oedema in the nasal sector of his right papilla. Blood biochemistry, a haemogram, erythrocyte sedimentation rate and C-reactive protein were all normal. The patient was diagnosed as having a non-arteritic anterior ischaemic optic neuropathy. One week later slit lamp examination showed diffuse stromal corneal oedema and a dendritic lesion in the nasal zone of the corneal epithelium. RESULTS: Serology for varicela-zoster virus was positive. Treatment was started with valacyclovir given orally and topical acyclovir ointment. A week later, the optic disc swelling and corneal lesions had resolved. CONCLUSIONS: The precise mechanism through which the papilla and cornea were successively affected in our patient is unclear but the sensitive innervation of both these structures is provided by the nasal branch of the nasociliary nerve and the spread of herpes via this nerve could affect both sites.

Charles Bonnet syndrome in a child with congenital glaucoma. / Síndrome de Charles Bonnet en un niño con glaucoma congénito.

CASE REPORT: The case is presented of a 12 year-old boy with congenital glaucoma and low visual acuity diagnosed with Charles Bonnet syndrome. This consisted of the acute onset of complex, repetitive, persistent, and with visual hallucinations (people, brooms and coffeemakers) of self-limited evolution without treatment. The patient was diagnosed with congenital glaucoma at 3 years of age, and subjected to a trabeculectomy in right eye, and trabeculectomy and keratoplasty in his left eye. DISCUSSION: Charles Bonnet syndrome symptoms have been described in adults, but their presence in children is poorly reflected in literature, with unknown characteristics and prevalence.

[Acute angle-closure glaucoma resulting from treatment with nebulised bronchodilators]. / Bloqueo angular agudo tras broncodilatadores nebulizados.

CASE REPORT: A 78-year-old woman, with an acute exacerbation of chronic obstructive airways disease, was treated with nebulised ipratropium bromide and salbutamol. Twenty hours after beginning this treatment, she developed acute angle-closure glaucoma (AACG) in her left eye which resolved rapidly with appropriate treatment. DISCUSSION: Nebulised ipratropium bromide and salbutamol increases the intraocular pressure and may cause an AACG in susceptible patients (those with a shallow anterior chamber, hypermetropia, or chronic angle-closure glaucoma). Increased vigilance in such patients treated with these bronchodilators may avoid this adverse effect. Ensuring the mask is correctly fitted, using a T-piece or unvented nebuliser and protective eye wear, are some of the many recommendations made to minimize the development of AACG in these patients.

Pigment dispersion syndrome associated with optic nerve melanocytoma.

CASE REPORT: A 60-year old patient was referred for cataract surgery. The examination showed retrokeratic pigment in the left eye, which had an intraocular pressure of 24 mm Hg. The funduscopy showed a brown lesion on the left optic disk, with adjacent vitreous seeding of pigment. The patient was thus diagnosed with secondary pigment dispersion syndrome due to optic disk melanocytoma. DISCUSSION: Although melanocytoma is most commonly a benign, stationary tumor, it may present with major complications leading to significant visual loss. A patient with melanocytoma of the optic disk should be examined periodically.

Corneal Segmentation Analysis Increases Glaucoma Diagnostic Ability of Optic Nerve Head Examination, Heidelberg Retina Tomograph's Moorfield's Regression Analysis, and Glaucoma Probability Score.

Purpose. To study whether a corneal thickness segmentation model, consisting in a central circular zone of 1 mm radius centered at the corneal apex (zone I) and five concentric rings of 1 mm width (moving outwards: zones II to VI), could boost the diagnostic accuracy of Heidelberg Retina Tomograph's (HRT's) MRA and GPS. Material and Methods. Cross-sectional study. 121 healthy volunteers and 125 patients with primary open-angle glaucoma. Six binary multivariate logistic regression models were constructed (MOD-A1, MOD-A2, MOD-B1, MOD-B2, MOD-C1, and MOD-C2). The dependent variable was the presence of glaucoma. In MOD-A1, the predictor was the result (presence of glaucoma) of the analysis of the stereophotography of the optic nerve head (ONH). In MOD-B1 and MOD-C1, the predictor was the result of the MRA and GPS, respectively. In MOD-B2 and MOD-C2, the predictors were the same along with corneal variables: central, overall, and zones I to VI thicknesses. This scheme was reproduced for model MOD-A2 (stereophotography along with corneal variables). Models were compared using the area under the receiver operator characteristic curve (AUC). Results. MOD-A1-AUC: 0.771; MOD-A2-AUC: 0.88; MOD-B1-AUC: 0.736; MOD-B2-AUC: 0.845; MOD-C1-AUC: 0.712; MOD-C2-AUC: 0.838. Conclusion. Corneal thickness variables enhance ONH assessment and HRT's MRA and GPS diagnostic capacity.

