Inadvertent Orbital Mitomycin C Injection as a Cause of Ptosis and Ophthalmoplegia from Orbital Necrosis.

Mitomycin C is an alkylating agent with the ability to suppress fibroblast proliferation and activity, making it a powerful antifibrotic. It has therefore become popular in glaucoma filtering surgeries, used both intraoperatively during bleb formation and postoperatively as an adjunct to bleb needling. This report presents a rare but serious risk of bleb needling with Mitomycin C at the slit lamp, where inadvertent movement of the patient resulted in an orbital injection. The patient quickly developed focal tissue inflammation and necrosis, presenting one day after the procedure with complete ptosis, ophthalmoplegia, and a palpable orbital mass. After appropriate imaging and an excisional biopsy to exclude infectious, infiltrative, and neoplastic causes, this was managed with close observation and continued improvement, and resolution of most orbital sequelae.

Modeling the effects of glaucoma surgery on intraocular pressure.

Minimally invasive glaucoma surgeries (MIGS) offer an effective way to lower intraocular pressure without inducing extensive trauma to the anterior segment. In order to predict their efficacy, an analytical model of the conventional aqueous humor outflow pathway is developed using a resistor network. The model describes outflow through the normal eye and allows for the effects of geometric changes in the outflow pathway as IOP changes. By selectively removing these resistors, the model can be used to examine and predict the outcomes of several surgical procedures currently used to treat glaucoma. Treatments examined include traditional trabeculectomy, several ab interno methods for trabeculotomy and trabeculectomy, as well as recently developed trabecular stents that bypass the trabecular meshwork and dilate Schlemm canal. The model's predictions for the efficacy of these procedures generally matched well with the efficacy determined in experimental studies, although it tended to somewhat overestimate the efficacy of these procedures. Matching the model to experimental data indicated that a partial trabeculotomy substantially increases flow to collector channels within that region and approximately 1.5 clock hours past the ends of the trabeculotomized region. Similarly, trabecular bypass stents substantially increase flow to collector channels up to 1.5 clock hours past the open ends of the stent. The resistor model we have developed can be used to predict the efficacy of a variety of MIGS procedures. Circumferential flow in Schlemm canal extends the efficacy of MIGS, but this effect is limited to a few clock hours.

XEN Gel Stent Open Conjunctiva Technique: A Practical Approach Paper.

The Xen Gel Stent lowers intraocular pressure by shunting aqueous humor to the subconjunctival space. While published studies include both open conjunctiva and closed conjunctiva approaches, most publications feature a closed conjunctiva, ab interno approach. While this approach is widely used, other approaches may be preferred for some patients. This paper provides details on surgical steps and tips for enhancing outcomes for an open conjunctiva technique for the implantation of the Xen Gel Stent, as well as reasoning as to when this approach should be used.

Intraoperative complication rates in cataract surgery performed by ophthalmology resident trainees compared to staff surgeons in a Canadian academic center.

PURPOSE: To compare the intraoperative complication rates in cataract surgery performed by resident trainees and staff ophthalmologists. SETTING: Kensington Eye Institute, University of Toronto, Toronto, Canada. DESIGN: Prospective case series. METHODS: This study included 8738 consecutive cases of primary phacoemulsification cataract surgery performed by staff surgeons and resident trainees from January to December 2016. There were no exclusion criteria. Data collected included the level of resident training, case complexity, degree of resident involvement, and intraoperative complications. Primary outcome measures included intraoperative complication rates and level of complexity of cataract surgeries performed by resident trainees and staff surgeons. RESULTS: Resident trainees were involved in 44% of surgeries. Of those, 82% were completed in their entirety by a resident and 18% were performed by both the staff surgeon and resident. Staff surgeons performed 56% of all surgeries without resident involvement. Sixty-seven percent of surgeries were simple and 33% were complex, with small pupil or intraoperative floppy-iris syndrome being the most common reason for complex cases. For simple cases, there was no difference in the overall complication rates (1.7% and 2.0%; P = .52), posterior capsule rupture rates (0.9% and 0.8%; P = .76), or vitreous loss rates (0.4% and 0.2%; P = .08) between staff and residents, respectively. CONCLUSION: There were no differences in complication rates between the two groups.

