A Health-Related Quality of Life Measure for Patients Who Undergo Minimally Invasive Glaucoma Surgery.

PURPOSE: To develop a patient-reported outcome measure to assess the impact of glaucoma and treatment, including minimally invasive glaucoma surgery (MIGS). DESIGN: Observational study before and after concomitant cataract and Food and Drug Administration-approved implantable MIGS device surgery. SETTING: Survey administration was on a computer, iPad, or similar device. PATIENT POPULATION: 184 adults completed the baseline survey, 124 a survey 3 months after surgery, and 106 the 1-month test-retest reliability survey. The age range was 37 to 89 (average age = 72). Most were female (57%), non-Hispanic White (81%), and had a college degree (56%). MAIN OUTCOME MEASURES: The Glaucoma Outcomes Survey (GOS) assesses functional limitations (27 items), vision-related symptoms (7 items), psychosocial issues (7 items), and satisfaction with microinvasive glaucoma surgery (1 item). These multiple-item scales were scored on a 0 to 100 range, with a higher score indicating worse health. RESULTS: Internal consistency reliability estimates ranged from 0.75 to 0.93, and 1-month test-retest intraclass correlations ranged from 0.83 to 0.92 for the GOS scales. Product-moment correlations among the scales ranged from 0.56 to 0.60. Improvement in visual acuity in the study eye from baseline to the 3-month follow-up was significantly related to improvements in GOS functional limitations (r = 0.18, P = .0485), vision-related symptoms (r = 0.19, P = .0386), and psychosocial concerns (r = 0.18, P = .0503). Responders to treatment ranged from 17% for vision-related symptoms to 48% for functional limitations. CONCLUSIONS: This study supports using the GOS for ophthalmic procedures such as MIGS. Further evaluation of the GOS in different patient subgroups and clinical settings is needed.

Addressing Glaucoma in Myopic Eyes: Diagnostic and Surgical Challenges.

Epidemiological and genetic studies provide strong evidence supporting an association between myopia and glaucoma. The accurate detection of glaucoma in myopic eyes, especially those with high myopia, remains clinically challenging due to characteristic morphologic features of the myopic optic nerve in addition to limitations of current optic nerve imaging modalities. Distinguishing glaucoma from myopia is further complicated by overlapping perimetric findings. Therefore, longitudinal follow-up is essential to differentiate progressive structural and functional abnormalities indicative of glaucoma from defects that may result from myopia alone. Highly myopic eyes are at increased risk of complications from traditional incisional glaucoma surgery and may benefit from newer microinvasive glaucoma surgeries in select cases.

Vision rehabilitation in glaucoma patients.

PURPOSE OF REVIEW: Vision rehabilitation services are important but underutilized resources for patients with glaucoma. Glaucoma and its impact on vision can affect patients' abilities to read and drive, two activities of daily living that are associated with quality of life and functional independence. In this review, we provide an overview of low vision, discuss barriers to vision rehabilitation, and outline various strategies and interventions to optimize visual function and quality of life in patients with glaucoma. RECENT FINDINGS: Studies have shown that glaucoma negatively impacts reading, driving and overall quality of life. Decreased visual acuity, visual field loss and reduced contrast sensitivity play a role. Low vision services and interventions can help patients maximize visual function and improve their quality of life. Barriers to receiving these services exist at multiple levels and an increased awareness and integration into routine ophthalmic care are needed to deliver comprehensive care. SUMMARY: Glaucoma is one of the leading causes of low vision. Ophthalmologists who treat glaucoma often tend to focus on objective measures to monitor progression and disease severity, but the functional impact of glaucoma should also be addressed. Low vision services can benefit patients, particularly for reading and driving, and should be considered as an essential component of patient care.

Cataract surgery in myopic eyes.

PURPOSE OF REVIEW: We discuss the preoperative, intraoperative, and postoperative considerations for cataract surgery in eyes with high myopia. We also reviewed the recent literature on refractive outcomes and complications of cataract surgery in myopic eyes. RECENT FINDINGS: Several novel intraocular lens (IOL) power calculation formulas have recently been developed to optimize refractive outcomes. Haigis formula is the most accurate among the third-generation IOL formulas. Novel formulas such as Barrett Universal II, Kane, and modified Wang-Koch adjustment for Holladay I formula provide a better refractive prediction compared with old formulas. Intraoperatively, the chopping technique is preferred to minimize pressure on weak zonules and reduce the incidence of posterior capsule rupture. Anterior capsular polishing is recommended to reduce the risk of postoperative capsular contraction syndrome (CCS). Postoperatively, complications such as refractive surprises, intraocular pressure spikes, and CCS remain higher in myopic eyes. Only 63% of myopic patients with axial length more than 26 mm achieve a visual acuity at least 20/40 after cataract surgery, mainly because of coexisting ocular comorbidities. SUMMARY: There are multiple preoperative, intraoperative, and postoperative considerations when performing cataract surgery in myopic eyes. Further research is needed to optimize the refractive outcomes in these eyes and determine the best IOL formula. Surgeons should be adept and knowledgeable with different techniques to manage intraoperative complications.

