Intrascleral intraocular lens fixation with ab interno trabeculotomy in patients with exfoliation glaucoma with lens subluxation.

PURPOSE: To evaluate the surgical outcomes of intrascleral intraocular lens (IOL) fixation using ab interno trabeculotomy (LOT) in patients with exfoliation glaucoma with lens subluxation. STUDY DESIGN: Retrospective case series. METHODS: Twenty eyes of 18 patients with exfoliation glaucoma and lens or IOL subluxations were included. Three success criteria were based on postoperative intraocular pressure (IOP) (A, ≤15 mmHg; B, ≤18 mmHg; C, ≤21 mmHg). The IOP, number of glaucoma medications, and visual acuity were compared before and after surgery. Success probability was analyzed using Kaplan-Meier survival curves. Cox proportional hazards' regression models were used to examine prognostic factors for surgical failure. RESULTS: The mean follow-up period was 23.4 ± 7.8 months. The mean IOP significantly decreased from 23.2 ± 6.8 mmHg preoperatively to 14.0 ± 4.4 mmHg at 1 year postoperative (P<0.001). Postoperative hyphema and vitreous hemorrhage were observed in seven and 15 eyes, respectively, and washout in the anterior chamber or vitreous cavity was performed in four eyes. Postoperative IOP spikes and hypotony were observed in four eyes each. Glaucoma reoperation was performed in two eyes. The success rates at 12 months were 65%, 85%, and 90% using criteria A, B, and C, respectively. The IOP at 1 month after surgery was a significant prognostic factor for surgical failure according to criterion A (hazard ratio: 1.08; P=0.034). CONCLUSION: Intrascleral IOL fixation combined with microhook LOT is a promising option in cases of exfoliation glaucoma with subluxated lens/IOL; however, the high rate of postoperative hyphema and vitreous hemorrhage should be noted.

A novel bleb revision technique: lining with tenon's patch graft for treatment of large, ischemic, leaking blebs with severe conjunctival scarring after trabeculectomy.

PURPOSE: We report a new bleb lining technique with Tenon's patch graft for late-onset leakage from large ischemic bleb with severe conjunctival scarring and impractical conjunctival mobilization after trabeculectomy. STUDY DESIGN: Retrospective case series. METHODS: This study includes six cases with late-onset leakage from large ischemic blebs. Small Tenon's tissue is dissected from the incisional site or a previously made inferior incision for Tenon's anesthesia. A passage is created from the small incision to the leaking area of the bleb using a bleb knife or micro scissors. The Tenon's tissue, stained with indocyanine green, is inserted under the ischemic bleb's conjunctiva. A transconjunctival compression suture is placed across the leaking point to fix the Tenon patch graft positionally. RESULTS: In all cases, bleb leakage was completely sealed immediately after surgery. In 4 cases, the closure of the bleb leakage was maintained after surgery during the follow-up period (6-17 months). In two cases, bleb leakage recurred from different leaking points 7 or 9.5 months after the surgery; however, repeated tenon's patch lining revisions successfully closed these leakages. The intraocular pressure at the final visit was 5-13 mmHg (median, 10 mmHg) without glaucoma medication or additional glaucoma surgery. CONCLUSION: Tenon's patch-lining technique is a promising method for bleb leakage with large ischemic bleb and impractical conjunctival mobilization.

Parapapillary choroidal microvasculature dropout in eyes with primary open-angle glaucoma.

The purpose of this study was to evaluate how various parameters are related to microvasculature dropout (MvD) area measured using optical coherence tomography angiography (OCTA). We measured the area of MvD in 55 patients with primary open-angle glaucoma (POAG). Using OCTA, MvD area and peripapillary choroidal atrophy (PPA) area were assessed in a 4.5 mm × 4.5 mm region. The following were examined: circumpapillary nerve fiber layer (cpRNFL) thickness, optic disc area, optic disc cupping area, optic disc rim area, Humphrey Field Analyzer (HFA) 24/10-2 mean deviation (MD), and pattern standard deviation (PSD). The relationship between MvD area and each parameter was evaluated using Spearman's rank correlation coefficient analysis. Mean MvD area and PPA area were 0.18 ± 0.17 mm2 and 1.13 ± 0.72 mm2, respectively. MvD area was significantly correlated with optic disc rim area (p = 0.0017), cpRNFL (p = 0.0027), HFA 24/10-2 MD, and PSD (p < 0.001). In eyes with POAG, MvD area indicates the severity of glaucoma, which might be associated with structural changes in the peripapillary vasculature around the optic disc.

