Knowledge, attitude, and practice (KAP) towards glaucoma among new glaucoma patients and their first-degree relatives: A cross-sectional study in a tertiary eye care centre in Riyadh, Saudi Arabia.

PURPOSE: Glaucoma, a disease characterized by optic nerve damage and associated visual field defects, is the main cause of irreversible loss of vision, both globally and locally. Appropriate management of glaucoma involves early diagnosis in addition to early and continuous control of the disease to protect the optic nerve from further damage. This study aimed to assess the knowledge, attitude, and practice (KAP) towards glaucoma among patients making their first visit to the glaucoma clinics, at King Khaled Eye Specialist Hospital in Riyadh, and their first-degree relatives. METHODS: This cross-sectional study used self-administered questionnaires. Informed consent was obtained prior to questionnaire distribution. The questionnaire included four sections on sociodemographic data, and awareness, and KAP towards glaucoma. RESULTS: Overall, 120 participants were included in our study: 70 (58.3%) were glaucoma patients and 50 (41.7%) were first-degree relatives. Forty-four (62.9%) participants in the patient group and 39 (78%) in the relative group were men. Thirty-four (48.6%) patients were aged 41-65 years, whereas 41 (82%) relatives were aged 18-40 years. Thirty-six patients (52.2%) and 35 relatives (70%) had heard of the term 'glaucoma'. The correct definition of glaucoma was selected by only 12 participants (17.1%) in the patient group and 4 (8.2%) in the relative group. Living outside the central region of Saudi Arabia and having a negative systemic medical history were associated with poorer knowledge of glaucoma definition (p < 0.05). Although 84.8% of patients believed that compliance with anti-glaucoma medications helps in disease control, only 22.7% reported good compliance. The correct method of instilling eye drops was stated by 43.9% of the patients, and good hospital visit habits were reported by 53.03%. Eighty percent of glaucoma patients strongly recommended that their first-degree relatives be screened for glaucoma. CONCLUSION: Knowledge about glaucoma is still limited, and awareness programs need to be further activated to spread correct knowledge about the nature of glaucoma, the importance of compliance with treatment, the correct method of instilling eye drops, and the significance of screening at-risk individuals. Patient families should also be involved in educational programs.

Evaluation of Surgical Requirements and Competencies of the Saudi Ophthalmology Training Program in a Tertiary Eye Specialist Hospital- A Cross-Sectional Study.

Purpose: To evaluate the adequacy of a Saudi ophthalmology training programs in achieving the competencies outlined by the Saudi Commission for Health Specialties (SCFHS) and the Accreditation Council for Graduate Medical Education (ACGME) and to assess resident satisfaction with their training. Methods: A cross-sectional survey was sent electronically to all trainees (n=50) enrolled in the King Khaled Eye Specialist Hospital (KKESH) ophthalmology training program by email and messaging app (Whatsapp). The survey was sent between January 20, 2021, and January 30, 2021. It evaluated the level of satisfaction with surgical training and skills. The surgical logbooks of all trainees were extracted, and identifiers were removed. Then they were compared with SCFHS and ACGME curriculums for ophthalmology training. Results: Out of 50 invitees, 47 returned the questionnaire. All trainees were confident they could meet surgical requirements by the end of their training. Most trainees were satisfied (n=29, 61.7%) with their performance in core competency requirements. There was no difference between female and male trainees' comfort levels when performing surgical steps in core competency requirements (P=0.2). Senior trainees seem more satisfied with their performance, especially in core competency requirements (P=0.087). All trainees practice at the wet lab and a virtual reality simulator to improve their skills. Obstacles faced during training were highlighted, including low exposure in the operating theater (n=18, 37.50%), competition on cases (n=5, 10.42%), attending surgeons not willing to teach (n=5, 10.42%), COVID-19 pandemic (n=5, 10.42%), and complex cases (n=4, 8.33%). Conclusion: The outcomes of the current study indicate that trainees at KKESH were adequately satisfied with their surgical training in general. Also, competencies outlined by both the SCFHS and the ACGME were adequately fulfilled.

