Dysphotopsia and location of laser iridotomy: a systematic review.

This systematic review aimed to clarify the relationship between the location of laser peripheral iridotomy (LPI), a common procedure to prevent or treat angle-closure glaucoma, and the incidence of post-procedure visual disturbances known as dysphotopsias. Understanding this relationship is crucial due to the high frequency of LPIs performed and the significant impact dysphotopsia can have on vision and quality of life. Articles investigating the relationship between LPI location and dysphotopsia in at least five patients were identified via a literature search of OVID MEDLINE (1946-November 19, 2022) and EMBASE (1946-November 19, 2022). Non-comparative and non-English studies were excluded. Studies did not require a control group to be included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and Cochrane Risk of Bias 2 (RoB2) tool were used to appraise included studies. Our review included three studies encompassing 1756 eyes from 878 patients. The location of LPI was grouped into superior (604 patients, 889 eyes), inferior (150 patients, 150 eyes), and nasal/temporal (443 patients, 717 eyes). The analysis showed no significant difference in the incidence of any new dysphotopsia types among the location groups post-LPI. Overall, the incidence of lines, ghost images, and blurring significantly increased after LPI, while halos and glare significantly decreased. In conclusion, the current literature suggests that the location of LPI has no significant relationship to the types and rates of dysphotopsia experienced thereafter. While there is a 2-3% risk of linear dysphotopsia after LPI regardless of location, LPI may also resolve pre-existing halos and glare.

Ensemble of deep convolutional neural networks is more accurate and reliable than board-certified ophthalmologists at detecting multiple diseases in retinal fundus photographs.

AIMS: To develop an algorithm to classify multiple retinal pathologies accurately and reliably from fundus photographs and to validate its performance against human experts. METHODS: We trained a deep convolutional ensemble (DCE), an ensemble of five convolutional neural networks (CNNs), to classify retinal fundus photographs into diabetic retinopathy (DR), glaucoma, age-related macular degeneration (AMD) and normal eyes. The CNN architecture was based on the InceptionV3 model, and initial weights were pretrained on the ImageNet dataset. We used 43 055 fundus images from 12 public datasets. Five trained ensembles were then tested on an 'unseen' set of 100 images. Seven board-certified ophthalmologists were asked to classify these test images. RESULTS: Board-certified ophthalmologists achieved a mean accuracy of 72.7% over all classes, while the DCE achieved a mean accuracy of 79.2% (p=0.03). The DCE had a statistically significant higher mean F1-score for DR classification compared with the ophthalmologists (76.8% vs 57.5%; p=0.01) and greater but statistically non-significant mean F1-scores for glaucoma (83.9% vs 75.7%; p=0.10), AMD (85.9% vs 85.2%; p=0.69) and normal eyes (73.0% vs 70.5%; p=0.39). The DCE had a greater mean agreement between accuracy and confident of 81.6% vs 70.3% (p<0.001). DISCUSSION: We developed a deep learning model and found that it could more accurately and reliably classify four categories of fundus images compared with board-certified ophthalmologists. This work provides proof-of-principle that an algorithm is capable of accurate and reliable recognition of multiple retinal diseases using only fundus photographs.

Minimally Invasive Glaucoma Surgery: A Review of the Literature.

Minimally invasive glaucoma surgery (MIGS) has emerged as a novel approach in the glaucoma treatment spectrum, offering a range of diverse procedures and devices aimed at reducing intraocular pressure (IOP). MIGS can be broadly classified into several categories: those that enhance trabecular outflow (Trabectome, iStent, Hydrus Microstent, Kahook Dual Blade, high frequency deep sclerotomy, and gonioscopy-assisted transluminal trabeculotomy), those that augment suprachoroidal outflow (CyPass Microstent and iStent Supra), those that target Schlemm's canal (TRAB360 and the OMNI Surgical System, Streamline, and Ab Interno Canaloplasty), and conjunctival bleb-forming procedures (EX-PRESS Glaucoma Filtration Device, Xen Gel Stent and PreserFlo MicroShunt). MIGS is considered to have a shorter surgical time and fewer severe complications when compared to traditional glaucoma surgeries such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves). This literature review comprehensively examines the distinct MIGS devices and procedures, their underlying mechanisms, and clinical outcomes, emphasizing the importance of evaluating the efficacy and complications of each approach individually. As the field of MIGS continues to evolve, it is crucial to prioritize high-quality, long-term studies to better understand the safety and effectiveness of these innovative interventions in glaucoma management.