Relationship between Inter-Eye Asymmetries in Corneal Hysteresis and Visual Field Severity in Patients with Primary Open-Angle Glaucoma.

This study investigated the influence of asymmetric corneal hysteresis (CH) on asymmetric visual field impairment between right and left eyes in patients with primary open-angle glaucoma (POAG) without a history of intraocular surgery. CH, corneal resistance factor (CRF), and corneal compensated intraocular pressure (IOPcc) were measured using the Ocular Response Analyzer. Differences between the eyes (right eye-left eye: DIFRL) and CH-based and in target parameters (higher CH eye-lower CH eye: DIFCH) were calculated in the same patient. In 242 phakic eyes of 121 patients, older age (p < 0.001), lower CH (p = 0.001), and lower CRF (p = 0.007) were significantly associated with worse standard automated perimetry (SAP) 24-2 mean deviation (MD). The DIFsRL in axial length (p = 0.003), IOPcc (p = 0.028), and CH (p = 0.001) were significantly associated with the DIFRL in SAP24-2 MD, but not in central corneal thickness (CCT), Goldmann applanation tonometry (GAT) measurement, and CRF. When dividing the patients into two groups based on the median of the CH DIFsCH (0.46), the DIFsCH in CRF (p < 0.001), IOPcc (p < 0.001), CCT (p = 0.004), SAP24-2 MD (p < 0.001), and SAP10-2 MD (p = 0.010) were significantly different between the groups. Large inter-eye asymmetry in CH is an important explanatory factor for disease worsening in patients with POAG.

Efficient measurements for the dynamic range of human lightness perception.

PURPOSE: Patients with an eye disease often report nyctalopia, hemianopia, and/or photophobia. We hypothesized that such symptoms are related to the disease impacting the dynamic range of lightness perception (DRL). However, there is currently no standardized approach for measuring DRL for clinical use. We developed an efficient measurement method to estimate DRL. STUDY DESIGN: Clinical trial METHODS: Fifty-five photophobic patients with eye disease and 46 controls participated. Each participant judged the appearance of visual stimuli, a thick bar with luminance that gradually changed from maximum to minimum was displayed on uniform background. On different trials the background luminance changed pseudo-randomly between three levels. The participants repeatedly tapped a border on the bar that divided the appearance of grayish white/black and perfect white/black. We defined the DRL as the ratio between the luminance values at the tapped point of the border between gray and white/black. RESULTS: The mean DRL of the patients was approximately 15 dB, significantly smaller than that of the controls (20 dB). The center of each patient's DRL shift depending on background luminance, which we named index of contextual susceptibility (iCS), was significantly larger than controls. The DRL of retinitis pigmentosa was smaller than controls for every luminance condition. Only the iCS of glaucoma was significantly larger than controls. CONCLUSIONS: This measurement technique detects an abnormality of the DRL. The results support our hypothesis that the DRL abnormality characterizes lightness-relevant symptoms that may elucidate the causes of nyctalopia, hemeralopia, and photophobia.

Clinical Features of Patients with Exfoliation Glaucoma Requiring Surgical Intervention.

PURPOSE: To clarify the clinical features of patients with exfoliation glaucoma (XFG) requiring surgical intervention. Study Design. Retrospective study. METHODS: The study included 46 eyes from 36 XFG patients, 85 eyes from 53 primary open-angle glaucoma (POAG) patients, and 54 eyes from 35 normal-tension glaucoma (NTG) patients. Age, duration of previous glaucoma treatment, intraocular pressure, medication scores, visual function, and surgical procedure were compared among the three patient groups. RESULTS: The XFG group had the highest mean age (XFG: 75.7 ± 8.3 years, POAG: 65.8 ± 12.8 years, and NTG: 53.3 ± 12.8 years; p < 0.001) and the shortest mean duration of previous treatment with glaucoma medication (XFG: 5.1 ± 3.5 years, POAG: 8.9 ± 6.9 years, and NTG: 8.9 ± 5.9 years; p < 0.001). Intraocular pressure and medication scores were slightly higher in the XFG group than in the POAG group, although the differences were not significant. Among XFG patients, trabeculectomy was performed in 20 eyes from 16 patients (55.6%) and trabeculotomy was performed in 16 eyes from 14 patients (44.4%). Both trabeculectomy (3 eyes) and trabeculotomy (14 eyes) were performed in combination with cataract surgery. CONCLUSIONS: The XFG patients referred to our department for initial examination were older than the POAG and NTG patients, and their duration of treatment before referral was shorter. Moreover, intraocular pressure and the eye drop medication score were higher in the XFG patients. A significantly higher percentage of XFG patients required surgical intervention compared to patients with other disease types.