Evaluation of Retinal Nerve Fiber Layer, Ganglion Cell-Inner Plexiform Layer, and Optic Nerve Head in Glaucoma Suspects With Varying Myopia.

PRCIS: Myopic glaucoma suspects, particularly with high myopia, experience thinning of nontemporal parameters of retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL), without change in optic nerve head (ONH) parameters. PURPOSE: The aim was to assess the effect of myopia on RNFL, GCIPL, and ONH parameters in glaucoma suspects. MATERIALS AND METHODS: Seventy-six eyes of glaucoma suspects studied with Cirrus high definition optical coherence tomography were divided into low (n=27), moderate (n=25), and high myopia (n=24) groups. Optical coherence tomography parameters were correlated with spherical equivalent (SE) and evaluated with areas under the receiver operating characteristic curve for quantifying diagnostic ability to differentiate high myopia from nonhigh myopia. RESULTS: In high myopia, SE was positively correlated with thinning of average, minimum, and nontemporal GCIPL and thinning of average and nontemporal RNFL (P<0.05 for all), but not for inferior RNFL (P=0.28). In moderate myopia, SE was correlated with thinning of inferonasal and minimum GCIPL as well as superior and inferior RNFL (P<0.05 for all). SE was not correlated with ONH parameters in moderate or high myopia (P>0.05). The largest areas under the receiver operating characteristic curve for RNFL and GCIPL parameters were for superior (0.82) and superonasal (0.80) regions, respectively, with comparable diagnostic ability (P=0.74). CONCLUSION: High myopia, in particular, is associated with thinning of average RNFL, average and minimum GCIPL, and nontemporal parameters of both RNFL and GCIPL, warranting consideration of refractive status in glaucoma suspects.

New strategies for the management of ocular surface disease in glaucoma patients.

PURPOSE OF REVIEW: Glaucoma patients commonly suffer from ocular surface disease (OSD). As treatment strategies, medications and devices for the treatment of OSD as well as glaucoma surgical approaches evolve rapidly, it is important to consider their application to these patients. RECENT FINDINGS: OSD in glaucoma patients may lead to reduced reliability of diagnostic tests, decreased medication compliance, poor surgical outcomes, and overall decreased quality of life. Chronic use of topical glaucoma medications has been linked to the development of limbal stem cell deficiency, and the role of preservatives in OSD continues to be demonstrated. Preservative free glaucoma medications as well as new anti-inflammatory agents for the treatment of OSD are now available. Omega-3 fatty acid supplementation and punctal plugs have been shown to benefit glaucoma patients with OSD. Drop burden may be reduced through the use of the new sustained-release delivery systems, selective laser trabeculoplasty, and minimally invasive glaucoma surgery. SUMMARY: There are multiple emerging strategies for managing OSD that may be applied to patients with glaucoma. With continued research and clinical experiences, we hope to better understand the multifaceted relationship between glaucoma and OSD and develop evidence-based algorithms for the management of these complex patients.

Anticlotting agents and the surgical management of glaucoma.

PURPOSE OF REVIEW: A large subset of patients with glaucoma uses anticlotting agents. No standardized guidelines currently exist for managing these agents in the specific perioperative setting of glaucoma surgery. The present review focuses on currently available anticlotting agents, their influence on hemorrhagic complications following glaucoma surgery, and management strategies for their use in the perioperative period RECENT FINDINGS: Anticlotting agents increase the risk of perioperative hemorrhagic complications following glaucoma surgery. Other factors that increase that risk have been identified as well, including the type of glaucoma surgery, preoperative intraocular pressure, postoperative hypotony, previous ocular surgeries, and race. Although general guidelines in the perioperative management of blood thinning agents exist, the best way to apply these guidelines specifically to glaucoma surgery remains unclear. SUMMARY: Blood thinners are widely used and can increase the risk of hemorrhagic complications in patients undergoing glaucoma surgery. Managing these agents in the perioperative setting is challenging and should be done in collaboration with the patient's primary care provider, hematologist, or cardiologist. Management strategies should be tailored to each individual's risk of hemorrhage versus thromboembolism. Additionally, surgical plans can be modified to help minimize hemorrhagic outcomes, especially in patients who are deemed to be at high risk for perioperative bleeding.