An inducible rodent glaucoma model that exhibits gradual sustained increase in intraocular pressure with distinct inner retina and optic nerve inflammation.

Glaucoma is a chronic and progressive neurodegenerative disease of the optic nerve resulting in loss of retinal ganglion cells (RGCs) and vision. The most prominent glaucoma risk factor is increased intraocular pressure (IOP), and most models focus on reproducing this aspect to study disease mechanisms and targets. Yet, current models result in IOP profiles that often do not resemble clinical glaucoma. Here we introduce a new model that results in a gradual and sustained IOP increase over time. This approach modifies a circumlimbal suture method, taking care to make the sutures 'snug' instead of tight, without inducing an initial IOP spike. This approach did not immediately affect IOPs, but generated gradual ocular hypertension (gOHT) as the sutures tighten over time, in comparison to loosely sutured control eyes (CON), resulting in an average 12.6 mmHg increase in IOP at 17 weeks (p < 0.001). Corresponding characterization revealed relevant retinal and optic nerve pathology, such as thinning of the retinal nerve fiber layer, decreased optokinetic response, RGC loss, and optic nerve head remodeling. Yet, angles remained open, with no evidence of inflammation. Corresponding biochemical profiling indicated significant increases in TGF-ß2 and 3, and IL-1 family cytokines in gOHT optic nerve tissues compared to CON, with accompanying microglial reactivity, consistent with active tissue injury and repair mechanisms. Remarkably, this signature was absent from optic nerves following acute ocular hypertension (aOHT) associated with intentionally tightened sutures, although the resulting RGC loss was similar in both methods. These results suggest that the pattern of IOP change has an important impact on underlying pathophysiology.

Postural Changes and the Trans-Lamina Cribrosa Pressure Difference: A Pilot Study in Neurosurgical Patients without Glaucoma.

PURPOSE: To evaluate the effect of changes in position in the trans-lamina cribrosa pressure difference (TLCPD) by simultaneously measuring and comparing intracranial pressure (ICP) with intraocular pressure (IOP) in seated and supine positions. DESIGN: Prospective cohort study. PARTICIPANTS: Patients admitted to the neurosurgery unit at Toronto Western Hospital with an external ventricular drain placed for ICP monitoring. Exclusion criteria were any ophthalmic surgical procedures within the preceding 6 months, history of glaucoma, and corneal abnormalities affecting IOP measurement. METHODS: Intraocular pressure and ICP were recorded simultaneously in both the supine and seated positions with the order of positions randomized. Measurements were made 10 minutes after assuming each position. The TLCPD (IOP minus ICP) was calculated for the sitting and supine positions. The paired t test was used to assess significance of differences. MAIN OUTCOME MEASURE: The TLCPD. RESULTS: Twenty patients were included in the study. The average age was 54±17 years. Results were similar for left and right eyes. Data are shown for right eyes only. Mean sitting and supine IOPs were 15.3±3.5 mmHg and 15.9±3.7 mmHg, respectively (P = 0.32). Mean sitting and supine ICPs were 12.5±6.8 mmHg and 12.8±5.1 mmHg, respectively (P = 0.66). Mean TLCPD was 3.1±6.0 mmHg in the sitting position and 3.1±7.0 mmHg in the supine position (P = 1.00). Supine TLCPD increased in 10 patients (50%), decreased in 8 patients (40%), and was unchanged in 2 patients (10%). CONCLUSIONS: In this pilot study of 20 neurosurgical patients without glaucoma, posture-induced TLCPD changes were variable.