[Correlating cup-to-disc ratios measured by HRT-III, SD-OCT and the new color imaging Laguna ONhE procedure]. / Correlación de la relación excavación/papila óptica medida mediante HRT-III, SD-OCT y el dispositivo de colorimetría fotográfica Laguna OnhE.

OBJECTIVE: To examine correlations between cup-to-disc (C/D) ratios determined by the new Laguna ONhE (optic nerve hemoglobin) color imaging procedure, spectral domain optical coherence tomography (OCT), confocal scanning laser tomography using Heidelberg retina tomography (HRT), and examining retinal images. METHODS: C/D ratio measurements were made on 154 eyes of 154 subjects (52 healthy controls, 36 with ocular hypertension and 66 with primary open-angle glaucoma) using the Laguna ONhE, HRT-III (Heidelberg Engineering) and OCT Spectralis (Heidelberg Engineering) instruments and photographs of the optic disc were examined by a blinded observer (experienced glaucoma specialist). RESULTS: Global intraclass correlation coefficients (ICC) were: 0.379 (95% CI: 0.233-0.508) for Laguna ONhE-HRT, 0.621 (95% CI: 0.513-0.709) for Laguna ONhE-OCT, and 0.558 (95% CI: 0.398-0.678) for the Laguna ONhE-observer, indicating significant agreement in each case (P<.001). The highest ICC was recorded for OCT- observer (0.715; 95% CI: 0.605-0.795). CONCLUSIONS: C/D ratios measured using the Laguna ONhE procedure correlated well with OCT measurements and retinography measurements made by an experienced observer. Best correlation was observed for OCT versus observer measurements. Agreement was good between the Laguna ONhE, OCT and observer measurements, and was somewhat lower between HRT and the remaining procedures.

Guidelines for treatment of chronic primary angle-closure glaucoma.

OBJECTIVE: To present a clinical practice guideline update on the medical, laser, and surgical treatment of primary angle closure glaucoma (PACG) in adults. METHODS: Following the formulation of key questions using the PICO scheme (Patient/Problem, Intervention, Comparison, Outcome), a systematic review was performed on the literature published to date, including international clinical practice guidelines. The AMSTAR and Risk of Bias tools were used for evaluating the quality of the information. The level of evidence and grade of recommendation was established following the Scottish Intercollegiate Guidelines Network (SIGN) system. RESULTS: Following the above methodology, recommendations of medical, laser and surgical treatment in adult PACG and levels of evidence are presented. CONCLUSIONS: Although the level of scientific evidence for many of the questions raised is not very high, a review is presented on updated treatment recommendations for adult PACG. Among the limitations for the implementation of these recommendations is that most studies have been conducted in Asian populations, and that the effectiveness is measured almost exclusively in terms of reducing intraocular pressure, and does not include visual function, quality of life or cost-effectiveness parameters.

Concomitant administration of travoprost and brinzolamide versus fixed latanoprost/timolol combined therapy: three-month comparison of efficacy and safety.

PURPOSE: To compare the efficacy and safety of the concomitant administration of travoprost 0.004% once daily and brinzolamide 0.1% twice daily with those of a fixed combination of latanoprost 0.005%/timolol 0.5% once daily. RESEARCH, DESIGN AND METHODS: Forty-four patients with primary open-angle glaucoma or ocular hypertension with elevated IOP insufficiently responsive to monotherapy were randomly assigned to one of the two treatment groups: concomitant administration of travoprost 0.004% once daily and brinzolamide 0.1% twice daily (TB group: 22 patients) or latanoprost 0.005% plus timolol 0.5% once daily (LT group: 22 patients). Visits were undertaken at screening (current ocular hypotensive therapy was discontinued), baseline (randomization), and after 2 weeks, 1 month, 2 months and 3 months of therapy. MAIN OUTCOME MEASURES: IOP was determined at 9 a.m., 12 p.m. and 4 p.m. at each study visit, and diurnal IOP was calculated as the mean of these recordings. Adverse events were recorded at each visit. RESULTS: IOP at the baseline visit was similar in both groups. Overall mean IOP was significantly lower in the TB as compared to the LT group after 1 month, 2 month and 3 month follow-up; only 9 a.m. measurements were significantly different, reaching a maximum difference (16.9 +/- 0.9 mmHg vs 18.4 +/- 1.8 mmHg, p < 0.001) at the 3 month check. The percentage of responders (IOP decrease > or = 30%) was higher in the TB group. Both treatments were well tolerated and there were no cases of withdrawal from treatment. CONCLUSIONS: Travoprost 0.004% and brinzolamide 0.1% concomitant therapy showed a greater efficacy than the fixed latanoprost 0.005%/timolol 0.5% combination in terms of absolute IOP decreases. Travoprost/brinzolamide therapy also offered the advantages of a greater percentage of responders.