Use of Anti-VEGF Agents in Glaucoma Surgery.

A number of antivascular endothelial growth factor agents are currently available to treat various ocular conditions. These agents have similar, but distinct, biologic qualities and have been explored in the management of neovascular glaucoma and in glaucoma surgery. Several different delivery methods are described, and because these medications are routinely given as intraocular injections, some benefits over traditional antifibrotic medications when used in glaucoma surgery are noted. These agents effectively induce regression of anterior segment neovascularization and facilitate initial surgical management of neovascular glaucoma, but the long-term outcome of this condition remains dependent on definitive management of the underlying process. Use in trabeculectomy or tube shunt procedures for other types of glaucoma has shown promise in modulating bleb morphology but has not yet been found to be as effective as traditional antifibrotic agents. There are reports of persistently raised intraocular pressure after repeated use of the anti-VEGF agents, possibly related to frequency of injection. These medications have wide application in the field of surgical glaucoma, but a definitive role has yet to be defined.

The Ophthalmology Surgical Competency Assessment Rubric for Trabeculectomy.

PURPOSE: To produce an internationally valid tool to assess skill in performing trabeculectomy surgery. METHODS: A panel of 5 experts developed a tool for assessing trabeculectomy surgery by using a modified Dreyfus scale of skill acquisition and providing descriptors for each level of skill for each category. The tool was then reviewed by a panel of 10 international content experts for their constructive comments, which were incorporated into the final rubric tool. RESULTS: A final rubric, incorporating the suggestions of the international panel, published here as the ICO-OSCAR: Trabeculectomy. CONCLUSIONS: The tool ICO-OSCAR: Trabeculectomy has content and face validity. It can be used internationally to assess trabeculectomy surgery skill. Predictive and construct validity, and reliability are yet to be determined.

Visualization of Radial Peripapillary Capillaries Using Optical Coherence Tomography Angiography: The Effect of Image Averaging.

OBJECTIVES: To assess the effect of image registration and averaging on the visualization and quantification of the radial peripapillary capillary (RPC) network on optical coherence tomography angiography (OCTA). METHODS: Twenty-two healthy controls were imaged with a commercial OCTA system (AngioVue, Optovue, Inc.). Ten 10x10° scans of the optic disc were obtained, and the most superficial layer (50-µm slab extending from the inner limiting membrane) was extracted for analysis. Rigid registration was achieved using ImageJ, and averaging of each 2 to 10 frames was performed in five ~2x2° regions of interest (ROI) located 1° from the optic disc margin. The ROI were automatically skeletonized. Signal-to-noise ratio (SNR), number of endpoints and mean capillary length from the skeleton, capillary density, and mean intercapillary distance (ICD) were measured for the reference and each averaged ROI. Repeated measures analysis of variance was used to assess statistical significance. Three patients with primary open angle glaucoma were also imaged to compare RPC density to controls. RESULTS: Qualitatively, vessels appeared smoother and closer to histologic descriptions with increasing number of averaged frames. Quantitatively, number of endpoints decreased by 51%, and SNR, mean capillary length, capillary density, and ICD increased by 44%, 91%, 11%, and 4.5% from single frame to 10-frame averaged, respectively. The 10-frame averaged images from the glaucomatous eyes revealed decreased density correlating to visual field defects and retinal nerve fiber layer thinning. CONCLUSIONS: OCTA image registration and averaging is a viable and accessible method to enhance the visualization of RPCs, with significant improvements in image quality and RPC quantitative parameters. With this technique, we will be able to non-invasively and reliably study RPC involvement in diseases such as glaucoma.

Clinical Management of Malignant Glaucoma.

Malignant glaucoma remains one of the most challenging complications of ocular surgery. Although it has been reported to occur spontaneously or after any ophthalmic procedure, it is most commonly encountered after glaucoma surgery in eyes with prior chronic angle closure. The clinical diagnosis is made in the setting of a patent peripheral iridotomy and axial flattening of the anterior chamber. Intraocular pressure is usually elevated, but it may be normal in some cases. Although the exact etiology of this condition is not fully understood, several mechanisms have been proposed and it is thought to result from posterior misdirection of aqueous humor into or behind the vitreous. This review discusses pathophysiology, differential diagnosis, imaging modalities, and current treatment strategies for this rare form of secondary glaucoma.

Comparison of central corneal thickness measured by hand-held and desk-mounted ultrasound pachymeters in glaucoma patients.