Minimally Invasive Glaucoma Surgery: A Critical Appraisal of the Literature.

Micro- or minimally invasive glaucoma surgeries (MIGS) have been the latest addition to the glaucoma surgical treatment paradigm. This term refers not to a single surgery, but rather to a group of distinct procedures and devices that aim to decrease intraocular pressure. Broadly, MIGS can be categorized into surgeries that increase the trabecular outflow [Trabectome, iStent (first and second generations), Hydrus microstent, Kahook Dual Blade and gonioscopy-assisted transluminal trabeculotomy], surgeries that increase suprachoroidal outflow (Cypass microstent and iStent Supra), and conjunctival bleb-forming procedures (Xen gel stent and InnFocus microshunt). Compared to traditional glaucoma surgeries, such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves), MIGS are touted to have less severe complications and shorter surgical time. MIGS represent an evolving field, and the efficacy and complications of each procedure should be considered independently, giving more importance to high-quality and longer-term studies.

The cost of publishing in an indexed ophthalmology journal in 2019.

OBJECTIVE: To determine the proportion of indexed ophthalmology journals with article processing charges (APCs) and potential factors associated with APCs. DESIGN: Cross-sectional study. PARTICIPANTS: Web of Science-indexed Ophthalmology journals in 2019. METHODS: Indexed ophthalmology journal web sites were reviewed to obtain information on APCs, impact factor (IF), publication mode, publisher type, journal affiliation, waiver discount, and continent of origin. For data unavailable on the web site, the journal was contacted. Journal publication mode was categorized into subscription, fully open access, and hybrid (open access and subscription combined). Linear regression analysis was used to evaluate the association between APCs and the above variables. MAIN OUTCOME MEASURE: Proportion of ophthalmology journals with APCs. RESULTS: 59 indexed ophthalmology journals were identified; 3 (5.1%) subscription only, 10 (16.9%) open access, and 46 (78.0%) hybrid. Overall 52/59 (88.1%) journals had APCs; 10 of 59 journals (16.9%) required APCs for publication (7 fully open access and 3 hybrid journals), whereas 42/59 (71.2%, all hybrid journals) had optional APCs for open access. The 7/59 journals (11.9%) without APCs included 100% (3/3) of the subscription-only journals, 30% (3/10) of the open access, and 2% (1/46) of the hybrid journals. The mean cost for journals with APCs was US$2854 ± 708.9 (range US$490-5000). Higher IF, publication mode, and commercial publishers were associated with higher APCs. CONCLUSIONS: 16.9% of indexed ophthalmology journals in 2019 required APCs, and additional 71.2% hybrid journals had APCs for the option of open access. Independent predictors of APCs were IF and publication mode.

Intraocular pressure control after trans-scleral intraocular lens fixation in glaucoma patients.

BACKGROUND: Intraocular lens fixation surgery is associated with fluctuations in intraocular pressure. This may be significantly relevant in glaucoma patients. OBJECTIVES: To assess short- and medium-term intraocular pressure control after trans-scleral intraocular lens fixation surgery in glaucoma patients. METHODS: The charts of all glaucoma patients who underwent trans-scleral intraocular lens fixation surgery with at least 6 months follow-up by a single surgeon between the years 2004 and 2017 were reviewed. Primary outcomes were intraocular pressure at 1 day and 6 months after surgery. Secondary outcome measures were hypotensive medication use and the need for further intraocular pressure lowering interventions. RESULTS: Eleven eyes of 10 patients were included in the analysis. Mean follow-up post intraocular lens fixation surgery was 54.6 months. Mean intraocular pressure before, 6 months, and last follow-up after intraocular lens fixation surgery was 15.8 ± 5.3 mmHg (range 10.6-25.3), 13.5 ± 3.8 mmHg (range 8-21, p = 0.2), and 11.8 ± 5.6 (range 6-21, p = 0.09) on a mean of 2.3 ± 1.6, 2 ± 1.6 (p = 0.23), and 1.7 ± 1.5 (p = 0.08) hypotensive medications, respectively. A pressure spike was noted in 5 of the 11 eyes on the first post-operative day (mean spike 15.2 mmHg, range 6-23). Four of 11 eyes in the study (36%) needed additional interventions to control intraocular pressure by the 6-month point. One eye required the addition of two classes of topical medications, one eye required laser trabeculoplasty, and two eyes required trabeculectomy. CONCLUSION: Over a third of glaucomatous eyes required a change in the management of their disease in the early post-operative period. Close follow-up of patients undergoing trans-scleral intraocular lens fixation surgery is warranted.