Estimation of the central 10-degree visual field using en-face images obtained by optical coherence tomography.

PURPOSE: To estimate the central 10-degree visual field of glaucoma patients using en-face images obtained by optical coherence tomography (OCT), and to examine its usefulness. PATIENTS AND METHODS: Thirty-eight eyes of 38 patients with primary open angle glaucoma were examined. En-face images were obtained by swept-source OCT (SS-OCT). Nerve fiber bundles (NFBs) on en-face images at points corresponding to Humphrey Field Analyzer (HFA) 10-2 locations were identified with retinal ganglion cell displacement. Estimated visual fields were created based on the presence/absence of NFBs and compared to actual HFA10-2 data. κ coefficients were calculated between probability plots of visual fields and NFBs in en-face images. RESULTS: Actual HFA10-2 data and estimated visual fields based on en-face images were well matched: when the test points of <5%, <2%, and <1% of the probability plot in total deviation (TD) and pattern deviation (PD) of HFA were defined as points with visual field defects, the κ coefficients were 0.58, 0.64, and 0.66 in TD, respectively, and 0.68, 0.69, and 0.67 in PD. In eyes with spherical equivalent ≥ -6 diopters, κ coefficients for <5%, <2%, and <1% were 0.58, 0.62, and 0.63 in TD and 0.66, 0.67, and 0.65 in PD, whereas for the myopic group with spherical equivalent < -6 diopters, the values were 0.58, 0.69, and 0.71 in TD and 0.72, 0.71, and 0.71 in PD, respectively. There was no statistically significant difference in κ coefficients between highly myopic eyes and eyes that were not highly myopic. CONCLUSIONS: NFB defects in en-face images were correlated with HFA10-2 data. Using en-face images obtained by OCT, the central 10-degree visual field was estimated, and a high degree of concordance with actual HFA10-2 data was obtained. This method may be useful for detecting functional abnormalities based on structural abnormalities.

Foveal Avascular Zone Measurement Via Optical Coherence Tomography Angiography and its Relationship With the Visual Field in Eyes With Open-angle Glaucoma.

PRECIS: The foveal avascular zone (FAZ) in optical coherence tomography angiography is significantly correlated with retinal inner layer thickness, Humphrey field analyzer (HFA) 10-2 sensitivity threshold, and mean deviation (MD) value in open-angle glaucoma patients. PURPOSE: The purpose of this study was to measure the FAZ area using optical coherence tomography angiography and investigate its relationship with retinal inner layer thickness and visual field defects in eyes with open-angle glaucoma. PARTICIPANTS AND METHODS: A total of 52 eyes with open-angle glaucoma from 52 patients. FAZ area was measured using optical coherence tomography angiography in angio-macula mode. Thicknesses of retinal nerve fiber layer (RNFL), ganglion cell layer plus inner plexiform layer (GCL+IPL), and ganglion cell complex (GCC) were determined using a 7 mm×7 mm macular (V) map via 3D-OCT. Correlations of FAZ area with sensitivity threshold measurements, foveal threshold (FT), and MD value in the HFA10-2 visual field were analyzed for each inner retinal layer. RESULTS: FAZ area was 0.26±0.07 mm; overall mean thicknesses were 19.14±6.55 µm (RNFL), 57.34±5.93 µm (GCL+IPL), and 75.87±10.96 µm (GCC); mean FT was 35.23±3.15 dB, and sensitivity threshold was 20.81±7.22 dB in the HFA10-2 visual field. FAZ area was significantly correlated with the thickness of individual retinal layers in the entire field (RNFL, P<0.001; GCL+IPL, P<0.001; GCC, P<0.001), sensitivity threshold (P=0.01), FT (P<0.001), and MD value (P=0.011). CONCLUSION: FAZ area was significantly negatively correlated with retinal inner layer thickness, sensitivity threshold, FT, and MD value in the HFA10-2 visual field.

