Evaluating target intraocular pressures in primary congenital glaucoma.

Purpose: The aim of this study was to evaluate long-term intraocular pressures that provide stabilization/reversal of glaucomatous neuropathy after surgery in primary congenital glaucoma (PCG). Methods: Prospective evaluation of consecutive PCG patients who underwent trabeculectomy-trabeculotomy and followed up for ≥2 years. Records of regularly performed examination under anesthesia were maintained to ascertain intraocular pressure, (IOP), fundus, refraction and corneal diameter. Outcomes - Primary: cup: disc ratio and intraocular pressure, Secondary: corneal changes and refractive error. Results: A total of 174 eyes of 108 children with PCG had a preoperative IOP of 22.44 ± 9.5 mm Hg. Postoperative review IOP was 11.8 ± 4.5 mm Hg, cup-disc-ratio was 0.52 ± 0.23 and corneal diameter was 12.75 ± 0.9 mm. Primary outcomes: Linear regression analysis showed a significant positive correlation of review IOP with cup disc ratio, P = 0.004. 67.9%, of eyes at a review IOP range of 6-12 mm Hg showed reversal, 14.1%, were stable, at 6-15 mm Hg, while 3.84% showed an increase in cup: disc ratio 16-22 mm Hg. Patients operated before 6 months of age had a significantly smaller final cup-disc ratio, P = 0.0013. Patients with a final cup: disc ratio of >0.9 were significantly older at surgery, P < 0.001. Secondary outcomes: There was a positive correlation of final myopia with review IOP on linear regression analysis, P = 0.012. The final spherical error in eyes having cup disc ratio of ≤ 0.5 was -0.96 ± 4.5 diopters, as against -3.45 ± 7.7 diopters in eyes having cup-disc ratio of 0.6-0.8 and -3.8 ± 6.9 diopters in eyes with cup disc ratio of ≥0.9, P = 0.015. There was no significant change in corneal diameter. Conclusion: Patients operated after 6 months of age had a larger final cup: disc ratio, while postoperative review intraocular pressures over 2 years of at least ≤15 mm Hg in primary congenital glaucoma eyes, commonly lead to reversal/stability of the neuropathy, and a lower incidence and degree of myopia.

The role of clinical examination of the optic nerve head in glaucoma today.

PURPOSE OF REVIEW: The study was undertaken to assess the current importance of clinical examination of the optic nerve head (ONH) in glaucoma management. RECENT FINDINGS: ONH changes in glaucoma are easily assessed with good specificity on examination, whereas imaging has not been able to identify pallor of the neuroretinal rim (NRR), disc hemorrhages, or vascular signs of acquired cupping. Glaucomatous neuropathy in primary open angle glaucoma (POAG) has extensive databases on imaging machines, however, other glaucomas such as primary angle closure glaucoma (PACG), juvenile open angle glaucoma (JOAG), congenital, and secondary glaucomas have been reported to have a significantly different ONH morphology. Clinical evaluation with knowledge of the underlying cause of glaucoma allows easy diagnosis of any abnormality, whereas the absence of an imaging database in such eyes makes diagnosis difficult on optical coherence tomography (OCT) and so forth. In eyes with congenital anomalies and dysplastic discs, clinical examination and history provide better identification of glaucomatous damage. Staging of glaucoma on ONH examination when perimetry is unreliable provides a means of determining the amount of damage and appropriate reduction of intraocular pressure (IOP). SUMMARY: Clinical examination of the ONH is very relevant for screening, diagnosis, staging, and management of all glaucomas, and is irreplaceable in detecting nonglaucomatous causes of ONH cupping and visual field defects similar to those in glaucoma.

Trabeculectomy on Animal Eye Model for Resident Surgical Skill Training: The Need of the Hour.

Purpose: To describe a goats' eye training model for teaching of trabeculectomy and releasable suture techniques for Ophthalmology residents. Methods: A descriptive report explaining the methodology for setting up a goats' eye wet-lab model for teaching trabeculectomy for Ophthalmology residents. It details the approaches to eyeball preparation, steps of surgery, application and release of two representative types of 'releasable sutures' in a step-by-step manner. Conclusion: A systematic approach using goats' eye model to teach trabeculectomy and releasable suture techniques can enhance residents' understanding, confidence and expertise to operate upon human eyes.

