Alterations in contact lens fitting parameters following cross-linking in keratoconus patients of Indian ethnicity.

BACKGROUND: Most studies have either excluded patients using contact lens or not taken their effect while analyzing post-collagen cross-linkage (CXL) changes. This study aims to study impact of CXL on lens fit in both quantitative and qualitative manner. OBJECTIVE: To evaluate changes in CL fit post-CXL and to correlate these changes with alterations in corneal topographic parameters. STUDY DESIGN: Prospective intervention study on 20 keratoconic eyes of 14 patients (age > 18 years), with mean follow-up of 6 months. METHODS: Preoperative evaluation included UCVA, BCVA, corneal topography, AS-OCT and contact lens fit. Patients were evaluated at 2 weeks, 1, 3, 4 and 6 months post-CXL; contact lens trial with standard rigid gas permeable (RGP) lens performed at 3 and 6 months. MAIN OUTCOME MEASURE: Changes in objective and subjective parameters of lens fit. RESULTS: Over 6-month follow-up post-CXL, improvement in visual acuity by one Snellen line, both UCVA and BCVA, and decrease in flat/mean/apical K by 0.8 D, 0.8 D and 1.3 D, respectively, resulted in significant improvement in RGPCL fit. Almost 20% increase in near-ideal fit, 100% acceptable fit, 65% improved subjective comfort with 8 h/day increase in duration of comfortable CL wear were observed. CONCLUSION: Despite no statistically significant change in objective parameters of lens fit, a tendency for flatter lens fit along with contact lens induced further flattening of the ectatic cornea which resulted in marked improvement in both objective and subjective contact lens fit.

Diode laser cyclophotocoagulation paves way to a safer trabeculectomy in eyes with medically uncontrollable intraocular pressure.

High intraocular pressure (IOP) not responding to systemic and topical anti-glaucoma medications renders the eye at risk for both intra- and post-operative complications of glaucoma filtration surgery. Laser cyclophotocoagulation is able to lower IOP in such refractory glaucoma eyes and may make the surgical event safer. This study assessed diode laser cyclophotocoagulation (DLCP) when used as a temporary measure for lowering IOP prior to performing trabeculectomy. This study is a  retrospective analysis of cases planned for trabeculectomy surgery, uncontrolled on maximally tolerable systemic anti-glaucoma medications. They were analysed for response to DLCP in terms of IOP control, vision-related complications, increased inflammation, post-trabeculectomy hypotony and chances of phthisis and ciliary shutdown. Twelve eyes of ten patients aged 35-65 years were identified and all followed up for at least 2 years. One week following DLCP, the IOP (mean ± SD) declined by 51 % from 46.8 ± 5.4 to 22.8 ± 3.3 mmHg. The IOP was further reduced to 15.4 ± 2.7 mmHg at 4 weeks after trabeculectomy; it remained in the mid-teens for a minimum of 2 years in all cases. The mean (±SD) visual acuity improved from 1.4 ± 0.4 to 0.8 ± 0.4 LogMAR equivalents following trabeculectomy. In four eyes, phacoemulsification was performed 5-7 months after trabeculectomy with improvement in best-corrected visual acuity. One patient developed transient hypotony, post-trabeculectomy, which resolved by 6 days. There were no other complications like increased inflammation, prolonged hypotony or suprachoroidal haemorrhage. DLCP is, thus, effective and safe for temporarily controlling IOP; thereby trabeculectomy can be performed in a quieter ocular milieu.

Our experience with transcanalicular laser-assisted endoscopic dacryocystorhinostomy (TCLADCR) in patients of chronic dacryocystitis with deviated nasal septum.