Intraoperative intraocular pressure changes during robot-assisted radical prostatectomy: associations with perioperative and clinicopathological factors.

BACKGROUND: Steep Trendelenburg position (ST) during robot-assisted radical prostatectomy (RARP) poses a risk of increase in intraocular pressure (IOP) in men receiving robot-assisted radical prostatectomy (RARP). The aim of the study was to identify clinicopathological factors associated with increased IOP during RARP. METHODS: We prospectively studied 59 consecutive prostate cancer patients without glaucoma. IOP was measured at 6 predefined time points before, during and after the operation (T1 to T6). RESULTS: Compared with T1, IOP decreased after beginning of anesthesia(T2) (by - 6.5 mmHg, p < 0.05), and increased 1 h after induction of pneumoperitoneum in the steep Trendelenburg position (ST) (T3) (+ 7.3 mmHg, p < 0.05). IOP continued to increase until the end of ST (T4) (+ 10.2 mmHg, p < 0.05), and declined when the patient was returned to supine position under general anesthesia (T5) (T1: 20.0 and T5: 20.1 mmHg, p above 0.05). The console time affected the elevation of IOP in ST; IOP elevation during ST was more prominent in men with a console time of ≥4 h (n = 39) than in those with a console time of < 4 h (n = 19) (19.8 ± 6.3 and 15.4 ± 5.8 mmHg, respectively, p < 0.05). Of the 59 patients, 29 had a high baseline IOP (20.0 mmHg or higher), and their IOP elevated during ST was also reduced at T5 (T1: 22.6 and T5: 21.7 mmHg, p above 0.05). There were no postoperative ocular complications. CONCLUSIONS: Console time of < 4 h is important to prevent extreme elevation of IOP during RARP. Without long console time, RARP may be safely performed in those with relatively high baseline IOP.

Optical coherence tomography angiography of the peripapillary capillaries in primary open-angle and normal-tension glaucoma.

OBJECTIVES: To evaluate the vascular architecture of the radial peripapillary capillaries (RPCs) and its relation with visual function in patients with open-angle glaucoma (OAG) and normal-tension glaucoma using spectral-domain optical coherence tomography (SD-OCT) angiography. SUBJECTS AND METHODS: Clear OCT angiography images of blood vessels in the optic disc and peripapillary retina were obtained from 52 patients (52 eyes) aged 55.42±10.64 (range 28-72) years with primary OAG. The mean spherical equivalent was -3.19±2.31 diopters, and the mean deviation (MD) of the central 24/30-2 threshold test using the Humphrey Field Analyzer (HFA) was -10.47±7.99 dB. The correlations between the disappearance angle of the RPCs on OTC images, flow density (FD) and the circumpapillary retinal nerve fiber layer (cpRNFL) thickness, the angle of retinal nerve fiber layer (RNFL) defect, the MD and pattern standard deviation (PSD) values of the HFA central 24/30-2 threshold test using the Swedish interactive thresholding algorithm, the sensitivity threshold, age, corneal thickness, and refractive value were analyzed. In addition, the correlation between FD and the cpRNFL thickness was analyzed at FD measurement points. RESULTS: FD was significantly correlated with cpRNFL thickness, PSD value, MD value, and sensitivity threshold, whereas the disappearance angle of the RPCs was significantly correlated with the angle of the RNFL defect (P<0.001), MD value (P<0.01), and sensitivity threshold (P<0.01). There was a negative correlation between FD and age (P<0.05). The Pearson correlation coefficient of FD and cpRNFL thickness in the area surrounding the optic disc revealed the most significant correlation in the inferior visual field (r = 0.851, P<0.001), followed by the superior visual field (r = 0.803, P<0.001) and then the temporal visual field (r = 0.653, P<0.001). CONCLUSION: SD-OCT angiography enabled thorough observation of the RPCs. FD and the disappearance angle of the RPCs were significantly and independently correlated with glaucoma-related functional and morphological changes in the optic nerve, suggesting that these two factors are novel functional and morphological indicators of visual defects due to glaucoma.

Rate of progression of total, upper, and lower visual field defects in patients with open-angle glaucoma and high myopia.