Achieving low target intraocular pressures in severe glaucoma.

PURPOSE: This study aimed to assess details of therapy required to achieve an intraocular pressure (IOP) of ⩽12 mmHg in patients with severe glaucoma of different etiologies. METHODS: Patients with a follow-up of at least 1 year, who fulfilled inclusion criteria were selected, and data analyzed with respect to baseline IOP, number of medications, and/or surgeries required to achieve an IOP of ⩽12 mmHg and ⩾6 mmHg. Final IOP, visual field status and medications/surgery required were noted. RESULTS: About 127 eyes of 85 patients met all criteria. There were 48 eyes having primary angle closure glaucoma (PACG), 16 eyes with primary open angle glaucoma (POAG), 17 eyes of juvenile open angle glaucoma (JOAG), and 46 eyes of secondary glaucoma. The mean baseline IOP was 33.14 ± 11.07 mmHg and final IOP 10.25 ± 1.81 mmHg. In the age group >40 years, 29.63% of patients were controlled on medication as compared to 9.09% and 5.71% in the age group of <20 years and 20-40 years (p = 0.007). With a baseline IOP of <25 mmHg, 48.65% required a trabeculectomy, whereas for 25-30, and >30 mmHg, 62.5% and 97.29% respectively, required surgery (p < 0.001).66.67% of patients having mean deviation of -12 to -16 dB (decibels) on Humphrey field analyzer (HFA) underwent surgery to achieve target IOP in comparison to 83.52% who had mean deviation greater than -16 dB (p = 0.036). CONCLUSION: Only 21.26% of severe glaucoma eyes could be controlled on medications alone. A baseline IOP of >25 mmHg, age <40 years and mean deviation worse than -16 dB, had a higher frequency of trabeculectomies to achieve an IOP of ⩽12 mmHg.

Does TRABECULECTOMY meet the 10-10-10 challenge in PACG, POAG, JOAG and Secondary glaucomas?

PURPOSE: Evaluation of the intraocular pressure (IOP) lowering efficacy of trabeculectomies over > 10 years and their ability to stabilize glaucomatous optic neuropathy. METHODS: In total, 181 eyes (136 patients), which underwent trabeculectomy (10 min surgery) at least 10 years prior and were on regular follow-up, were evaluated. Qualified/complete success was taken as criteria A: IOP ≤ 12 mmHg, B: IOP ≤ 15 mmHg and C: IOP ≤ 18 mmHg, with all > 5 mmHg, with/without medications. Target IOP in advanced glaucoma is about 10 mmHg, therefore trabeculectomy 10-10-10 challenge! RESULTS: The mean age of patients was 46.32 ± 11.50 years. Absolute success was 50.27%, 54.14% and 59.66% according to criteria A, B and C at last follow-up, while qualified success was 70.11%, 81.77% and 96.13%. An IOP of ≤ 12 mmHg was noted in 34, 64.15%, PACG eyes, 14, 73.68%, POAG, 15, 65.22%, JOAG and 64, 74.42%, secondary glaucoma eyes. The reduction in IOP overall was 64.83 ± 16.80% at last review and was 59.47 ± 16.07% in PACG, 62.40 ± 17.72% in POAG, 71.89 ± 8.50% in JOAG and 67.74 ± 18.10% in secondary glaucoma eyes. "Target" IOP was achieved in 97.29% of early glaucoma, 85.71% moderate glaucoma and 70% severe glaucoma eyes. 97.24% of patients were perimetrically stable. 2.21% of eyes post-trabeculectomy had a shallow anterior chamber needing surgical intervention. Visual acuity was maintained or better in 93.92% of patients, with a cataract surgery performed in 6.63% eyes. A repeat trabeculectomy was performed in 3.31% of eyes. CONCLUSION: Trabeculectomy 10-10-10 is achievable in the long term, with few complications or repeat surgical interventions in the majority of POAG, PACG, JOAG and secondary glaucomas. Therefore, trabeculectomy should not be relegated to a last resort, but should be undertaken as soon as possible, if medical therapy is inadequate, unaffordable or compliance is an issue.

Clinical and ASOCT evaluations of 'bleb-sparing epithelial exchange' in paediatric and adult dysfunctional blebs over 5 years.

