The Canonical Wnt Signaling Pathway Inhibits the Glucocorticoid Receptor Signaling Pathway in the Trabecular Meshwork.

Glucocorticoid-induced glaucoma is a secondary open-angle glaucoma. About 40% of the general population may develop elevated intraocular pressure on prolonged glucocorticoid treatment secondary to damages in the trabecular meshwork (TM), a tissue that regulates intraocular pressure. Therefore, identifying the key molecules responsible for glucocorticoid-induced ocular hypertension is crucial. In this study, Dickkopf-related protein 1 (Dkk1), a canonical Wnt signaling inhibitor, was found to be elevated in the aqueous humor and TM of glaucoma patients. At the signaling level, Dkk1 enhanced glucocorticoid receptor (GR) signaling, whereas Dkk1 knockdown or Wnt signaling activators decreased GR signaling in human TM cells as indicated by luciferase assays. Similarly, activation of the GR signaling inhibited Wnt signaling. At the protein level, glucocorticoid-induced extracellular matrix was inhibited by Wnt activation using Wnt activators or Dkk1 knockdown in primary human TM cells. In contrast, inhibition of canonical Wnt signaling by ß-catenin knockdown increased glucocorticoid-induced extracellular matrix proteins. At the physiological level, adenovirus-mediated Wnt3a expression decreased glucocorticoid-induced ocular hypertension in mouse eyes. In summary, Wnt and GR signaling inhibit each other in the TM, and canonical Wnt signaling activators may prevent the adverse effect of glucocorticoids in the eye.

Evidence-based management of primary angle closure glaucoma.

PURPOSE OF REVIEW: To review the classification of primary angle closure (PAC) and discuss the evidence-based management of each type. RECENT FINDINGS: There is limited evidence to support the prophylactic treatment of primary angle closure suspects. Cataract and clear lens extraction may be more effective than traditional therapy in controlling intraocular pressure (IOP) in patients with PAC, primary angle closure glaucoma, and acute angle closure crisis. SUMMARY: Treatment of angle closure depends on the signs of chronic angle damage and glaucomatous optic neuropathy. In the absence of such evidence, serial gonioscopy may be the preferred therapy. If signs or symptoms are present, medical therapy and laser peripheral iridotomy are beneficial. However, recent data suggest that cataract extraction may be more effective at controlling the IOP than laser or incisional glaucoma procedures.

Scleral fixation of a one-piece toric intraocular lens.

PURPOSE: To describe a novel technique for toric intraocular lens (IOL) repositioning and fixation in the absence of adequate capsular support. METHODS: Case report and literature review. RESULTS: Two cases are presented with scleral fixation of a one-piece toric IOL (SN6AT series; Alcon Laboratories, Inc., Fort Worth, TX). In both cases, toric IOLs initially placed within the capsular bag became decentered due to poor capsular support. To avoid the potential complications of lens explantation and maintain the astigmatic benefits of the toric IOL, scleral fixation of the lenses was performed. The Hoffman technique was used to create reverse scleral pockets without conjunctival dissection. A 10-0 non-dissolvable suture was used to capture and then secure the lens haptics in a lasso-type fashion. Sutures were then buried within the previously created scleral pockets. Both patients had well-centered lenses postoperatively that remained stable at last follow-up, 30 months postoperatively. CONCLUSION: In the absence of adequate capsular support, scleral fixation is a viable option for one-piece toric IOL fixation to avoid IOL explantation.

Twenty-Four-Month Outcome of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Corneal Transplant Surgery.

PURPOSE: Glaucoma is a well-known sequelae of corneal transplant surgery and is a leading cause of visual loss in this patient group. We evaluated the performance and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in this population. DESIGN: Noncomparative retrospective case series. PARTICIPANTS: Consecutive eyes of patients receiving the GATT procedure for uncontrolled intraocular pressure (IOP) following corneal transplant surgery from 2016 to 2019. METHODS: Retrospective analysis of eyes with a history of prior corneal transplant undergoing GATT at Glaucoma Associates of Texas between 2016 and 2019 was performed. Data included IOP, patient demographics, preoperative and postoperative medications, preoperative and postoperative corneal procedures, complications, and need for reoperation for IOP control. MAIN OUTCOME MEASURES: IOP reduction and medication use following the procedure. RESULTS: Thirty-nine eyes of 32 patients with prior corneal transplant surgery underwent a GATT procedure. Prior corneal surgery included penetrating keratoplasty (59.0%), Descemet's stripping endothelial keratoplasty (35.9%), Descemet's membrane endothelial keratoplasty (2.6%), and deep anterior lamellar keratoplasty (2.6%). Patient age ranged from 24 to 94 years (mean 68.0 y) with 44% female and 81% Caucasian. The majority of patients had secondary open angle glaucoma (64.1%). There was a significant reduction in IOP and number of medications at all postoperative time points after censoring patients requiring reoperation to control IOP (P<0.001). At 24 months the pressure decreased from baseline of 30.9±11.5 to 13.9±4.7 mm Hg. Medications decreased from 4.2±1.0 medications at baseline to 0.6±1.0 at 24 months. Visual acuities decreased significantly over the first postsurgical month (all P<0.05), but these recovered at subsequent follow-up visits with 2-Snellen line improvements exceeding losses from month 3 to 36. Seven eyes required reoperation for uncontrolled glaucoma at a median of 8.5 months (range: 1.6 to 16.2 mo) after GATT. The cumulative proportion of eyes undergoing repeat cornea surgery was 2.6%, 2.6%, and 14.3% at 12, 24, and 36 months post-GATT, respectively. CONCLUSIONS: This case series describes a group of glaucoma patients, with a history of prior corneal surgery, that were safely and successfully treated with GATT. While classically traditional glaucoma surgeries are considered the standard of care for eyes following corneal transplant surgery, GATT should be considered as a reasonable, safe and effective alternative for surgically lowering IOP.