Comparison of the Ahmed and Baerveldt Glaucoma Drainage Implants in the Treatment of Primary Congenital Glaucoma.

PURPOSE: To compare the outcomes of the Ahmed glaucoma valve (AGV) (New World Medical, Inc) with the Baerveldt glaucoma implant (BGI) (Johnson & Johnson Vision) in primary congenital glaucoma (PCG). METHODS: This was a retrospective review of children with PCG who underwent AGV or BGI implantation with a minimum follow-up of 6 months. Main outcome measures were intraocular pressure (IOP), the number of glaucoma medications, success rate, complications, and surgical revisions. RESULTS: The study included 153 eyes of 86 patients (120 eyes in the AGV group and 33 eyes in the BGI group), and the mean follow-up period was 58.7 ± 6.9 months in the AGV group and 58.5 ± 5.0 months in the BGI group. At baseline, IOP was lower in the AGV group (33 ± 6.3 vs 36.4 ± 6.1 months; P = .004) and the number of glaucoma medications was comparable between groups (3.4 ± 0.9 vs 3.6 ± 0.5 medication; P = .183). At 5 years, the mean IOP (18.4 ± 5.0 vs 16.3 ± 2.5 mm Hg; P = .004) and number of glaucoma medications (2.1 ± 1.3 vs 1.0 ± 1.0 medication; P = .001) were significantly less in the BGI group. Furthermore, the surgical success was 53.4% in the AGV group and 78.8% in the BGI group (P = .013). CONCLUSIONS: Both the AGV and BGI were successful in providing adequate IOP control in patients with PCG. Long-term follow-up showed that the BGI was associated with a lower IOP, fewer glaucoma medications, and a higher success rate. [J Pediatr Ophthalmol Strabismus. 2023;60(6):448-454.].

Risk Factors for Glaucoma Drainage Device Exposure in Children: A Case-Control Study.

PURPOSE: To identify the risk factors for glaucoma drainage device (GDD) exposure in children. DESIGN: Retrospective case-control study. METHODS: The study population comprised children (one eye each) who presented with a history of GDD exposure to a tertiary care eye hospital over the period January 2014 to January 2020. Consecutive children (age <18 years) were included. A control group from the same time period (children without GDD exposure) were included in the ratio of 5 controls to every 1 case of exposure. The main outcome measures included risk factors for exposure (univariate and multivariate analysis). RESULTS: A total of 21 eyes (of 21 children with implant exposure) and 115 eyes (of 115 children without exposure) were included in this study. During the same study period, a total of 494 eyes had undergone GDD implantation, giving an estimated incidence of exposure of 4.25%). In the bivariate analysis, GDD exposure was associated with multiple previous ocular surgeries (P = .001), longer follow-up duration (P < .001), combined procedure at the time of primary implantation (P = .002), and a younger age at the time of primary implantation (P = .006). The former 3 risk factors continued to prove a statistically significant association on multivariable regression analysis. Postoperative use of eye lubricants was more common among children in the control group (P = .007). CONCLUSION: In pediatric glaucoma patients, younger age and combined procedure at the time of primary GDD implantation, in addition to multiple previous ocular surgeries, were associated with greater risk of implant exposure. Postoperative use of eye lubricants may be protective.

Barriers and adherence to glaucoma medication in a paediatric glaucoma population: A cross-sectional survey in central Saudi Arabia.