The purpose of this study is to study the operative difficulties and success rate of transcanalicular laser-assisted endoscopic dacryocystorhinostomy in patients of chronic dacryocystitis with deviated nasal septum (DNS). A prospective interventional clinical study of 36 consecutive patients suffering from chronic dacryocystitis with nasolacrimal duct obstruction with DNS undergoing primary TCLADCR from March to June 2011 was carried out. Diode laser was used to create a 16-mm(2) ostium which was enlarged to 64 mm(2) using Blakesley's forceps. Success was defined as anatomical patency and absence of symptoms at 12 months of follow-up. Out of the 36 patients, 25 were females with ages 20-72 years, and 19 were left sided. There were 12 high, 12 mid and 12 basal DNS towards the side of surgery, mild to moderate in severity. Intraoperatively there was difficulty in visualising the aiming beam in the nose, tedious manipulation of endoscope and excessive bleeding in 3 patients. Increased bleeding and failures were significantly higher in high DNS (Fisher exact test-2 tailed: 0.0045). The procedure was successful in 94.4 % cases with average ostium size of 21.94 mm(2) at 12 months and no statistically significant difference in success rates between mild and moderate DNS (Fisher exact test-2 tailed: 1.000). Also there was no difference in the complication rate between mild and moderate DNS (Fisher exact test-2 tailed: 0.0841). TCLADCR is an effective procedure in patients with mild to moderate mid and basal DNS and obviates the need for multiple procedures and a cutaneous scar.

Pediatric Craniopharyngioma: The Effect of Visual Deficits and Hormone Deficiencies on Long-Term Cognitive Outcomes After Conformal Photon Radiation Therapy.

PURPOSE: Pediatric patients with craniopharyngioma risk cognitive deficits when treated with radiation therapy. We investigated cognitive outcomes after conformal photon radiation therapy (CRT) and the effect of visual deficits and hormone deficiencies. METHODS AND MATERIALS: One hundred one pediatric patients were enrolled on a single institutional protocol beginning in 1998 (n = 76) or followed a similar nonprotocol treatment plan (n = 25). CRT (54 Gy) was administered using a 1.0- or 0.5-cm clinical target volume margin. Median age at CRT was 9.50 years (range, 3.20-17.63 years). Patients were followed for 10 years with assessment of hearing, vision, hormone deficiencies, and cognitive performance. RESULTS: Intellectual functioning (intelligence quotient) was significantly lower in children treated at a younger age and those who received higher doses to temporal lobes and hippocampi. Black race (-17.77 points, P = .002) and cerebrospinal fluid shunting (-11.52 points, P = .0068) were associated with lower baseline intelligence quotient. Reading scores were lower over time in models incorporating age, shunt, and dose to specific brain structures. Patients treated for growth hormone deficiency within 12 months of CRT had better intelligence and attention outcomes. Among patients with normal baseline vision, the 10-year cumulative incidence of change in visual acuity was 4.00% ± 2.82% and in visual field 10.42% ± 4.48%. Reading scores decreased after treatment (0.7873 points/y, P = .0451) in those with impaired baseline vision. CONCLUSIONS: Cognitive outcomes are selectively affected by dose to brain subvolumes, comorbidities of visual deficits, and treatment of endocrinopathy in pediatric craniopharyngioma. Improved treatment selection, normal tissue sparing methods of irradiation, and posttreatment management of endocrinopathy should be considered.

Comparison of Clinical Outcomes with Open Versus Closed Conjunctiva Implantation of the XEN45 Gel Stent.