Early Results of Goniotomy with the Kahook Dual Blade, a Novel Device for the Treatment of Glaucoma.

PURPOSE: To report the outcomes of patients who underwent goniotomy with the Kahook Dual Blade (KDB) either as a standalone procedure or in combination with cataract extraction. PATIENTS AND METHODS: This retrospective chart review included 111 eyes of 90 patients who underwent KDB goniotomy from January to November 2016 at Glaucoma Associates of Texas. KDB goniotomy was combined with cataract surgery in 100 eyes. The main outcome measures were postoperative intraocular pressure (IOP) and number of IOP lowering medications. RESULTS: Preoperatively, mean IOP was 17.1 ± 4.7 mmHg (range 8-34 mmHg) and mean number of IOP lowering medications was 2.4 ± 1.3 (range 0-6). Postoperatively, mean IOP was 14.9 mmHg, 13.9 mmHg, 14.1 mmHg, 14.4 mmHg, and 14.7 mmHg at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.004). Mean numbers of IOP lowering medications were 0.8, 1.0, 1.0, 1.0, and 1.6 at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.001). The cumulative reoperation rates for uncontrolled IOP after KDB were 0%, 1.0%, 2.1%, and 4.6% at 3, 6, 9, and 12 months, respectively. Eyes with a preoperative IOP >21 mmHg were significantly more likely to undergo reoperation (p = 0.038, log-rank test). There were no serious complications at any time point in the follow-up period. CONCLUSION: The Kahook Dual Blade results in a reduction in IOP and use of glaucoma medications after one year of follow-up. Further prospective studies are needed to fully characterize safety and efficacy.

Micropulse Cyclophotocoagulation: Initial Results in Refractory Glaucoma.

PURPOSE: The purpose of this study is to evaluate the use of micropulse transscleral cyclophotocoagulation (MP-TSCPC), a new and increasingly popular treatment, in patients with uncontrolled glaucoma. METHODS: A retrospective chart review was performed for all patients who underwent a MP-TSCPC at the Glaucoma Associates of Texas. RESULTS: A total of 84 eyes were treated with MP-TSCPC in this study with a mean follow-up time of 4.3 months. The mean age of treated patients was 74 years and 48 (57%) were female. Preoperatively, mean intraocular pressure (IOP) was 27.7 mm Hg and mean number of ocular antihypertensive medications used was 3.3. Mean postoperative IOP at months 1, 3, 6, and 12 were lowered to 16.3 mm Hg (41.2% reduction), 14.6, 13.0, and 11.1 mm Hg, respectively. Postoperative ocular antihypertensive medication use was also lowered to 1.9, 2.0, 2.0, and 2.3 medications at months 1, 3, 6, and 12, respectively. Five patients required further laser or surgical intervention for adequate IOP control. Complications included hypotony, IOP spike, hyphema, serous choroidal detachment, persistent inflammation, and vision loss. At 3 months, inflammation was still present in 46% of eyes and vision loss of at least 1 line was present in 41% of eyes. CONCLUSIONS: MP-TSCPC is effective at lowering IOP and decreasing the need for ocular antihypertensive medications. Eyes with limited visual potential or at high risk for incisional glaucoma surgery can successfully be treated with MP-TSCPC as a reasonable and effective alternative to traditional CPC. These results present short-term data and both longer follow-up and further studies are necessary.

Indications for a systemic work-up in glaucoma.

Most glaucomas are primary in nature. However, many adult and childhood glaucomas are secondary, and they require systemic evaluation to pick up associated systemic disease. Conditions such as nocturnal hypotension and sleep apnea may contribute to glaucomatous progression, whereas neurologic diseases may mimic normal tension glaucoma based on disc appearance. This review highlights those conditions in which a focused systemic work-up can improve glaucoma management and potentially discover life-threatening disease.

An aggressive sphenoid wing meningioma causing foster kennedy syndrome.

Foster Kennedy syndrome is a rare neurological condition with ophthalmic significance that can manifest as acute visual loss. It is classically characterised by unilateral optic nerve atrophy and contralateral papilledema resulting from an intracranial neoplasm. Physicians should consider Foster Kennedy syndrome in patients who present with visual loss and who have a history of intracranial neoplasm. In addition to ophthalmologic examination, neuroimaging is essential for the diagnosis of Foster Kennedy syndrome.

Sick sinus syndrome associated with topical timolol maleate instillation.

A 70-year-old black woman presented with intermittent palpitations and dyspnea was found to be bradycardic with a normal sinus rhythm. She had instilled her topical timolol maleate approximately 30 minutes prior to each of these episodes. Topical timolol was discontinued and the conduction abnormality resolved. She was diagnosed as having intermittent sinus bradycardia with intermittent atrioventricular block, likely induced by topical beta-blocker therapy. Topical timolol maleate is an effective treatment for ocular hypertension, acting by reducing aqueous fluid production. However, it can induce systemic side effects and should be used with caution in patients with, or predisposed to, cardiac or respiratory depression.