PURPOSE: The purpose of this study was to compare the accuracy and reproducibility of central corneal thickness measured by hand-held and desk-mounted ultrasound pachymeter in glaucoma patients under treatment. METHODS: Prospective study of 65 glaucoma patients. Central corneal thickness was measured by two ultrasound pachymeters: the hand-held, portable PachPen (Accutome, Lynwood, WA), and the desk-mounted PacScan 300 (Sonomed, Lake Success, NY). RESULTS: The mean ± SD central corneal thickness was 526.5 ± 44.8 µm and 530.0 ± 44.7 µm for the hand-held and desk-mounted pachymeters, respectively (p = 0.15). Linear regression analysis revealed a slope of 0.97 with Pearson correlation coefficient of 0.96. Bland-Altman analysis showed a mean difference of measurements by both pachymeters of 3.22 µm with two standard deviations = 9.51. Both instruments showed high intraobserver correlation: 0.972 for the hand-held pachymeter and 0.993 for the desk-mounted pachymeter. CONCLUSION: Central corneal thickness measurements were comparable with the use of hand-held and desk-mounted ultrasound units in glaucoma patients with good intraobserver reproducibility.

Glaucoma in pregnancy.

PURPOSE OF REVIEW: Glaucoma management during pregnancy generates numerous therapeutic challenges and potential risks for both the patient and the fetus. Data are limited on this topic given the lack of large, prospective, and randomized clinical trials because of ethical and legal constraints in this patient population. Therefore, many ophthalmologists remain unsure about treating glaucoma during pregnancy and lactation. This review focuses on the importance of preconception planning, the natural course of intraocular pressure during pregnancy, and a discussion of various therapeutic modalities during pregnancy and lactation. RECENT FINDINGS: The risks of glaucoma medications during pregnancy are not well established for the human fetus or infant and are often inferred from animal studies. Some guidelines have been provided by the US Food and Drug Administration (FDA) about medication safety during pregnancy. Currently, brimonidine is classified as a category B medication with presumed safety based on animal studies. Other glaucoma medications (beta blockers, carbonic anhydrase inhibitors, parasympathomimetics, and prostaglandin analogues) are classified as category C medications with uncertain safety from the lack of human studies and reported adverse effects in animal studies. SUMMARY: The treatment of glaucoma during pregnancy and lactation requires careful consideration and understanding of disease status, stage of pregnancy, FDA classification and guidelines, and potential benefits and limitations of various therapeutic modalities. A multidisciplinary team approach is necessary to appropriately balance the risks and benefits of any intervention and to individualize treatment to achieve the best outcomes for both mother and fetus.

Randomized, prospective, comparative trial of EX-PRESS glaucoma filtration device versus trabeculectomy (XVT study).

PURPOSE: To compare the clinical outcomes of the EX-PRESS glaucoma filtration device placed under a partial-thickness scleral flap with trabeculectomy. DESIGN: Randomized, prospective, multicenter trial. METHODS: A total of 120 eyes in 120 subjects were analyzed, including 59 eyes treated with EX-PRESS and 61 eyes treated with trabeculectomy. Both the EX-PRESS and the trabeculectomy groups were treated intraoperatively with mitomycin C and followed postoperatively for 2 years. Surgical success was defined as 5 mm Hg ≤ intraocular pressure ≤ 18 mm Hg, with or without medications, without further glaucoma surgery. RESULTS: Mean intraocular pressure was significantly reduced compared with baseline in both groups (P < 0.001). Average intraocular pressure and number of medications were similar in both groups during follow-up, with mean intraocular pressure at 2 years after surgery of 14.7 ± 4.6 mm Hg and 14.6 ± 7.1 mm Hg in the EX-PRESS and trabeculectomy groups, respectively (P = 0.927). At 2 years after surgery, the success rate was 83% and 79% in the EX-PRESS and trabeculectomy groups, respectively (P = 0.563). Although visual acuity (logMAR) was significantly decreased on day 1 in both groups, the vision was not significantly different compared with baseline at 1 month after EX-PRESS implant (P = 0.285) and 3 months after trabeculectomy (P = 0.255). The variance of early postoperative intraocular pressure values was similar between groups on the first postoperative day but higher after trabeculectomy compared with EX-PRESS implant on day 7 (P = 0.003). The total number of postoperative complications was higher after trabeculectomy than after EX-PRESS implantation (P = 0.013). CONCLUSIONS: Mean intraocular pressures, medication use, and surgical success were similar at 2 years after treatment with the EX-PRESS device and trabeculectomy. Vision recovery between groups was also similar throughout the study, although return to baseline vision was more rapid in the EX-PRESS group. Intraocular pressure variation was lower during the early postoperative period, and postoperative complications were less common after EX-PRESS implantation compared with trabeculectomy.