PURPOSE: To evaluate the long-term outcome of 'bleb-sparing epithelial exchange' surgery for dysfunctional filtering blebs in paediatric and adult eyes. METHODS: Patients who had undergone bleb revision ≥ 5 years back and were on regular follow-up were included. Age, ocular diagnosis, details of primary filtering surgery including mitomycin-C (MMC) usage, indication and year of bleb revision were recorded. After bleb revision, the mean intraocular pressure (IOP), glaucoma medications and best corrected visual acuity (BCVA) up to 5 years were noted. On last review, clinical details, bleb characteristics and swept source anterior segment tomographic (SSOCT) assessment of bleb were recorded. Comparative analysis of paediatric and adult eyes was performed. MAIN OUTCOME MEASURES: Change in IOP and BCVA. 'Complete success' was defined as IOP ≥ 6 to ≤ 18mmHg without use of any topical glaucoma medications and 'Qualified success' when ≥ 1 topical glaucoma medication(s) was required. RESULTS: A total of 51 eyes of 51 consecutive patients were studied, among which 22 were children. The mean duration between filtering surgery and bleb revision was 4.54 ± 1.53 years in paediatric and 6.48 ± 3.5 years in the adult group, p = 0.04. Children underwent trabeculotomy + trabeculectomy with 0.04% MMC, while adults underwent trabeculectomy with 0.02% MMC. The mean pre-revision IOP was 6.38 ± 2.80 and 6.51 ± 2.78 mmHg in the paediatric and adult group respectively, p = 0.86. At 3 months post-revision, it increased to 11.81 ± 3.48 and 12.75 ± 3.52 mmHg respectively (p < 0.001). At final review, mean IOP of paediatric group was 10.90 ± 2.59 and adult group was 11.86 ± 2.66 mmHg, p = 0.20. At 5 years, complete success was 68.18% and 72.41%, and qualified success was 31.87% and 27.59% in the former and latter group respectively, p = 0.49. No failures were seen. Kaplan-Meier probability at 5 years for IOP target ≤ 18, ≤ 15 and ≤ 12 in children was 95.45%, 63.64% and 50% and in adults 93.10%, 65.52% and 41.38% respectively. BCVA improved up to 1 year in paediatric group, with continued improvement in adults up to 3 years. SSOCT measured bleb height was 0.88 ± 0.37 and 1.32 ± 0.49mm in children versus adults (p = 0.006) and wall thickness, 0.35 ± 0.22 and 0.58 ± 0.24mm respectively, p = 0.008. CONCLUSION: Bleb-sparing epithelial exchange is an equally safe and effective technique with good long-term success in both paediatric and adult dysfunctional blebs.

A Novel Mathematical Model of Glaucoma Pathogenesis.

BACKGROUND: Conventional experimental approaches to understand glaucoma etiology and pathogenesis and, consequently, predict its course of progression have not seen much success due to the involvement of numerous molecular, cellular, and other moieties. An overwhelming number of these moieties at different levels combined with numerous environmental factors further complicate the intricacy. Interaction patterns between these factors are important to understand yet difficult to probe with conservative experimental approaches. METHODS: We performed a system-level analysis with mathematical modeling by developing and analyzing rate equations with respect to the cellular events in glaucoma pathogenesis. Twenty-two events were enlisted from the literature survey and were analyzed in terms of the sensitivity coefficient of retinal ganglion cells. A separate rate equation was developed for cellular stress also. The results were analyzed with respect to time, and the time course of the events with respect to various cellular moieties was analyzed. RESULTS: Our results suggest that microglia activation is among the earliest events in glaucoma pathogenesis. This modeling method yields a wealth of useful information which may serve as an important guide to better understand glaucoma pathogenesis and design experimental approaches and also identify useful diagnostic/predictive methods and important therapeutic targets. CONCLUSION: We here report the first mathematical model for glaucoma pathogenesis which provides important insight into the sensitivity coefficient and glia-mediated pathology of glaucoma. HOW TO CITE THIS ARTICLE: Faiq MA, Sidhu T, et al. A Novel Mathematical Model of Glaucoma Pathogenesis. J Curr Glaucoma Pract 2019; 13(1):3-8.