An observational study of bimatoprost 0.01% in patients on prior intraocular pressure-lowering therapy: the Canadian Lumigan(®) RC Early Analysis Review (CLEAR) trial.

PURPOSE: To evaluate the ocular hyperemia and intraocular pressure (IOP)-lowering efficacy of bimatoprost 0.01% in subjects with elevated IOP due to primary open-angle glaucoma (POAG) or ocular hypertension (OHT) in a real-world clinical setting. SUBJECTS AND METHODS: This open-label, 12-week, observational study was conducted at 67 centers in Canada. Subjects with elevated IOP due to POAG or OHT instilled bimatoprost 0.01% as monotherapy once daily. Ocular hyperemia was graded by the investigator at baseline, week 6, and week 12 using a standardized photographic 5-point grading scale. Change in IOP from baseline was also evaluated at these time points. This analysis includes the subgroup of 268 subjects who had been previously treated with latanoprost 0.005%, bimatoprost 0.03%, travoprost 0.004%, and travoprost 0.004% with SofZia™ or nonselective beta-adrenergic receptor blockers prior to the study. RESULTS: After 12 weeks of treatment with 0.01% bimatoprost, ocular hyperemia was graded as none-to-mild hyperemia (grades 0, +0.5, or +1) for 94.1% of subjects and as moderate-to-severe hyperemia (grades +2 or +3) for 5.9%. No statistically significant shifts in ocular hyperemia ratings were observed at week 12 for any of the prior IOP-lowering therapies except bimatoprost 0.03%, in which 20.8% of subjects experienced an improvement. The mean percentage change from baseline IOP at week 12 following the switch to bimatoprost 0.01% monotherapy ranged from -2.3%±17.3% to -26.3%±12.4%. Furthermore, the decreased mean percentage change from baseline IOP was statistically significant across all prior IOP-lowering medications, except for bimatoprost 0.03% at the 6- and 12-week visits and travoprost 0.004% at the 6-week visit. CONCLUSION: This observational study demonstrates that bimatoprost 0.01% was well tolerated among POAG and OHT subjects who switched from prior IOP-lowering medication. Furthermore, a switch in ocular hypertensive treatment to bimatoprost 0.01% was associated with an additional 10%-15% reduction in IOP.

An observational study of bimatoprost 0.01% in treatment-naïve patients with primary open angle glaucoma or ocular hypertension: the CLEAR trial.

BACKGROUND: This study was designed to evaluate the occurrence and severity of ocular hyperemia in subjects with elevated intraocular pressure (IOP) due to primary open angle glaucoma (POAG) or ocular hypertension (OHT) following treatment with bimatoprost 0.01% in a real-world clinical setting. METHODS: This was an open-label, observational study conducted at 67 centers in Canada. Subjects with elevated IOP due to POAG or OHT instilled bimatoprost 0.01% topically as monotherapy once daily. Ocular hyperemia was graded by the investigator at baseline and weeks 6 and 12 using a photographic five-point grading scale. Change in IOP from baseline was also evaluated at these time points. This analysis includes only the subgroup of 522 subjects who were naïve to IOP-lowering medication prior to the study. RESULTS: After 12 weeks of treatment with bimatoprost 0.01%, hyperemia was graded as none-to-mild (grades 0, +0.5, or +1) for 93.3% of subjects and as moderate-to-severe (grades +2 or +3) for 6.7%. At weeks 6 and 12, most subjects (93.2% and 93.5%) had no change in hyperemia grade from baseline. IOP was reduced by 7.4 mmHg (29.8%) at week 6 and 7.7 mmHg (30.9%) at week 12 from baseline. CONCLUSION: This real-world, observational study found that bimatoprost 0.01% instilled once daily reduced IOP by a mean of 30% from baseline without moderate or severe ocular hyperemia in 93% of treatment-naïve subjects with POAG or OHT.