Explantation of BrightOcular cosmetic iris implant and goniosynechialysis: A case report.

A 48-year-old lady presented with bilateral symptomatic uveitis. She had bilateral cosmetic iris implantation 4 years ago. She underwent bilateral cosmetic iris explantation and goniosynechialysis to open up areas of angle compromise. This patient presented before significant angle compromise. This case report also serves to highlight the serious potential risks associated with cosmetic iris implantation. Patients with cosmetic iris implants should be warned of the potential complications and advised explantation at the earliest.

Adherence to World Glaucoma Association Guidelines for Surgical Trials in the Era of Microinvasive Glaucoma Surgeries.

PURPOSE: To determine how well microinvasive glaucoma surgical (MIGS) trials conform to the World Glaucoma Association (WGA) guidelines. Lack of well-designed MIGS studies hinders meaningful evaluation of these technologies. DESIGN: Cross-sectional literature survey. METHODS: Using a predefined search strategy, the following databases were searched for comparative trials involving MIGS in the English peer-reviewed literature from January 1, 2000, through June 21, 2018: Medline, EMBASE, BIOSIS, Cochrane, and Web of Science. From the WGA guidelines, 53 outcomes were selected for evaluation: methodology (n = 31), definition of success (n = 7), ethics (n = 10), postoperative complications (n = 1), economic evaluation (n = 1), and statistical reporting (n = 3). Each article was assessed by 2 reviewers; differences were resolved by consensus. RESULTS: Twenty-five eligible publications were identified: 10 randomized controlled trials (RCTs) and 15 nonrandomized comparative trials (non-RCTs). The mean follow-up was 19.9±11.6 months (range, 6-48 months). The mean number of outcomes adhering to the WGA guidelines of the 53 evaluated was 24.2±6.1 (45.6% compliance): 28.0±6.2 (52.8%) and 21.6±4.7 (40.8%) for RCTs and non-RCTs, respectively (P = 0.01). Mean percent compliance for each subsection were: methodology, 48.8%; definition of success, 21.1%; ethics, 55.6%; postoperative complications, 88%; economic evaluation, 0%; and statistical reporting, 37.3%. In 16 studies (64%), at least 1 author reported an association with the industry. Thirty-two percent of studies reported an author being a shareholder. Twenty-four percent of studies had an industry employee author. The primary intraocular pressure (IOP) end point was defined as both an upper limit and percentage reduction in only 4 studies (16%; 1 RCT, 3 non-RCTs). An IOP-based survival curve was provided in 7 studies (28%; none of the RCTs). Two studies (8%) included an IOP scatterplot. Twelve studies (48%) reported 95% confidence intervals. Only 4 studies (16%) used the mean of 3 diurnal IOP readings as the baseline IOP. CONCLUSIONS: Published comparative MIGS trials show low adherence (45.6%) to the WGA guidelines. Development of standardized methodology and outcomes could enhance interpretation and transparency of study results and facilitate comparisons between trials. Authors and journals should be encouraged to follow the WGA guidelines.