Phacomorphic glaucoma in a high myope with phakic intraocular lens.

We report a case of a young, one-eyed woman with high myopia who presented to our emergency department with sudden onset painful diminution of vision in the right eye after undergoing laser treatment. Her right eye had a phakic intraocular lens (pIOL) implantation 4 years back and her left eye had absent light perception. She was diagnosed as right eye lens induced secondary angle closure glaucoma with pIOL touching the corneal endothelium and left eye atrophic bulbi. She was admitted under eye emergency for medical intraocular pressure control followed by pIOL explantation with lens aspiration of the cataractous lens and posterior chamber intraocular lens implantation.

Meditation enhances brain oxygenation, upregulates BDNF and improves quality of life in patients with primary open angle glaucoma: A randomized controlled trial.

BACKGROUND: Glaucoma (POAG) is a kind of neurodegenerative disease known to be closely associated with stress and adverse quality of life (QOL). Stress has also been shown to be involved in etiopathogenesis of primary open angle glaucoma (POAG). Complementary treatment in form of Meditation has been reported to improve QOL, brain oxygenation and decrease markers of stress. With this premise, a randomized controlled trial was carried out to assess the effect of Meditation on intraocular pressure, subjective QOL and objective markers of stress and brain oxygenation in patients with POAG. METHODS: Sixty patients were randomized into intervention and control groups. Intervention group underwent 45 minutes of Meditation daily for 6 weeks in addition to standard medical treatment while controls received only standard medical treatment. Inclusion criteria were patients with POAG, age >45 years, best corrected visual acuity >6/60. Patients with other ocular co-morbid conditions contributing to vision loss, systemic diseases, patients already practicing meditation in any form were excluded. An assessment of IOP, brain oxygenation using functional near infrared spectroscopy (fNIRS), QOL (WHO-BREF QOL) and stress markers in serum (cortisol, ß-endorphins, interleukin-6, brain derived neurotrophic factor (BDNF), reactive oxygen species) was made at baseline and at 6 weeks. RESULTS: 21 female and 39 male patients were enrolled with a mean age of 57.28±9.37 years. All parameters were comparable between two groups at baseline. At 6 weeks mean level of IOP decreased significantly in intervention group (15.9±1.8 mmHg to 14.4±1.21 mm Hg, p-value 0.0001) as compared to control group (15.7±1.4 mmHg to 15.65±1.41, p-value 0.41). fNIRS showed significant improvement in oxygenated hemoglobin change (ΔHbO) in intervention group in the prefrontal cortex (p-value <  0.0001) as compared to control group (p-value 0.52). WHO-BREF QOL score increased significantly in intervention group (86.6±6.16 to 93.3±5.66, p-value 0.0001) as compared to control (89±7.25 to 89.07±3.24, p-value 0.74).Mean serum cortisol decreased significantly in intervention group (497±46.37 ng/ml to 447±53.78 ng/ml, p-value 0.01) as compared to control group (519.75±24.5 to 522.58±26.63 ng/ml, p-value 0.64). Mean ß-endorphin levels increased significantly (33±5.52pg/ml to 43.27pg/ml, p-value <  0.0001) as compared to control group (34.78±4.1pg/ml to 36.33pg±4.07pg/ml p-value 0.27). Interleukin-6 decreased significantly in intervention group (2.2±0.5 ng/ml to 1.35±0.32 ng/ml, p-value <  0.0001) as compared to control group (2.03±0.37 to 2.17±0.34 ng/ml p-value 0.25). BDNF increased significantly in intervention group (52.24±6.71 to 63.25±13.48 ng/ml p-value 0.004) as compared to control group (53.23±5.82 to 54.42±5.66 ng/ml p-value 0.54). ROS decreased significantly in intervention group (1596.19±179.14 to 1261±244.31 RLU/min/104 neutrophils p-value 0.0001) as compared to control group (1577.5±172.02 to 1662.5±84.75 RLU/min/104 neutrophils p-value 0.16). CONCLUSIONS: A short term course of Meditation was associated with significant improvement in brain oxygenation and QOL along with a reduction in IOP and stress markers. Meditation may be a useful as an adjunct to standard treatment in patients with POAG and potentially decrease the risk of glaucoma progression.

Systemic Associations of Childhood Glaucoma: A Review.