PURPOSE: To examine barriers and adherence to topical glaucoma medication in a pediatric glaucoma population in Saudi Arabia. METHODS: This cross-sectional study was undertaken at the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia during 2016-2017. Parents (father or mother) of children aged 6 months to 15 years with a history of glaucoma were interviewed. Rasch analysis was performed to assess the psychometric properties of the developed 12-item barriers-to-adherence tool (BAT-12) and to identify barriers deemed highly important. The 12-items were adapted from previous studies examining different barriers to adherence in different populations. Medication adherence was assessed by asking parents a series of closed-ended questions about the frequency of missed medications. Determinants of missed medications on at least 1 out of the last 3 days were examined using Poisson regression. RESULTS: One hundred and six parents were interviewed. The 12-item scale had acceptable psychometric properties. Barriers deemed important were forgetfulness (logit -0.59), complex dosing regimen (logit 0.09), and being too busy with other work/activities (logit 0.14). When asked how often, on average, their child missed the prescribed medication, 26 (24.5%) reported daily, 17(16.0%) reported few times per week, and 32 (30.2%) reported once per week. A third of parents (n = 37, 34.9%) reported having missed giving all drops on at least one day in the last 3 days. Poisson regression with robust variance revealed that increase in age of the child (prevalence ratio, 1.08 [95% CI, 1.03-1.14]; p = 0.003) and increase in parents' barriers score (prevalence ratio, 2.13 [95% CI, 1.49, 3.03]; p < 0.001) were significantly associated with having missed medications on at least one out of the last three days while adjusting for the effect of father's current employment status and area of residence. CONCLUSIONS: The tool we used to examine barriers to glaucoma medication had acceptable psychometric properties and could be used and strengthened in future studies. Our study highlights poor adherence to glaucoma medications among children with glaucoma.

Comparison of Glaucoma Therapy Escalation After Penetrating Keratoplasty to Descemet Stripping Automated Endothelial Keratoplasty for the Treatment of Pseudophakic Bullous Keratopathy: A Cohort Study.

PURPOSE: The purpose of this study was to compare glaucoma therapy escalation (GTE), graft survival, vision, and glaucoma following penetrating keratoplasty (PK group) and Descemet stripping automated endothelial keratoplasty (DSAEK group) to treat pseudophakic bullous keratopathy (PBK). METHODS: This cohort included cases of PBK managed with PK from 2009 to 2014. We compared the incidences and determinants of GTE, graft survival, and visual disability. P < 0.05 was statistically significant. RESULTS: There were 58 eyes in the PK group and 117 eyes in the DSAEK group. The incidence of GTE in the PK and DSAEK groups at the last follow-up was 34.2% (95% confidence interval [CI]: 19.5-48.9) and 46.6% (95% CI: 27.7-65.4), respectively. The risk of GTE was similar between the groups (relative risk [RR] = 1.36 [95% CI: 0.94-1.98], P = 0.12). GTE was significantly associated with graft survival in the PK group (RR = 3.25 [95% CI: 1.5-7.0], P < 0.001) and the DSAEK group (RR = 3.77 [95% CI: 2.6-5.6], P < 0.001). Glaucoma (P = 0.001) and previous keratoplasty (P < 0.001) were significant predictors for GTE. At the final follow-up visit, severe visual disability was not significantly different between the groups (RR = 0.9 [95% CI: 0.3-2.9], P = 0.88). There was a statistically significant improvement in vision after DSAEK (P < 0.001) but not after PK (P = 0.67). CONCLUSION: GTE was similar in eyes with PBK managed by PK or DSAEK. Glaucoma and previous keratoplasty were predictors of GTE post-keratoplasty. DSAEK gave better visual outcomes than PK for managing PBK.

Perception of Medical Professionalism Among Ophthalmology Residents in Saudi Arabia: A National Survey Study.

PURPOSE: Studies have shown that there are significant differences in the concepts of medical professionalism among residents. Very few studies have specifically evaluated the perception of medical professionalism in a specific specialty. The aim of the study is to evaluate the perception of medical professionalism among ophthalmology residents and to assess the differences in the concept of professionalism between junior and senior residents. METHODS: This cross-sectional study used a questionnaire to survey ophthalmology residents enrolled in different regions of Saudi Arabia in 2020. The ophthalmology residents included both junior and senior residents. In this study, "professionalism" concurred with the definition in the American Board of Internal Medicine's "Project Professionalism" and the Accreditation Council for Graduate Medical Education. RESULTS: A total of 167 participants were recruited in the study. Out of the 127 participants who completed the survey, 60 (47.24%) were junior residents and 67 (52.76%) were senior residents. The scores for the attributes varied markedly. The lowest score obtained was 6.54 ± 3.349 for the attribute "In an emergency putting the welfare of others over my own safety" in the "Altrusim" domain and the highest score obtained was 9.62 ± 0.854 for the attribute "respect for co-workers" in the "Respect for others" domain. Out of the total residents who completed the survey (n = 127), 84 (66.14%) agreed that professionalism is teachable through a residency curriculum and 85 (66.93%) thought that it is testable. CONCLUSION: The characteristics of different attributes of professionalism varied significantly among the residents. The findings of the present study highlights that the conceptualization and perception of professionalism is changing and there is a need to focus on the resident curriculum to instill the values of professionalism. Targeted training is needed on the concepts of professionalism to develop behaviors consistent with medical professionalism and to evaluate the levels of professionalism among residents.