Long-term Follow-up of Ahmed Glaucoma Valve Tube Position Changes.

PURPOSE: To evaluate long-term (4.5 to 6 y) changes in the position of Ahmed glaucoma valve (AGV) tubes. MATERIALS AND METHODS: Adult patients aged 18 years and above, 1 to 2 months post-AGV implantation were enrolled. Tube position was evaluated using anterior segment optical coherence tomography at baseline and final follow-up. The intracameral tube length (ICL), tube-cornea (TC) distance, and cornea-tube angle were measured. Wilcoxon-signed rank test was used to assess whether the changes in parameters from baseline were significant. RESULTS: In total, 11 eyes of 9 patients were included in the analysis. Mean duration of follow-up was 5.2±0.8 years (4.4 to 6.1 y). The ICL increased from 1.58±0.40 to 1.74±0.62 mm (P=0.18). The TC decreased from 0.36±0.12 to 0.29±0.05 mm (P=0.04). The cornea-tube angle decreased from 27.76±5.57 to 24.82±5.69 degrees (P=0.08). Overall, 73% of the tubes moved toward the cornea (mean 0.11 mm, over 4.4 to 6.1 y). In total, 73% showed an increase in ICL; 45% showed an increase of >0.3 mm [mean 0.50 mm (33%) increase]. Two of 11 tubes (18%) showed no significant change in the parameters (ICL, 0.03 and 0.01 mm increase; TC, 0 and 0.01 mm increase); these tubes were noted to lie on the iris. CONCLUSIONS: Tubes tend to move toward the cornea over time. To avoid corneal damage and involvement of the visual axis in the future, tubes should be reasonably short and inserted tangentially, preferably in the posterior one third of the anterior chamber.

Preoperative Brimonidine Tartrate 0.2% Does not Prevent an Intraocular Pressure Rise During Prostatectomy in Steep Trendelenburg Position.

PURPOSE: This study evaluated the effect of preoperative brimonidine tartrate 0.2% on intraocular pressure (IOP) during robotic-assisted laparoscopic radical prostatectomy in steep Trendelenburg position (sTBURG). MATERIALS AND METHODS: In this prospective randomized controlled masked interventional trial, eligible patients scheduled for robotic-assisted laparoscopic radical prostatectomy in sTBURG at the Toronto General Hospital had one eye randomized to placebo (artificial tears) or drug (brimonidine tartrate 0.2%) preoperatively. Visual acuity (VA), tonometry, disc photography, visual field (VF), and retinal nerve fiber layer (RNFL) assessments were performed preoperatively and postoperatively. A standardized anesthetic protocol was followed intraoperatively. IOP was measured using Tono-Pen AVIA (Reichert Inc., New York, NY) as follows: preanesthesia supine, anesthetized supine, hourly in sTBURG and awake supine. The primary outcome was IOP in sTBURG in the drug group compared with the placebo group. Secondary outcomes were changes in VA, VF, RNFL thickness, mean arterial pressure, and ocular perfusion pressure. This study was approved by University Health Network Research Ethics Board. RESULTS: In total, 26 eligible patients, mean age 61.9±5.1 years, were randomized to brimonidine (11 patients) and placebo (15 patients). Baseline IOP was not significantly different between the drug and placebo groups (P=0.42). Significant and sustained IOP elevation of >1.5X baseline in the sTBURG was noted in both groups. The mean IOP 1 hour after sTBURG was 29.4±6.9 and 27.2±3.4 mm Hg in the drug and placebo groups, respectively (P=0.35). No significant changes were noted in VA, VF, or RNFL. CONCLUSIONS: Significant and sustained IOP increases occur during sTBURG. Preoperative brimonidine does not prevent IOP spikes in sTBURG.

Presumed Chemotherapy-Induced Optic Neuropathy and Maculopathy: A Case Report.