PURPOSE: To review systemic associations of childhood glaucoma. METHODS: Patients younger than 15 years and diagnosed as having glaucoma were divided into four groups: isolated primary congenital glaucoma, glaucoma with other congenital ocular anomalies, congenital glaucoma with known systemic diseases, and secondary glaucoma. Prevalence and type of systemic associations in each group were studied. RESULTS: A retrospective analysis of 371 patients diagnosed as having glaucoma was done. In the primary congenital glaucoma group, 13 of 218 (5.9%) patients had an associated systemic illness: congenital heart disease and global developmental delay were the most common systemic manifestations. In the congenital ocular anomalies group, 10 of 63 (15.8%) patients had an associated systemic illness. Axenfeld-Reiger syndrome, aniridia, and Peters' anomaly frequently had systemic comorbidities with congenital heart disease. In the known systemic diseases group, all 18 (100%) patients had systemic manifestations of an associated syndrome: Sturge-Weber and Down syndrome were the most frequent. In the secondary glaucoma group, 9 of 72 (12.5%) patients had systemic involvement, which was often seen as the most common cause after congenital cataract surgery. These children had congenital heart disease and global developmental delay as a consequence of congenital rubella and congenital cytomegalovirus infection. CONCLUSIONS: The study found that 12.9% of patients with childhood glaucoma had an associated systemic abnormality. Patients with congenital glaucoma and other ocular anomalies have a three times higher risk of an underlying systemic anomaly than patients with isolated primary congenital glaucoma. A team comprising an ophthalmologist, pediatrician, and anesthesiologist is recommended to treat these cases. [J Pediatr Ophthalmol Strabismus. 2018;55(6):397-402.].

Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial.

BACKGROUND: Reducing intraocular pressure (IOP) in primary open-angle glaucoma (POAG) is currently the only approach to prevent further optic nerve head damage. However, other mechanisms such as ischemia, oxidative stress, glutamate excitotoxicity, neurotrophin loss, inflammation/glial activation, and vascular dysregulation are not addressed. Because stress is a key risk factor affecting these mechanisms, we evaluated whether mindfulness-based stress reduction can lower IOP and normalize typical stress biomarkers. MATERIALS AND METHODS: In a prospective, randomized trial 90 POAG patients (180 eyes; age above 45 y) were assigned to a waitlist control or mindfulness meditation group which practiced daily for 21 days. We measured IOP (primary endpoint), quality of life (QOL), stress-related serum biomarkers [cortisol, ß-endorphins, IL6, TNF-α, brain-derived neurotrophic factor (BDNF), reactive oxygen species (ROS), total antioxidant capacity (TAC)], and whole genome expression. RESULTS: Between-group comparisons revealed significantly lowered IOP in meditators (OD: 18.8 to 12.7, OS 19.0 to 13.1 mm Hg) which correlated with significantly lowered stress-biomarker levels including cortisol (497.3 to 392.3 ng/mL), IL6 (2.8 to 1.5 ng/mL), TNF-α (57.1 to 45.4 pg/mL), ROS (1625 to 987 RLU/min/104 neutrophils), and elevated ß-endorphins (38.4 to 52.7 pg/mL), BDNF (56.1 to 83.9 ng/mL), and TAC (5.9 to 9.3) (all P<0.001). These changes correlated well with gene expression profiling. Meditators improved in QOL (P<0.05). CONCLUSIONS: A short course of mindfulness-based stress reduction by meditation in POAG, reduces IOP, improves QOL, normalizes stress biomarkers, and positively modifies gene expression. Mindfulness meditation can be recommended as adjunctive therapy for POAG.

Is combined mechanism glaucoma a distinct entity?