Magnetic resonance imaging findings in Axenfeld-Rieger syndrome.

Axenfeld-Rieger syndrome (ARS) is a genetic disorder representing a disease spectrum resulting from neural crest cell maldevelopment. Glaucoma is a common complication from the incomplete formation of the iridocorneal angle structures. Neural crest cells also form structures of the forebrain and pituitary gland, dental papillae, aortic arch walls, genitalia, and long bones; therefore, patients with ARS manifest a wide range of systemic findings. To our knowledge, detailed magnetic resonance imaging findings have not been previously reported. We report a case of a 19-month-old Indian male diagnosed with ARS with emphasis on magnetic resonance imaging findings of the globes, brain, teeth, and skull base.

Anterior segment imaging in glaucoma.

Anterior segment imaging allows objective assessment of the anterior segment of the eye, particularly the anterior chamber angle. Both qualitative and quantitative analyses are possible and aid in detecting and managing closed-angle and open-angle mechanisms in various forms of glaucoma. This review focuses primarily on anterior segment optical coherence tomography and ultrasound biomicroscopy, with emphasis on principles of technology, commercially available devices, and clinical applications in glaucoma with potential advantages and disadvantages of each technology.

The role of the Ex-PRESS glaucoma filtration device in glaucoma surgery.

The Ex-PRESS glaucoma filtration device is a safe and effective alternative to standard trabeculectomy in the surgical management of glaucoma patients. This latest modification of glaucoma filtration surgery has been shown to be equally efficacious to trabeculectomy in lowering intraocular pressure. With its unique features of small incision surgery, consistent lumen size with more uniform filtration, and no tissue removal, this technique has been shown to reduce both intraoperative and postoperative complications. This review updates clinical outcomes of this new variation of glaucoma filtration surgery and its current role in the glaucoma surgical armamentarium.

Incidence and management of elevated intraocular pressure with antivascular endothelial growth factor agents.

PURPOSE: To review recent literature regarding ocular hypertension following intravitreal antivascular endothelial growth factors (anti-VEGF). METHOD: An electronic literature search was performed using MEDLINE, OVID, and PubMed. Key search terms were elevated IOP, anti-VEGF, sustained IOP elevation in anti-VEGF, chronic intraocular pressure elevation in anti-VEGF, high IOP with anti-VEGF, acute elevation in intraocular pressure with anti-VEGF, glaucoma and anti-VEGF. RESULT: Transient elevation of intraocular pressure after intravitreal anti-VEGF injection is due to temporary increase in volume, and the acute spike generally does not affect a healthy eye. Caution should be taken in a glaucomatous eye, and pretreatment with an IOP-lowering medication is recommended. Persistent elevation of intraocular pressure is more common than previously thought and may be correlated to several factors including increased number of intravitreal injections. CONCLUSION: Persistent ocular hypertension may be associated with intravitreal anti-VEGF injections. Physicians should be aware of this condition and monitor their patients for persistent ocular hypertension, especially in eyes with preexisting glaucoma. Prompt diagnosis and treatment can prevent potential loss of vision.

Comparison of intraocular pressure measurements and assessment of intraobserver and interobserver reproducibility with the portable ICare rebound tonometer and Goldmann applanation tonometer in glaucoma patients.

PURPOSE: The goals of our study were to analyze the correlation of rebound tonometer (RBT) and Goldmann applanation tonometer (GAT), assess the intraobserver and interobserver reproducibility of these tonometers, and investigate the influence of central corneal thickness (CCT) on intraocular pressure (IOP) measurements recorded with both tonometers in glaucoma patients under treatment. METHODS: In a prospective study of 65 eyes with glaucoma, IOP was measured using RBT and GAT, followed by measurements of CCT. RESULTS: A clear correlation between RBT and GAT was found (r=0.89, P<0.001). Bland-Altman analysis showed a mean difference of measurements by GAT and RBT of 2.45 mm Hg with 2 SD=4.24 mm Hg. Both tonometers were affected by CCT. High intraobserver correlation coefficients were found with both tonometers (0.981 and 0.979 for RBT for examiner 1 and examiner 2, respectively, and 0.989 for GAT for both examiners). Interobserver agreement appeared to be better with GAT when compared with RBT (variation coefficients were 4.6% for GAT and 7.1% for RBT). CONCLUSIONS: RBT may have a potential role and use in routine evaluation and management of glaucoma patients given its high correlation with GAT and high reproducibility in IOP measurements. As with GAT, measurements obtained with RBT are affected by CCT, reinforcing the role of pachymetry in glaucoma management.