PURPOSE: With the advent of more aggressive cytotoxic chemotherapy regimens, the incidence of ocular toxicity due to these drugs is also on the rise. We report a case of Presumed Chemotherapy-Induced optic neuropathy and maculopathy secondary to treatment with cytarabine and daunorubicin for Acute Myeloid Leukaemia (AML). CASE REPORT: A 50-year-old man with AML developed sudden decrease in vision in his left eye after three cycles of chemotherapy with cytarabine and daunorubicin. He presented to us six weeks later with bilateral optic atrophy and foveal atrophic changes with early bull's eye maculopathy. A diagnosis of presumed chemotherapy-induced optic neuropathy with maculopathy was made, and the patient was put on an alternative chemotherapeutic regimen. There was no further decrease in vision on follow up. CONCLUSION: To the best of our knowledge, this is the first report of clinically demonstrable macular toxicity in the form of macular atrophic changes and bull's eye maculopathy associated with the use of cytarabine and daunorubicin. Early diagnosis and appropriate management of such cases is imperative to prevent further visual deterioration.

An Unusual Case of Extensive Lattice Degeneration and Retinal Detachment.

Lattice degeneration of the retina is not infrequently encountered on a dilated retinal examination and many of them do not need any intervention. We report a case of atypical lattice degeneration variant with peripheral retinal detachment. An asymptomatic 35-year-old lady with minimal refractive error was found to have extensive lattice degeneration, peripheral retinal detachment and fibrotic changes peripherally with elevation of retinal vessels on dilated retinal examination. There were also areas of white without pressure, chorioretinal scarring and retinal breaks. All the changes were limited to beyond the equator but were found to span 360 degrees. She was treated with barrage laser all around to prevent extension of the retinal detachment posteriorly. She remained stable till her latest follow-up two years after the barrage laser. This case is reported for its rarity with a discussion of the probable differential diagnoses. To the best of our knowledge, this is the first report of such findings in lattice degeneration.

Valsalva retinopathy with double ring sign: Laser membranotomy for twin bleeds.

This report describes the case of a 27-year-old lady who presented with sudden decrease in vision in the right eye for one week. She was suffering from constipation and had a history of straining while passing stools. She was found to have two large sub-internal limiting membrane haemorrhages with the classical double ring sign, which were drained using laser membranotomy, following which her vision rapidly improved. This case of two sub-internal limiting membrane haemorrhages is reported for its rarity and also highlights the usefulness of laser hyaloidotomy or membranotomy in large haemorrhages of recent onset. The literature was also reviewed to discuss the other treatment options in brief.

Ocular myiasis in a glioma: a case report.

BACKGROUND: Ocular myiasis though rare, is usually found in association with basal cell carcinoma. It is rarer still in tumors other than basal cell carcinoma. We report a case of ocular myiasis in a glioma which is hitherto unreported to the best of our knowledge. CASE: A 50 year old male presented with bleeding and maggots emanating from a tumourous outgrowth which had replaced his right eye. He complained of swelling and pain in his right eye for the last 2 years. Manual removal of maggots was carried out following which he underwent total excision of the mass and local debridement. Biopsy of the mass was consistent with astrocytoma. CONCLUSION: Myiasis though rare should be suspected in long standing neglected lesions with suggestive history. Infection, ischemic necrosis and malignancy coupled with overcrowding, poor living conditions, presence of excessive arthropods in the locality and low levels of hygiene drastically increase the risk of myiasis.

Bilateral macular colobomata: Temporal dragging of optic disc.

A 13-year-old male presented with decreased vision and squint from childhood. He had bilateral large colobomata at the macula in each eye, the one on the right being larger than the left. The disc was dragged temporally with straightening of the temporal retinal vessels. This is a case report of bilateral large macular coloboma and serves to report its association with a temporally dragged disc and straightened temporal retinal vessels. A dragged disc if present with a colobomatous defect at the macula may strengthen the case for diagnosis of macular coloboma and help exclude other differentials.