Incidence and Risk Factors of Ocular Hypertension and Glaucoma in Patients With Acanthamoeba Keratitis.

OBJECTIVES: To determine the incidence of ocular hypertension (OHT) and glaucoma in patients with acanthamoeba keratitis (AK) and to outline the risk factors for the development of glaucoma. METHODS: A retrospective review of patients diagnosed with AK at our institute during the period from 2000 to 2018. The main outcome measures were the incidence of OHT and glaucoma, and risk factors for the development of glaucoma. RESULTS: Fifty-two eyes diagnosed with AK were included. The incidence of OHT and glaucoma was 51.9% and 32.7%, respectively. The mean duration from disease onset to the first attack of elevated intraocular pressure was 8.4±16.6 months. The use of corticosteroids in the treatment regimen was significantly associated with the development of glaucoma (odds ratio, 3.93; 95% confidence interval, 0.96-16.15; P=0.049). At the last follow-up visit, both patients with glaucoma and nonglaucoma patients had improved visual acuity without a difference in the mean amount of logarithm of the minimum angle of resolution acuity improvement among them (0.56±0.91 vs. 0.67±0.87, P=0.686). CONCLUSION: Our findings confirm that OHT and glaucoma are frequent complications in AK. Patients treated with a regimen containing corticosteroids are at a higher risk; thus, they should receive close intraocular pressure monitoring.

Residents' Perceived Impact of COVID-19 on Saudi Ophthalmology Training Programs-A Survey.

PURPOSE: To evaluate the impact of the current pandemic on ophthalmology residency training in Saudi Arabia, focusing on its effects on clinical education, training, and the mental well-being of the trainees. METHODS: An online self-administered questionnaire was distributed among residents in the Saudi ophthalmology training programs between July 7 and 14, 2020. In this study, we explored residents' opinions regarding training disruption and virtual education. The patient health questionnaire (PHQ-9) was used to assess the COVID-19 pandemic's impact on their mental health. We used descriptive statistics for data analysis. RESULTS: Out of 183 registered ophthalmology residents, 142 participated in this study. Ninety-six participants (35.4%) were rotated at a specialized eye hospital during the COVID-19 pandemic, while 52 (19.2%) had rotations in the ophthalmology department at general hospitals. Those who rotated in both types of hospitals were 123 (45.4%). According to the participants, there was a significant decline in exposure to surgical and office-based procedures compared to emergency eye consultations (Friedman P <0.001). The COVID-19 pandemic's effect on mental health was reported by 100 (70.5%) participants. Eighty-five (55.4%) respondents were satisfied with the virtual method of education. CONCLUSION: COVID-19 pandemic has disrupted residents' clinical and surgical training in the Saudi ophthalmology training programs. Additionally, we believe that COVID-19 may have a negative impact on trainees' mental health. Fortunately, the current pandemic provided an innovative education method that will likely be used even after the pandemic.

Primary congenital glaucoma: An updated review.

Primary congenital glaucoma (PCG) is a rare disease affecting children early in life. PCG was considered untreatable with inevitable blindness. However, recent advances in biochemical and genetic studies, the introduction of new diagnostic tools, intraocular pressure (IOP) lowering medications and improvement of surgical techniques have led to a better understanding of this devastating disease and preserving the vision of affected children. This paper presents an updated and broad overview of PCG in terms of the epidemiology and genetic aspects, particularly in Saudi Arabia, the clinical presentation and diagnostic approach to PCG with major emphasis on the treatment options.