PURPOSE: We evaluated the rate of progression of total, upper, and lower visual field defects in patients with treated primary open-angle glaucoma (POAG) with high myopia (HM). SUBJECTS AND METHODS: Seventy eyes of 70 POAG patients with HM [≤-8 diopters (D)] were examined. The mean deviation (MD) slope and the upper and lower total deviation (upper TD, lower TD) slopes of the Humphrey Field Analyzer were calculated in patients with high-tension glaucoma (HTG) (>21 mmHg) versus normal-tension glaucoma (NTG) (≤21 mmHg). The mean age of all the patients (29 eyes with HTG and 41 eyes with NTG) was 48.5 ± 9.6 years. The MD slope, and upper and lower TD slopes of the HM group were compared to those of the non-HM group (NHM) (>-8 D) selected from 544 eyes in 325 age-matched POAG patients. In all, 70 eyes with HM and NHM were examined. RESULTS: The mean MD slope was -0.33 ± 0.33 dB/year in the HM, and -0.38 ± 0.49 dB/year in the NHM. There were no statistical differences between the HM and NHM (p = 0.9565). In the comparison of HTG versus NTG patients in both groups, the MD slope, and upper and lower TD slopes were similar. CONCLUSIONS: The rate of progression of total, upper, and lower visual field defects was similar among patients with HM and NHM. Although HM is a risk factor for the onset of glaucoma, HM may not be a risk factor for progression of visual field defects as assessed by the progression rate under treatment.

Effect on intraocular pressure of switching from latanoprost and travoprost monotherapy to timolol fixed combinations in patients with normal-tension glaucoma.

Purpose. To evaluate the effect on intraocular pressure (IOP) of switching from latanoprost and travoprost monotherapy to timolol fixed combinations in Japanese patients with normal-tension glaucoma (NTG). Methods. 27 NTG patients (54 eyes) were compared IOP, superficial punctuate keratitis (SPK) scores, and conjunctival injection scores in eyes treated with prostaglandin (PG) or PG analog/beta-blocker (PG/b) fixed-combination 6 months after the change in therapy. Results. The mean baseline intraocular pressure was 17.4 ± 1.59 mmHg in eyes receiving PG therapy only and 17.4 ± 1.69 mmHg in eyes switched to PG/b. Switching to fixed combination therapy from PG monotherapy, the mean IOP was 13.1 ± 1.79 mmHg (P < 0.001) (-24.71% reduction from baseline) at 6 months. The mean conjunctival injection score was 0.69 for eyes on PG monotherapy and 0.56 for eyes on fixed combination therapy (P = 0.028). The mean SPK scores were 0.46 and 0.53. This difference was not statistically significant (P = 0.463). Conclusions. Switching from PG monotherapy to PG/b fixed combination therapy for NTG resulted in a greater intraocular pressure reduction than PG alone without increasing the number of instillations.

Evaluation of the new digital goldmann applanation tonometer for measuring intraocular pressure.

Purpose. To compare a new digital Goldmann applanation tonometer (dGAT) that measures intraocular pressure (IOP) in 0.1 mmHg increments to a standard Goldmann applanation tonometer (sGAT). Methods. This study included 116 eyes of 60 subjects. A single examiner first measured IOP in triplicate using either sGAT or dGAT, which was randomly chosen. After a 5-minute interval, the next set of three consecutive IOP was measured using the other GAT. Results. The mean IOP measured with sGAT was 16.27 ± 6.68 mmHg and 16.35 ± 6.69 mmHg with dGAT. Pearson's correlation coefficient was 0.998 (P < 0.01). The subjects were divided into three groups based on the mean IOP: IOP < 14 mmHg, 14-20 mmHg, or >20 mmHg. The Pearson's correlation coefficient within each group was 0.935, 0.972, and 0.997 (P < 0.01), respectively. The difference within the three consecutive IOP measurements (maximum-minimum) for dGAT (0.72 ± 0.34 mmHg) was significantly smaller than those with sGAT (0.92 ± 0.42 mmHg, P < 0.01). Even in patients with equal IOP (zero left-right difference) with sGAT (n = 30), dGAT detected IOP differences between the left and right eyes (0.47 ± 0.31 mmHg). Conclusion. Compared to sGAT, dGAT measurements are highly reproducible and less variable.