PURPOSE: Primary adult glaucomas that have an occludable angle with peripheral anterior synechiae which are too few to account for the chronically raised IOP, or the glaucomatous optic neuropathy, do not fit the definition of either POAG or PACG and can be considered as combined mechanism glaucoma (CMG). We aimed to compare the clinical features and anatomical parameters of combined mechanism glaucoma with age, sex, and refraction-matched POAG and chronic PACG eyes. METHODS: Consecutive adult patients with definitive optic nerve head and perimetric changes of glaucoma were screened at a tertiary care center. All glaucomatous eyes having an IOP > 22 mmHg on at least three separate occasions and glaucomatous optic neuropathy consistent with moderate visual field loss in the eye were divided as POAG, PACG, and CMG. Eyes with occludable angles having < 90° of goniosynechiae were diagnosed as CMG. A detailed clinical examination, ocular biometry, and ASOCT were performed in the better eye of all individuals. RESULTS: A total of 93 patients with similar visual field index or pattern standard deviation on perimetry were evaluated: 32 POAG, 31 CMG, and 30 PACG. The mean anterior chamber depth was 3.47 ± 0.37 mm in POAG, 2.81 ± 0.32 mm in PACG, and 3.06 ± 0.26 mm in CMG (p < 0.0001). Mean lens thickness was 4.22 ± 0.27 mm in POAG, 4.53 ± 0.35 mm in PACG, and 4.44 ± 0.29 mm in CMG (p = 0.0004). Iridotrabecular contact on ASOCT was nil in POAG, a mean of 87.60 ± 12.802% in PACG eyes, and 15.23 ± 14.19% in CMG eyes, p < 0.0001. CMG was similar to PACG in terms of corneal diameters and lens thickness and had an axial length in between PACG and POAG. On ASOCT, all parameters had highest values in POAG eyes and the least in PACG eyes, with CMG eyes having values in between the other two groups, p value of < 0.0001 between each group for all parameters. CONCLUSION: This study has demonstrated significantly different anatomical parameters in eyes with CMG, in addition to the differences on gonioscopy and iridotrabecular contact, indicating that CMG is discernibly dissimilar to PACG and POAG.

Prospective Randomized Trial Comparing Mitomycin C Combined with Ologen Implant versus Mitomycin C Alone as Adjuvants in Trabeculectomy.

PURPOSE: Comparative evaluation of trabeculectomy with mitomycin C (MMC) versus trabeculectomy with MMC plus Ologen (Aeon Astron Europe, Leiden, The Netherlands). DESIGN: Prospective, randomized, comparative study. PARTICIPANTS: Fifty eyes of 50 patients with primary open-angle glaucoma or pseudophakic primary angle-closure glaucoma were recruited. METHODS: Twenty-five eyes underwent trabeculectomy with low-dose MMC alone (0.1 mg/ml for 1 minute; MMC group) and 25 eyes underwent trabeculectomy with low-dose MMC plus Ologen (Ologen group) at a tertiary eye care center. Only patients with minimum follow-up of 12 months were included in the study. MAIN OUTCOME MEASURES: Percentage reduction in intraocular pressure (IOP). Secondary outcome measures included percentage of patients achieving absolute and qualified success for IOP of less than 15 mmHg and less than 18 mmHg, bleb morphological features, need for antiglaucoma medications, and rate of complications. RESULTS: The mean preoperative IOP was 25.96±4.82 mmHg and 26.32±4.27 mmHg in the MMC and Ologen groups, respectively (P = 0.81). Mean postoperative IOP at 12 months was 11.33±3.18 mmHg in the MMC group and 14.35±3.34 mmHg in the Ologen group (P < 0.001 at all visits in both the groups). Significantly higher IOP reduction was noted in the MMC group at both 6 months (56.9% vs. 47.1%; P = 0.035) and 12 months (55% vs. 44.2%; P = 0.019). Cumulative success (absolute plus qualified success) was achieved in 86.3% of eyes in the MMC group compared with 73.9% of eyes in the Ologen group (P = 0.46) when IOP of 15 mmHg or less was considered as the definition of success. CONCLUSIONS: The addition of a biodegradable collagen implant (Ologen) does not improve efficacy of MMC-augmented trabeculectomy in primary adult glaucomas.

Effect of phacoemulsification on measurement of retinal nerve fiber layer and optic nerve head parameters using spectral-domain-optical coherence tomography.