Glaucoma With Crouzon Syndrome.

BACKGROUND: Crouzon syndrome is the most common form of craniosynostosis, and mutations in the fibroblast growth factor receptor 2 and 3 (FGFR2 and FGFR3) genes are implicated in its pathogenesis. OBSERVATION: A 10-year-old female patient with Crouzon syndrome and congenital glaucoma treated with trabeculectomy and ocular hypotensive medications was examined. The patient had proptosis, exposure keratopathy, megalocornea, thin central corneal thickness, a shallow anterior chamber, mild anterior subcapsular cataract, and a cup-to-disc ratio of 0.9. Ultrasound biomicroscopy revealed a shallow anterior chamber, posterior synechiae, and closed angle in the right eye, as well as a narrow angle in the left eye, despite an axial length of 28.9 mm in the right eye and 30.0 mm in the left eye, measured by A-scan ultrasound biometry. The crystalline lens thickness measured by ultrasound biomicroscopy was 4.18 mm in the right eye and 4.12 mm in the left eye. CONCLUSIONS AND IMPORTANCE: Despite long axial lengths, shallow anterior chambers with occluded angles are possible in Crouzon syndrome and are most likely caused by FGFR2-related anterior segment dysgenesis. To the best of our knowledge, this is the first report that describes closed angles and anterior segment dysgenesis as a secondary cause of congenital glaucoma in Crouzon syndrome.

Histopathologic and immunohistochemical features of capsular tissue around failed Ahmed glaucoma valves.

Impervious encapsulation around Ahmed glaucoma valve (AGV) results in surgical failure raising intraocular pressure (IOP). Dysregulation of extracellular matrix (ECM) molecules and cellular factors might contribute to increased hydraulic resistance to aqueous drainage. Therefore, we examined these molecules in failed AGV capsular tissue. Immunostaining for ECM molecules (collagen I, collagen III, decorin, lumican, chondroitin sulfate, aggrecan and keratan sulfate) and cellular factors (αSMA and TGFß) was performed on excised capsules from failed AGVs and control tenon's tissue. Staining intensity of ECM molecules was assessed using Image J. Cellular factors were assessed based on positive cell counts. Histopathologically two distinct layers were visible in capsules. The inner layer (proximal to the AGV) showed significant decrease in most ECM molecules compared to outer layer. Furthermore, collagen III (p = 0.004), decorin (p = 0.02), lumican (p = 0.01) and chondroitin sulfate (p = 0.02) was significantly less in inner layer compared to tenon's tissue. Outer layer labelling however was similar to control tenon's for most ECM molecules. Significantly increased cellular expression of αSMA (p = 0.02) and TGFß (p = 0.008) was detected within capsular tissue compared to controls. Our results suggest profibrotic activity indicated by increased αSMA and TGFß expression and decreased expression of proteoglycan (decorin and lumican) and glycosaminoglycans (chondroitin sulfate). Additionally, we observed decreased collagen III which might reflect increased myofibroblast contractility when coupled with increased TGFß and αSMA expression. Together these events lead to tissue dysfunction potentially resulting in hydraulic resistance that may affect aqueous flow through the capsular wall.

Outcomes of Ahmed Glaucoma Valve Revision in Pediatric Glaucoma.