[Ultrasound biomicroscopy in pigmentary glaucoma]. / Estudio de glaucoma pigmentario mediante biomicroscopia ultrasónica.

OBJECTIVE: To study the anterior chamber in pigmentary glaucoma by anterior ultrasound biomicroscopy (UBM), and to determine the effect of the YAG-laser iridotomy on intraocular pressure (IOP) and the iris morphology in pigmentary glaucoma. MATERIAL AND METHODS: Seven patients (14 eyes) with a diagnosis of pigmentary glaucoma were studied. YAG-laser iridotomy was performed on all the patients with demonstrable iris concavity by UBM, performing UBM one week post-iridotomy and control of the IOP at one week, six months and at one year following treatment. RESULTS: The existence of iris concavity was demonstrated in 6 of the 7 patients (12 of the 14 eyes), performing a YAG-laser iridotomy in all of them. Remission of the iris concavity was observed in 5 of the 6 patients (10 of the 12 eyes) and good control of the IOP was achieved without additional topical treatment in 3 (6 eyes). At one year, the number of drugs needed for IOP control decreases (p<0,005, Wilcoxon test, correction for small samples). CONCLUSIONS: In our sample, the YAG-laser iridotomy rectifies the iris concavity present in pigmentary glaucoma, reducing the IOP and the number of drugs needed for its control.

[Cystoid macular edema induced by travoprost]. / Edema macular quístico inducido por travoprost.

CASE REPORT: A 72 year old man with open-angle glaucoma was treated with trabeculectomy and cataract surgery. Two years later, intraocular pressure increased making it necessary to add travoprost 0.004%. Two weeks later, visual acuity decreased. The diagnosis of cystoid macular edema and post-treatment observation were carried out using optical coherence tomography. DISCUSSION: Cystoid macular edema is one of the most important effects of hypotensive lipids. Optical coherence tomography is a non-invasive method useful for the diagnosis and evolution of this complication.

[Papillitis due to Epstein-Barr virus infection in an adult patient]. / Papilitis por infección del virus de Epstein-Barr en paciente adulto.

CASE REPORT: A 70-year- old woman who consulted due to poor vision in her right eye for 2 weeks. The examination showed a visual acuity (VA) of 0.6 and 1.0, with normal anterior pole and intraocular pressure and a relative afferent pupillary defect. Some papillitis was observed in the fundus of her right eye. The high levels of acute phase reactants led to an initial diagnosis of arteritic anterior ischemic optic neuropathy (AAION) and treatment with corticosteroids was started. DISCUSSION: According to the age of the patient, the fundus and the high levels of acute phase reactants, the initial diagnosis was AAION. However, the atypical papillitis features, with good AV and non-specific perimetry, together with a suitable medical history, and a profile of viral characteristics, with laboratory confirmation, led to the diagnosis of a primary papillitis infection due to Epstein-Barr virus, a very rare case due to the advanced age of the patient.

[Paradoxical cessation in a case of Charles Bonnet syndrome]. / Cese paradójico de un caso de síndrome de Charles Bonnet.

CASE REPORT: 78-year-old male patient diagnosed with Charles Bonnet syndrome (CBS) showing secondary visual deficit toward end-stage glaucoma. He progressed to amaurosis, with an abrupt disappearance of hallucinations in parallel to the loss of residual vision. DISCUSSION: The paradoxical cessation of CBS occurs when the patient loses residual vision and progresses to amaurosis. The lack of stimulation, both in the corresponding retina and the cortex, lead to the disappearance of hallucinations because the desafferented and hyper-excited neurons lose the necessary stimulus that triggers CBS.