PURPOSE: To describe the efficacy and safety of open versus closed conjunctival implantation of the XEN45 Gel Stent (Allergan Inc). DESIGN: Retrospective, multicenter study. PARTICIPANTS: A total of 137 patients with glaucoma who underwent XEN45 implantation via open or closed conjunctival methods. The XEN45 was implanted as a stand-alone procedure or at the time of cataract surgery by 5 surgeons. METHODS: Patient demographics, diagnoses, preoperative and postoperative clinical data, outcome measures including intraocular pressure (IOP), use of glaucoma medications, visual acuity, and complications were collected. Statistical analyses were performed with P < 0.05 as significant. MAIN OUTCOME MEASURES: Failure was defined as less than 20% reduction of IOP from medicated baseline or IOP >21 mmHg at 2 consecutive visits at postoperative month 1 and beyond, the need for subsequent operative intervention or additional glaucoma surgery, or a catastrophic event such as loss of light perception. Eyes that had not failed by these criteria and were not on glaucoma medications were considered complete successes. Eyes that had not failed but required glaucoma medications were defined as qualified successes. RESULTS: Complete success was achieved in 31% and 56% of the closed and open groups, respectively (P = 0.01). Qualified success was achieved in 53% and 71% of the closed and open groups, respectively (P = 0.06). At postoperative month 12, the open conjunctiva group was using fewer glaucoma medications than the closed group (0.9 vs. 1.8, respectively; P = 0.02). At postoperative month 12, the open group had a significantly greater percentage of IOP reduction compared with the closed group (43.1% vs. 24.8%, respectively; P = 0.02). Postoperative needling rates were higher in the closed group compared with the open group (36.1% vs. 11.8%, P = 0.001). CONCLUSIONS: Implantation of the XEN45 with opening of the conjunctiva is a safe and efficacious procedure to lower IOP with comparable success rate and lower needling rate compared with the closed conjunctiva technique. Prospective evaluation of the various methods for XEN45 implantation will allow for further comparison.

Open Conjunctival Approach for Sub-Tenon's Xen Gel Stent Placement and Bleb Morphology by Anterior Segment Optical Coherence Tomography.

PRCIS: Sub-Tenon's implantation of the Xen Gel stent resulted in significant intraocular pressure (IOP) lowering along with a low rate of postoperative bleb needling, and a favorable bleb morphology on anterior segment optical coherence tomography (AS-OCT). PURPOSE: The aim was to assess clinical outcomes and bleb morphology following sub-Tenon's implantation of the Xen Gel Stent. METHODS: The medical records of patients who underwent sub-Tenon's Xen Gel Stent implantation with intraoperative mitomycin-C through an open conjunctival approach were reviewed. Postoperative IOP and number of glaucoma medications at 1, 3, 6, 9, and 12 months were assessed. Bleb morphology was analyzed at various timepoints using AS-OCT (Topcon DRI OCT version 1.1.1). RESULTS: Twenty-six eyes were included in the study. Mean age was 69.4±8.0 years. Mean preoperative IOP was 28.1±7.8 mm Hg on an average of 3.5±0.9 glaucoma medications. Mean IOP at postoperative month 12 (n=23 eyes) was 12.9±4.0 mm Hg (P<0.01) on an average of 0.3±0.6 (P<0.01) glaucoma medications. Three eyes (12%) required postoperative needle revision. Bleb morphology in the early postoperative period (≤3 mo) was characterized by multiple small subconjunctival microcysts on AS-OCT. At the intermediate (6 to 12 mo) and long-term (>12 mo) timepoints, reduction in microcysts with multiple internal parallel layers of aqueous flow and a uniform pattern were more frequently noted. All functional blebs were characterized by the presence of a posterior episcleral fluid lake. Failed blebs showed absence of aqueous humor around the distal end of the microshunt. CONCLUSION: Following an open conjunctival approach, sub-Tenon's placement of the Xen Gel Stent with significant IOP lowering was achieved. In eyes with good shunt function, bleb morphology by AS-OCT showed a posterior episcleral fluid lake similar to findings following trabeculectomy.

The Effect of Phacoemulsification on Intraocular Pressure in Eyes with Preexisting Glaucoma Drainage Implants.