The role of episcleral venous pressure in glaucoma associated with Sturge-Weber syndrome.

PURPOSE: To evaluate the role of episcleral venous pressure (EVP) in the pathogenesis of glaucoma associated with Sturge-Weber syndrome (SWS). METHODS: EVPs were determined prospectively using an episcleral venomanometer in 22 eyes of 11 patients aged 8-18 years with SWS with or without glaucoma. Pressure measurements in the glaucomatous eyes of patients with SWS were compared to those of patients with facial port wine marks but no glaucoma and to the contralateral uninvolved eye in both groups. RESULTS: EVP in eyes with glaucoma (mean, 20.9 mm Hg) was significantly higher (P < 0.01) than EVP in contralateral uninvolved eyes (mean, 9.6 mm Hg). In patients with unilateral port wine mark and no glaucoma, EVP was normal for ipsilateral and contralateral eyes (mean, 8.6 mm Hg and 9.6 mm Hg, respectively). CONCLUSIONS: Our data support the hypothesis that elevated EVP plays an important role in eyes with SWS glaucoma.

Three-month, randomized, parallel-group comparison of brimonidine-timolol versus dorzolamide-timolol fixed-combination therapy.

OBJECTIVE: Fixed combinations of 0.2% brimonidine-0.5% timolol and 2% dorzolamide-0.5% timolol are used to lower intraocular pressure (IOP). The objective of this study was to evaluate the IOP-lowering efficacy and ocular tolerability of brimonidine-timolol compared with dorzolamide-timolol when used as monotherapy or as adjunctive therapy to a prostaglandin analog (PGA) in patients with glaucoma or ocular hypertension. STUDY DESIGN AND METHODS: Pooled data analysis of two randomized, investigator-masked, 3-month, parallel-group studies with identical protocols (ten sites). In all, 180 patients with open-angle glaucoma or ocular hypertension who were in need of lower IOP received topical brimonidine-timolol BID or dorzolamide-timolol BID as monotherapy (n = 101) or as adjunctive therapy to a PGA (latanoprost, bimatoprost, or travoprost) (n = 79). CLINICAL TRIAL REGISTRATION: The studies are registered with the identifiers NCT00822081 and NCT00822055 at http://www.clinicaltrials.gov. MAIN OUTCOME MEASURES: IOP was measured at 10 a.m. (peak effect) at baseline and at months 1 and 3. Tolerability/comfort was evaluated using a patient questionnaire. RESULTS: There were no statistically significant between-group differences in patient demographics. Most patients were Caucasian, and the mean age was 68 years. There were also no statistically significant differences between treatment groups in baseline IOP. At month 3, the mean (SD) reduction from baseline IOP for patients on fixed-combination monotherapy was 7.7 (4.2) mmHg (32.3%) with brimonidine-timolol versus 6.7 (5.0) mmHg (26.1%) with dorzolamide-timolol (p = 0.040). The mean reduction from PGA-treated baseline IOP for patients on fixed-combination adjunctive therapy was 6.9 (4.8) mmHg (29.3%) with brimonidine-timolol versus 5.2 (3.7) mmHg (23.5%) with dorzolamide-timolol (p = 0.213). Patients on brimonidine-timolol reported less burning (p < 0.001), stinging (p < 0.001), and unusual taste (p < 0.001) than patients on dorzolamide-timolol. CONCLUSIONS: Fixed-combination brimonidine-timolol provided the same or greater IOP lowering compared with fixed-combination dorzolamide-timolol. Both fixed-combination medications were safe and well-tolerated. Brimonidine-timolol received higher ratings of ocular comfort than dorzolamide-timolol. The duration of the studies was 3 months, and additional studies will be needed to compare the efficacy and tolerability of brimonidine-timolol and dorzolamide-timolol during long-term treatment.