PURPOSE: The purpose of this study is to determine the effect of phacoemulsification cataract extraction on measurement of retinal nerve fiber layer and optic nerve head parameters using spectral domain optical coherence tomography. MATERIAL AND METHODS: A prospective, hospital-based study of 100 patients of 40 years of age and above, with no other ocular morbidity except cataract and planned for phacoemulsification with IOL implantation (SN60WF) at a tertiary centre at AIIMS, New Delhi, India. All patients underwent imaging with Cirrus SD-OCT model 400 and the optic disc cube 200x200 protocol at baseline and at 1 month follow up. Paired sample t-test was used to compare the RNFL parameters and ONH parameters. RESULTS: The mean age of subjects was 56.6 ± 12.3 years (70 males, 30 females). The average RNFL increased from 92.6 ± 5.4 µm to 101.3 ± 5.6 µm after phacoemulsification, an increase of 9% (P = 0.003) and the signal strength increased from 5.6 ± 0.5 to 7.6 ± 0.7, increasing by 35.7% (P = 0.004). There was a significant increase in the disc area (P = 0.004) and rim area (P = 0.004) but no significant change in vertical cup-disc ratio (P = 0.45) or average cup-disc ratio (P = 0.075). The quadrant-wise RNFL thickness increase in inferior, superior, nasal, and temporal quadrants was 12.6% (P = 0.001), 10% (P = 0.001), 5.6% (P = 0.001), and 3.2% (P = 0.001), respectively. The change in RNFL thickness was maximum in posterior subcapsular cataract (P = 0.001) followed by cortical (P = 0.001) and nuclear (P = 0.001) subtypes. CONCLUSIONS: A significant increase in RNFL thickness and signal strength was observed after cataract surgery using SD-OCT. The maximum change in RNFL thickness was in the inferior quadrant, where RNFL thinning is a significant predictor of glaucoma progression. The posterior subcapsular cataract interfered with RNFL measurement maximally due to its density and proximity to nodal point. After the cataract surgery, a new baseline needs to be established by obtaining fresh OCT images for assessing the longitudinal follow-up of a glaucoma patient.

Randomized Trial on Illuminated-Microcatheter Circumferential Trabeculotomy Versus Conventional Trabeculotomy in Congenital Glaucoma.

PURPOSE: To compare 1-year outcomes of illuminated microcatheter-assisted circumferential trabeculotomy (IMCT) vs conventional partial trabeculotomy (CPT) for primary congenital glaucoma (PCG). DESIGN: Randomized clinical trial. METHODS: Forty eyes of 31 patients with unilateral or bilateral primary congenital glaucoma aged less than 2 years were randomized to undergo IMCT (20 eyes) or CPT (20 eyes). Primary outcome measure was intraocular pressure (IOP) reduction. The success criterion was defined as IOP ≤ 12 mm Hg without and with antiglaucoma medications (absolute success and qualified success, respectively). RESULTS: The mean age of our study population was 8.35 ± 1.2 months. The mean preoperative IOP was 24.70 ± 3.90 mm Hg in the IMCT group and 24.60 ± 3.31 mm Hg in the CPT group. Both groups were comparable with respect to preoperative IOP, corneal clarity, corneal diameter, vertical cup-to-disc ratio, and refractive error. In the IMCT group, 360-degree cannulation was achieved in 80% (16/20) of eyes. For the IMCT group and CPT groups, respectively, the absolute success rates were 80% (16/20) and 60% (12/20) (P < .001) and qualified success rates were 90% (18/20) and 70% (14/20) (P < .001). Both procedures produced a statistically significant reduction in IOP, and eyes undergoing IMCT achieved a lower IOP than CPT group eyes at 12 months follow-up (9.5 ± 2.4 mm Hg and 11.7 ± 2.1 mm Hg, respectively, P < .001). CONCLUSION: In primary congential glaucoma, illuminated microcatheter-assisted 360-degree circumferential trabeculotomy performed better than conventional partial trabeculotomy at 1 year follow-up and resulted in significantly lower IOP measurements.

Innovations in glaucoma surgery from Dr. Rajendra Prasad Centre for Ophthalmic Sciences.

Trabeculectomy surgery is the current standard of care in glaucoma for achieving a low target intraocular pressure if medical therapy is not adequate. Augmentation of trabeculectomy with antimetabolites brought a revolutionary change in the long-term success rates of trabeculectomy, but along with it came a plethora of complications. There still is a big window for therapeutic innovations on this subject. The foremost target for these innovations is to modulate the wound healing response after glaucoma drainage surgery. Achieving the desired balance between long-term success of filtering blebs versus early failure due to scarring of blebs and hypotony due to dysfunctional filtering blebs poses a unique challenge to the ophthalmologists. Alternatives to trabeculectomy such as glaucoma drainage devices and minimally invasive glaucoma surgeries cannot solve the problem of glaucoma blindness in our country, mainly due to their unpredictable results and unfavorable cost-benefit ratio. In this article, we present a summary of our innovations in glaucoma surgery to advance patient care by making it more effective, safer, and economical.