PURPOSE: To study the effect of phacoemulsification on intraocular pressure (IOP) control in patients with preexisting glaucoma drainage implants (GDIs). DESIGN: Retrospective, observational case series. PARTICIPANTS: A total of 45 patients (51 eyes) with previously placed GDIs who underwent phacoemulsification between January 2013 and March 2018. METHODS: The list of patients was obtained from billing records. Clinical data were retrieved from the corresponding electronic medical records. MAIN OUTCOME MEASURES: Intraocular pressure, number of glaucoma medications before and after phacoemulsification (postoperative day 1, week 1, months 1, 3, 6, 12, 18, and 24), rate of failure (failure defined as IOP >18 mmHg and IOP increase >20% at 2 consecutive visits after month 1, need for additional glaucoma surgery, or loss of light perception vision), and postoperative complications. RESULTS: Mean follow-up was 23.0 ± 11.1 months. The average interval between GDI surgery and phacoemulsification was 9.4 ± 6.7 months. An Ahmed glaucoma valve (AGV; New World Medical) was implanted in 12 eyes, a Baerveldt glaucoma implant (BGI; Johnson & Johnson Surgical Vision) was implanted in 36 eyes, and a Molteno (Molteno Ophthalmic Limited) glaucoma implant was implanted in 3 eyes. Before phacoemulsification, the mean IOP was 14.4 ± 4.4 mmHg on 2.1 ± 1.3 glaucoma medications. At postoperative month 24, the mean IOP was 12.6 ± 4.4 mmHg (n = 29, P = 0.519) on 2.0 ± 1.6 (P = 0.457) glaucoma medications. The reduction in IOP was significant only at postoperative week 1 (P = 0.031). The cumulative failure rate was 3.9% at 1 year and 11.8% at 2 years. The AGV group had a significantly higher mean IOP before phacoemulsification than the BGI group (P = 0.016). Analysis of covariance, taking the baseline IOP as a covariate, revealed no differences in postoperative IOP and number of glaucoma medications between groups, except for month 18 (1 patient in the BGI group had uncontrolled IOP requiring surgery). Postoperative complications included cystoid macular edema (10%), corneal decompensation (6%), and choroidal effusion (4%). CONCLUSIONS: Phacoemulsification after GDI surgery resulted in a transient reduction in IOP at postoperative week 1. Patients with previously placed AGVs had similar postoperative outcomes compared with those with BGIs.

Downsizing a Baerveldt Glaucoma Implant For the Management of Persistent Postoperative Hypotony: A Case Series.

PURPOSE: The purpose of this study was to describe a surgical technique for treating persistent hypotony after Baerveldt glaucoma implant (BGI) surgery. MATERIALS AND METHODS: The medical records of 10 patients with persistent postoperative hypotony who underwent truncation of one or both wings of a previously placed BGI, combined with external ligation of the tube using a polypropylene suture, were retrospectively reviewed. RESULTS: All 10 eyes that underwent BGI truncation and placement of a single, external, nonabsorbable (polypropylene) tube ligature exhibited resolution of hypotony within 24 hours and resolution of choroidal effusions within the first 2 postoperative weeks. The median time interval between primary BGI surgery and truncation was 5 months (range, 1.5 mo to 8 y). Median postrevision follow-up time was 12 months (range, 5 mo to 16.2 y). The mean preoperative intraocular pressure (IOP) was 2.1±1.0 mm Hg, and the mean IOP rose to 29.2±13.9 mm Hg on postoperative day 1. Mean IOP at week 1, month 1, and month 3 was 20.5±10.4, 19.7±11.8, and 18.0±8.2 mm Hg, respectively, using an average of 1.4±1.4 glaucoma medications at postoperative month 3. Ligature release after BGI revision was performed in 9 (90%) of the 10 patients. The median time to ligature release was 1.5 months (range, 3 wk to 4 y). There was no recurrence of hypotony in any of these patients. At most recent follow-up, the mean IOP was 12.9±6.0 mm Hg on an average of 1.5±1.3 glaucoma medications. Five patients demonstrated improvement in visual acuity from their prerevision best-corrected visual acuity. CONCLUSIONS: Truncation of one or both wings of a BGI and complete closure of the tube with nonabsorbable, but releasable, suture ligature is an effective and safe method for reversing persistent postoperative hypotony while maintaining IOP control.

