Combined aqueous misdirection and persistent choroidal effusions following implantation of a Preserflo MicroShunt.

AIM: To describe a case of aqueous misdirection complicated by subsequent persistent choroidal effusions following implantation of a Preserflo MicroShunt (PMS) device to treat advanced closed angle glaucoma. METHODS: A 67-year-old caucasian female with advanced primary angle-closure glaucoma on four medications with an intraocular pressure (IOP) of 26 mm Hg was listed for a PMS insertion with mitomycin C (MMC). RESULTS: Past ocular history was significant for pseudophakia and previous yttrium aluminum garnet (YAG) peripheral iridotomy. Surgery was uneventful but on the first postoperative day, she developed aqueous misdirection complicated by subsequent development of persistent uveal effusions. Conventional treatment strategies including atropine drops, YAG hyaloidotomy and choroidal effusion drainage proved ineffective. A combination of oral steroids and pars plana vitrectomy (PPV) along with an irido-zonulo-hyloidectomy (IZH) proved efficacious. CONCLUSION: To the best of the author's knowledge, this is the first published case of aqueous misdirection complicated with the presence of significant, unresolving choroidal effusions, highlighting the possibility and sequelae of comorbid pathology in nanophthalmic eyes.

Agreement amongst consultant ophthalmologists on levels of visual disability required for eligibility for certificate of sight impairment : Sight impairment registration using binocular composite visual fields.

BACKGROUND: Registration as sight impaired allows access to services important for patients. The rates of sight impairment due to visual field loss are underestimated. Previous work has shown that evaluation of visual field defects in both eyes produces poor agreement among ophthalmologists for categorisation of patients as eligible for sight impairment registration. AIM: To evaluate the impact of binocular summation of both eye glaucomatous visual field defects on agreement for sight impairment registration. METHODS: Thirty consultant ophthalmologists (Graders), graded 50 glaucomatous visual field sets. Each consisted of both monocular fields and summated binocular plots. Graders classified the visual field sets as sight impaired (SI), severely sight impaired (SSI) or neither. Trichotomous, (SI, SSI or no sight impairment) and dichotomous (any sight impairment versus no sight impairment) concordance values were estimated for the group of graders as a whole and for glaucoma and non-glaucoma experts. RESULTS: For trichotomous analysis the overall kappa agreement rate was 0.29; for dichotomous analysis it was 0.40. There was no material difference between glaucoma experts and non-experts. CONCLUSION: Overall agreement was modest. Grading for SI showed the poorest levels of agreement. Using binocular fields does not appear to improve concordance for sight impairment registration. Moreover, there is no difference in agreement between glaucoma and non-glaucoma experts. An overall score for visual disability using mean deviation may be a more pragmatic approach.

Gonioscopy-assisted Transluminal Trabeculotomy in Uveitic Glaucoma Secondary to Juvenile Idiopathic Arthritis.

Gonioscopy-assisted transluminal trabeculotomy (GATT) is a minimally invasive ab interno procedure, performed with guidance of an illuminating microcatheter device (iTrack). The pathophysiology of raised intraocular pressure (IOP) in uveitic glaucoma is commonly due to increased resistance at the trabecular meshwork-Schlemm canal. By removing this resistance, GATT can potentially control the IOP. In addition, the ab interno approach avoids violating the conjunctiva and reduces the risk of complications including infection, leak, and hypotony. In this series, we discuss 3 uveitic glaucoma cases secondary to juvenile idiopathic arthritis (JIA) that underwent GATT. Case 1 was a 16-year-old phakic female with a preoperative IOP of 25 to 33 mm Hg had 360-degree GATT; her IOP remained stable at 6 to 10 mm Hg over 14 months. Case 2 was a 23-year-old pseudophakic female with a preoperative IOP of 28 to 34 mm Hg had 180-degree GATT; her IOP reduced to 8 mm Hg over 10 months. Case 3 was an 8-year-old aphakic male with a preoperative IOP of 21 to 32 mm Hg had 360-degree GATT; his IOP remained stable at 13 to 15 mm Hg over 21 months. In our limited case series, GATT is very successful in controlling IOP in young uveitic patients with JIA by surgically targeting the underlying pathophysiology.

Short-term effect of diode laser cyclophotocoagulation on intraocular pressure: a prospective study.

BACKGROUND: This aims to determine the immediate and short-term risk of intraocular pressure spikes following diode laser cyclophotocoagulation. DESIGN: This study is a prospective, consecutive cohort study in a UK teaching hospital. PARTICIPANTS: Fifty-three consecutive patients undergoing cyclophotocoagulation were invited to participate in this study. METHODS: Intraocular pressure (IOP) measurements were taken immediately prior to cyclodiode laser, hourly for the first 3 h after laser, on the first and seventh postoperative days, and at three months following laser. MAIN OUTCOME MEASURES: Eyes experiencing intraocular pressure elevation defined at two levels (≥3 mm Hg and ≥10 mm Hg from the pretreatment level) were identified. RESULTS: Seventeen eyes (34%) had an elevation in intraocular pressure (≥3 mmHg) during the first 3 h postoperatively with a mean increase of 10.3 mmHg. No preoperative or perioperative associations were found for a postcyclodiode spike within the first 3 postoperative hours.No association was found between pressure spikes and visual acuity, reduction of glaucoma medication or final postoperative intraocular pressure at 3 months. Eyes that did not have an IOP spike during the first 3 h postoperatively had a greater reduction in IOP at 3 months (15.2 mmHg vs. 10.2 mmHg; P = 0.184). CONCLUSION: IOP spikes are common in the immediate period after cyclophotocoagulation. An elevation in IOP is noted after the first hour in the vast majority who experience a spike in the first 3 h post-procedure.