Prognosis of different glaucomas seen at a tertiary center: A 10-year overview.

AIM: This study aims to determine treatment patterns, long-term intraocular pressure (IOP) and perimetric control in different glaucomas seen at a tertiary eye center. SETTINGS AND DESIGN: Hospital-based, cross-sectional chart review of patients routinely following up at an outpatient glaucoma service. METHODS: Patients with a follow-up of at least 10 years were evaluated. Their mean IOP, visual field (VF) status, and medications/surgery required at final assessment were noted. STATISTICAL ANALYSIS: Descriptive statistics (mean, standard deviation, and range) were used for all parameters. RESULTS: A total of 230 patients met our inclusion and exclusion criteria, 79 having ocular hypertension with open angles or primary angle closure (PAC), 35 primary open angle glaucoma (POAG), 50 PAC glaucoma (PACG), 20 primary congenital glaucoma (PCG), 46 secondary glaucoma patients. Ocular hypertensives with open angles showed progression to POAG in 3.7%, those with PAC in 5.2%, at a mean IOP of 17.3 ± 3.37 mmHg and 17.13 ± 4.41 mmHg, respectively. A progression on Humphrey Field Analyzer was seen in 11% of POAG and PACG eyes at a mean IOP of 13.50 ± 5.07 and 13.09 ± 3.95 mmHg, respectively. Fifteen percent of primary congenital glaucomas (PCGs) showed a glaucomatous VF defect after 10 years. In secondary glaucoma eyes, the mean IOP at last follow-up visit was 12.38 ± 3.74 mmHg, with progression noted in 7.69% of eyes. CONCLUSION: This study provides evidence that routine delivery of care can provide well controlled IOP in glaucomas, both primary and secondary, and the VF stabilized in about 90% of patients over a period of 10 years, with the currently available glaucoma medications and trabeculectomy.

Intraoperative Optical Coherence Tomography Guided Bleb Needling.

Two patients with history of trabeculectomy presented with uncontrolled intraocular pressure (IOP) postoperatively. The first patient had a flat and vasularized bleb 10 weeks after the surgery, and the second subject developed encapsulated bleb 3 months postoperatively. Both patients were taken to the operating room and intraoperative optical coherence tomography (OCT) guided bleb needling was performed to restore aqueous egress into the subconjunctival space. Postoperatively, IOP of the operated eyes ranged 14-18 mmHg at week 6 and month 3. None of the eyes had any intraoperative or postoperative complications. This novel application of the intraoperative OCT for bleb needling facilitates precision surgery under direct visualization and reduces the risk of complications.

Clinical utility of anterior segment swept-source optical coherence tomography in glaucoma.

UNLABELLED: Optical coherence tomography (OCT), a noninvasive imaging modality that uses low-coherence light to obtain a high-resolution cross-section of biological structures, has evolved dramatically over the years. The Swept-source OCT (SS-OCT) makes use of a single detector with a rapidly tunable laser as a light source. The Casia SS-1000 OCT is a Fourier-domain, SS-OCT designed specifically for imaging the anterior segment. This system achieves high resolution imaging of 10΅m (Axial) and 30΅m (Transverse) and high speed scanning of 30,000 A-scans per second. With a substantial improvement in scan speed, the anterior chamber angles can be imaged 360 degrees in 128 cross sections (each with 512 A-scans) in about 2.4 seconds. We summarize the clinical applications of anterior segment SS-OCT in Glaucoma. LITERATURE SEARCH: We searched PubMed and included Medline using the phrases anterior segment optical coherence tomography in ophthalmology, swept-source OCT, use of AS-OCT in glaucoma, use of swept-source AS-OCT in glaucoma, quantitative assessment of angle, filtering bleb in AS-OCT, comparison of AS-OCT with gonioscopy and comparison of AS-OCT with UBM. Search was made for articles dating 1990 to August 2015.