Trabeculectomy with subconjunctival collagen implant in Indian eyes: Long-term results.

PURPOSE: To report long-term safety and efficacy of trabeculectomy with collagen implant in Indian population. METHODS: All cases of trabeculectomy with Ologen® Collagen Matrix implant performed over a 7-year period from May 2008 through April 2015 at a tertiary referral institute were reviewed. A total of 30 eyes of 28 patients were included in the study with two patients undergoing bilateral trabeculectomy. Outcomes measured included intraocular pressure (IOP) control, number of antiglaucoma medications used, bleb morphology, and complications/reoperations. RESULTS: Trabeculectomy resulted in reduction in IOP from 36.46 to 11.65 mm Hg in the immediate postoperative period (day 1), a 68% decrease to 15.18 mm Hg at 84 months (58% decrease). The mean IOP reduction decreased over time from 63% in the first year to 55% after 5 years of follow-up. Fourteen eyes attained a follow-up of 5 years and eight eyes a follow-up of ≥7 years. No sight-threatening complication such as hypotony, bleb leak, and bleb-related endophthalmitis was observed in our series, and only intervention required was 5-fluorouracil needling in one case. CONCLUSION: Ologen-augmented trabeculectomy is effective in controlling IOP over a long-term follow up from minimal 3 to maximal 7 years. No untoward events jeopardizing bleb safety were noted at any time. This modality is a viable alternative for patients with contraindications to use of antimetabolites.

Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins.

AIM: To report a case of bilateral phacomatosis pigmentovascularis (PPV), in a young male,presenting with developmental glaucoma and high myopia along with systemic features of klippel trenanauy weber (KTW) syndrome. BACKGROUND: The co-existence of oculodermal melanocytosis (ODM)and port-wine stain was termed PPV by Ota. Port-wine stain presents as part of Sturge-Weber syndrome (SWS). KTW presents with varicose veins and tissue hypertrophy alongwith port-wine stain. CASE DESCRIPTION: A 22-year-old male presented with decreased vision owing to high myopia and advanced glaucoma. Incidental findings noted were pigmentary naevi along with facial port-wine stain, which collectively comprises PPV. Also noted were bilateral varicose veins which are usually seen in association with KTW. In view of advanced visual field damage and inability to control intraocular pressures (IOP) on topical medications, he underwent Glaucoma filtration surgery in both eyes. Intra-operatively care was taken to avoid sudden decompression by controlled anterior chamber paracentesis, and scleral flap closure with releasable sutures was done to prevent hypotony related complications in the immediate postoperative period. Such precautions lead to an uneventful postoperative recovery, and even at 3 years' follow-up, the patient is maintaining IOP in early teens along with a stable visual acuity and visual fields. CONCLUSION: This case highlights the overlapping features of congenital conditions like oculodermal melanocystosis (ODM), SWS, KTW; presenting in a young male. Systemic features reported less frequently with PPV, included palatal pigmentation and palatal vascular malformations. CLINICAL SIGNIFICANCE: This case re-emphasizes a common origin of these entities, PPV and KTW, from the neural crest cells. Early recognition of the systemic features and timely surgical intervention under appropriate precautions, can be vision salvaging in such cases of developmental glaucoma.How to cite this article: Singh K, Dangda S, Mutreja A, Bhattacharyya M, Jaisingh K. Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins. J Curr Glaucoma Pract 2018;12(2):94-98.

Simultaneous use of amniotic membrane and Mitomycin C in trabeculectomy for primary glaucoma.