Delayed presentation of melanoma-associated retinopathy and subsequent resolution with cytoreduction surgery.

BACKGROUND: To present a case of melanoma-associated retinopathy (MAR) which manifested 26 months prior to a formal diagnosis of melanoma. METHODS: Case report. RESULTS: A 72-year-old female presented with bilateral continuous photopsia consistent with MAR of 7-months duration. At this point, visual function appeared normal with the exception of mildly impaired colour vision (10/17 Ishihara plates). The flash electroretinographic (ERG) revealed extinguished rod responses, a normal a-wave and reduced b-wave (electronegative ERG) on the maximal combined response, absent oscillatory potentials and broadened a-wave trough on the cone response. Multifocal ERG (mfERG) responses were delayed and demonstrated atypical morphology. Nineteen months after the initial presentation, her visual symptoms had progressed significantly with constant debilitating photopsia in combination with 13 kg weight loss. Biopsy of a now evident left axillary mass demonstrated a metastatic high-grade malignant melanoma. No primary was detected, and an axillary lymph node clearance was undertaken. Subsequently, visual symptoms resolved with corresponding improvement in the ERG over the next 18 months. Rod responses recovered such that the amplitude was at the lower limit of normal and the mfERG response delay lessened. Unfortunately, the melanoma recurred and the patient passed away 6 months later. Visual symptoms did not recur. CONCLUSION: We present a case which demonstrates MAR may precede the formal diagnosis of melanoma by up to 26 months. The potential for improvement in the rod visual function persists over a period of years with normalisation of an electronegative waveform. In this case, cytoreductive surgery resulted in complete resolution of the MAR, which did not return even with a recurrence of the tumour.

Repeatability of ocular response analyzer metrics: a gender-based study.

PURPOSE: To assess the repeatability of Goldmann-correlated intraocular pressure (IOPG), corneal-compensated IOP (IOPCC), corneal hysteresis (CH), and the corneal resistance factor (CRF) obtained with the Ocular Response Analyzer (ORA) in normal eyes and to determine whether any differences in corneal biomechanical parameters or their repeatability exist between the sexes. METHODS: A prospective observational study assessing 100 normal adults (50 men and 50 women; median age, 54.5 years). Comparison of ORA parameters measured in both eyes in three sets of four consecutive readings by one examiner within a 30-minute period. RESULTS: The mean values of the ORA parameters assessed, the intraclass correlation coefficient (ICC) and the coefficient of repeatability (CR), were as follows for the right eye (n = 100): IOPG, 16.2 ± 3.3 mm Hg (ICC, 0.96; CR, 6.37); IOPCC, 16.2 ± 3.2 (ICC, 0.94; CR, 6.29); CRF, 10.9 ± 1.9 (ICC, 0.91; CR, 3.62); CH, 10.6 ± 1.7 (ICC, 0.94; CR, 3.37). The ICC between the readings was excellent (>0.9) for all the ORA parameters in both sexes, with the exception of one group (female CRF ICC, 0.86). Coefficient of repeatability of the instrument satisfies the British Standards Institution criteria for repeatability. There were no significant differences between corneal biomechanical factors and IOP results for men and women. CONCLUSIONS: Corneal biomechanical parameters measured by the ORA provide repeatable results in normal eyes, with no significant difference between the sexes.

Treating patients presenting with advanced glaucoma--should we reconsider current practice?

The management of patients presenting with advanced glaucoma presents a challenge to glaucoma clinicians. Presentation with advanced visual field loss is an important risk factor for progression to blindness in the affected eye(s) during the patients' lifetime. Maximising intraocular pressure (IOP) control in such situations is likely to minimise the risk of further visual field deterioration thus either preventing or slowing progression to blindness. Currently most patients presenting with advanced disease in the UK are managed on an escalating regime of medical treatment. Should this fail glaucoma surgery is usually employed to further lower IOP. Although glaucoma surgery is generally a safe and successful intervention it carries a small risk of severe visual loss and is considered by many clinicians as an intervention only to be used following failure of medical treatment. Recently however the National Institute for Clinical Excellence has suggested in its clinical guidelines for management of ocular hypertension and glaucoma that primary surgery should be offered to patients presenting with advanced glaucomatous visual field loss. This is contrary to the practice of most UK ophthalmologists. In this review the current available evidence underlying the management of presentation with advanced disease is examined.

Outcome of trabeculectomy with mitomycin C in patients with advanced glaucoma.

BACKGROUND/AIMS: To determine the medium-term intraocular pressure (IOP) control and visual outcomes for patients with advanced glaucoma undergoing trabeculectomy with mitomycin C. METHODS: All patients with advanced glaucoma (MD -20 dB or above) undergoing trabeculectomy with mitomycin C between 2000 and 2008 under the care of a single glaucoma surgeon were included. IOP, visual acuity and visual field outcomes were assessed from data prospectively collected into a surgical outcome database. RESULTS: 103 patients were eligible for inclusion. The post-trabeculectomy group mean IOP varied between 11.3 and 13.3 mm Hg between 1 and 7 years. At year 5, 85.2% had an IOP of <16 mm Hg, and 96.3% had an IOP of < 21 mm Hg. The number completing a reliable visual-field exam decreased significantly year on year, but the change in mean MD for the group as a whole and for individual patients remained stable. 28 patients experienced a significant reduction in acuity defined as two or more lines of Snellen, although this was not due to glaucoma surgery in the majority. The only preoperative determinant for a significant reduction in VA was the preoperative MD (-27.00 dB (n=21) compared with -24.79 dB (n=63; p=0.029)). CONCLUSION: Trabeculectomy is a successsful method of controlling IOP in the short to medium term in patients with advanced glaucoma.