Comparison of morning versus evening dosing and 24-h post-dose efficacy of travoprost compared with latanoprost in patients with open-angle glaucoma .

OBJECTIVE: To compare the IOP-lowering efficacy of a.m.-dosed travoprost and latanoprost at 24-h post-dose. RESEARCH DESIGN AND METHODS: Open-angle glaucoma patients not naïve to prostaglandin therapy and currently controlled on p.m.-dosed (2100) latanoprost (n = 21) or travoprost (n = 30) had baseline IOPs measured at 0900. In a randomized, single-masked, crossover design, patients received travoprost (Travatan † ) or latanoprost (Xalatan ‡ ) at 0900 for 4 weeks, then were crossed over to receive the second prostaglandin for another 4 weeks. Treatment IOP was measured at 0900 prior to morning dose at both 4 and 8 week visits. Patient dosing preference (a.m./p.m.) was surveyed on exit. MAIN OUTCOME MEASURE: Intraocular pressure (IOP). † Travatan is a registered trade name of Alcon Laboratories, Inc., Fort Worth, TX, USA ‡ Xalatan is a registered trade name of Pfizer, New York, NY, USA. RESULTS: The mean IOP in the first period when all patients were dosed in the evening was assessed 12 h after dosing at 09:00 and it was similar in the two treatment groups (mean ± standard deviation: 17.9 ± 2.7 mmHg for travoprost versus 17.7 ± 2.5 mmHg for latanoprost, p = 0.812). In the a.m.-dosing crossover comparison, the 24-h post-dose IOP was significantly lower ( p < 0.001) on travoprost (16.9 ± 3.1 mmHg) compared to latanoprost (18.6 ± 3.3 mmHg). In the exit survey, 51% of patients preferred a.m.-dosing. CONCLUSIONS: a.m.-dosed travoprost is superior to a.m.-dosed latanoprost by 1.7 mmHg at 24-h post-dose.

Relationship between central corneal thickness and hypotony maculopathy after trabeculectomy.

PURPOSE: To study the relationship of central corneal thickness and other factors and the development of hypotony maculopathy (HM). DESIGN: Prospective case-control study. PARTICIPANTS: Thirteen patients with HM and 25 controls with hypotony (defined as intraocular pressure [IOP] of 6 mmHg or less) without signs of maculopathy after trabeculectomy or combined phacotrabeculectomy. METHODS: Information from consecutive patients and controls was collected in a prospective manner. Factors associated with presence of HM were investigated by comparing the findings in the 2 groups in univariate and multivariate analysis. MAIN OUTCOME MEASURES: The following factors were investigated: demographic factors (age and gender), presenting IOP, central corneal thickness (CCT), refractive error, type of glaucoma surgery, and presence of choroidal effusion, among others. RESULTS: Among the variables evaluated, a significant difference between the 2 groups was observed in the age of the patients (patients with HM being significantly younger: 59+/-20 years vs. 73+/-9 years; P = 0.015) and in CCT (eyes with HM having significantly thicker cornea: 553+/-51 microm vs. 506+/-34 microm; P = 0.004). Both predictive factors (younger age and thicker CCT) persisted as significant in a multivariate logistic regression analysis. The measured IOP during hypotony was similar between eyes with HM and hypotony alone (4.7+/-3.2 mmHg and 3.9+/-1.6 mmHg, respectively; P = 0.649). No differences in gender, type of surgery, presence of choroidal detachment, lens status, or degree of myopia were observed between the 2 groups. CONCLUSIONS: This study shows that patients with hypotony and thinner central corneas have a lower risk of experiencing maculopathy. This association may result from the influence of CCT on applanation tonometry, although we can not rule out that CCT is related to the development of HM by other mechanisms. This study suggests that CCT should be taken in consideration when setting a target pressure after glaucoma filtering surgery, particularly if the target IOP is low.