PURPOSE: This study aimed to propose the role of amniotic membrane transplantation (AMT) as an additional modulator in primary Mitomycin C (MMC)-augmented trabeculectomy. METHODS: This was a randomized prospective interventional study. Forty eyes of 39 adult patients with uncontrolled primary glaucoma were randomly divided into two equal groups. Control group underwent trabeculectomy augmented with MMC while the study group underwent additional AMT. Patients were followed up for 12 months and outcomes measured were intraocular pressure (IOP), need for additional intervention, and bleb morphology. RESULTS: Complete success (defined as IOP <16 mmHg on no medication) could be achieved in 85% eyes in study group while it was 60% in control group (P = 0.04). IOP reduced by 71.1% in study group from 41.9 ± 10.6 to 12.1 ± 2.7 mmHg and from 40.5 ± 8.5 to 12.8 ± 4.5 mmHg in control group, a decline of 68.29%. Blebs in AMT group showed better bleb morphology in terms of significantly better extent (E3) on day 1 (P = 0.03) and better height (H2 and H3) (P = 0.04), according to the Indiana Bleb Appearance Grading Scale, at all follow-up visits along with normal vascularity. The study group required significantly lesser (P = 0.03) bleb needlings as compared to control group. CONCLUSION: Amnion enhanced the efficacy of MMC-modulated trabeculectomy in terms of eyes with complete success and lesser interventions such as bleb needling. This reiterates the role of amnion as a safe and effective bleb modulator. A diffusely elevated bleb with healthier conjunctiva can go a long way in predicting better health and longevity of the bleb.

Bleb reduction using combined photodisruptive and photocoagulative neodymium-doped yttrium-aluminum-garnet laser.

This case report aims to highlight the role of photodisruptive neodymium-doped yttrium-aluminum-garnet (Nd:YAG) (1064 nm) laser in the treatment of bleb dysesthesia, which occurs in overhanging blebs or with perilimbal spread. Although treatment of such dysesthetic blebs with laser photocoagulation has been previously described, cases where the height of bleb precludes laser penetration, desired effect might not be seen. We herein describe a technique using a combination of photocoagulative (532 nm) and photodisruptive (1064 nm) Nd:YAG laser for a high bleb migrating nasally and inferiorly along the limbus in a 64-year-old female, causing hypotony and consequent macular edema. Successful reduction could be achieved within a week of treatment. By 6 weeks, intraocular pressure improved to 8 mmHg, macular edema subsided, and visual acuity improved to 6/6. Although surgical procedures to correct bleb dysesthesia are available, laser procedures being quick outpatient modalities are more comfortable for the patients.

Television Video Games in the Treatment of Amblyopia in Children Aged 4-7 Years.

AIM: To investigate the role of television video games in childhood amblyopia treatment. METHOD: This prospective, randomized, interventional study included 40 patients between 4-7 years of age, with unilateral amblyopia (visual acuity in amblyopic eye between 1-0.6 LogMAR equivalents) attending the squint clinic at a tertiary eye hospital. All patients were prescribed optimal spectacle correction and occlusion therapy, i.e. full time patching according to patient's age, was initiated after six weeks.; full-time patching according to patient's age was initiated after 6 weeks. Subjects were randomly divided into two groups of 20 each. Patients in the first group, Group A (control), were prescribed patching alone. Patients in the second group, Group B (study), were made to play action video games, with the help of a commercial television set, along with patching. They attended 12 half-hour sessions each, at weekly intervals. Follow-up assessments included best corrected visual acuity (BCVA) (both distance and near) and stereoacuity measurements at 3, 6, 9, and 12 weeks. RESULTS: The mean age of patients was 6.03 ± 1.14 years. The distance BCVA in the amblyopic eye showed a significant improvement at final follow-up (12 weeks) in both groups: from 0.84 ± 0.19 to 0.55 ± 0.21 LogMAReq in Group A and 0.89 ± 0.16 to 0.46 ± 0.22 LogMAReq in Group B. However, improvement in BCVA was significantly better in group B at all visits (P=0.002, 12 weeks). The study group also had a significantly better outcome in terms near visual acuity improvement (P = 0.006, 12 weeks). There was also greater stereoacuity improvement in group B, with 7 patients improving to 100 secs of arc or better. CONCLUSION: Video games supplemental to occlusion may be considered favorable for visual development in amblyopic children, and the study encourages further research on this subject.