PURPOSE: Encapsulation of the Ahmed glaucoma valve (AGV) plate is a common cause for postoperative elevation of intraocular pressure, especially in children. Many reports have described the outcomes of AGV revision in adults. However, the outcomes of AGV revision in children are poorly documented. The aim of this study was to determine the outcomes of AGV revision in children. DESIGN: Retrospective cross-sectional study. METHODS: A retrospective chart review of patients less than 15 years of age who underwent AGV revision with a minimum postoperative follow-up of 6 months was conducted. Outcome measures included reduction in intraocular pressure from baseline, survival analysis, and reduction in the number of antiglaucoma medications. Postoperative complications were also noted. Complete success was defined as an IOP of 21 mm Hg or less without medications, while qualified success was defined as having an IOP of 21 mm Hg or less with medications. RESULTS: A total of 44 eyes met the inclusion criteria. Primary congenital glaucoma was present in 39 eyes (88.6%), aphakic glaucoma in 4 eyes (9.1%), and Peters anomaly-associated glaucoma in 1 eye (2.3%). The mean number of previous surgeries was 1.4, and the mean age was 6.7 years (range, 1.9-13 years) with a median follow-up of 12 months (range, 6-24 months). The IOP was reduced from a preoperative mean of 30.4 (± 10.3) to 24.9 (± 10.6) mm Hg at 6 months postoperatively. Kaplan-Meier analysis showed that the complete success rate at 1 month was 100% followed by a rapid decline at 6 months to 38.6%, 27.7% at 1 year, and 5.5% at 2 years. Qualified success rate was 100% at 1 month followed by a 6-month and 1-year survival rate of approximately 50% and a 2-year survival rate of approximately 16%. The median survival time was 14 months. No specific risk factors for failure were identified. Visual acuity remained unchanged following revision. The most common complication was recurrence of encapsulation with elevated IOP (15.9%). Other complications included hyphema (n = 3; 6.8%), endophthalmitis (n = 1; 2.3%), wound leak (n = 1; 2.3%), and choroidal detachment (n = 2; 4.5%). CONCLUSION: Although the short-term success rate of AGV revision in children is high, with longer follow-up the success rate decreases significantly.

Pharmacokinetics and Safety of Travoprost 0.004% Ophthalmic Solution Preserved with Polyquad in Pediatric Patients with Glaucoma.

PURPOSE: To evaluate the systemic pharmacokinetics (PKs) of travoprost 0.004% preserved with Polyquad® (TRAVATAN®) in pediatric patients with glaucoma or ocular hypertension. METHODS: This was a phase 1, open-label, multicenter clinical study of patients aged ≥2 months to <18 years. Patients received daily administration of travoprost 0.004% preserved with Polyquad in both eyes for 7 days. Plasma samples were collected 30 min before the final dose and at 10, 20, 40, and 80 min postdose. The main outcome measure was maximum concentration of travoprost free acid in plasma (Cmax). RESULTS: Included in the PK analysis were 24 patients (average age 9.6 ± 4.9 years). At least 1 sample with quantifiable levels of travoprost free acid was collected for 11 patients. The mean Cmax was 0.0471 ± 0.0105 ng/mL for patients aged 2 months to <3 years; 0.0258 ± 0.0128 ng/mL for ages 3 to <12 years; and 0.0109 ± 0.0005 ng/mL for ages 12 to <18 years. Travoprost was undetectable in samples collected predose from pediatric patients. Treatment-related adverse events (AEs) included hyperemia, eye pain, and eye pruritus (n = 1 each). There were no discontinuations or drug-related serious AEs. CONCLUSIONS: Travoprost free acid concentration in plasma was low in pediatric patients, detectable in only 11 of 24 patients. There was no accumulation of travoprost over the course of treatment. No clear relationship was observed between age/body surface area and Cmax. No increased risk was identified for the use of travoprost 0.004% preserved with Polyquad in patients <18 years of age.

Intraocular Pressure Outcomes Following Transscleral Diode Cyclophotocoagulation Using Long and Short Duration Burns.

PURPOSE: The purpose of this study was to compare outcomes of transscleral diode cyclophotocoagulation using short duration (SD) versus longer duration (LD) treatment. PATIENTS AND METHODS: Data were collected retrospectively on patients with glaucoma who underwent cyclophotocoagulation with LD (4000 ms) treatment with variable power ≤1000 mW versus SD using 1500 ms with variable power ≤2000 mW. The outcome measures included: intraocular pressure (IOP) at 12 months, decrease in number of antiglaucoma medications, complications and visual acuity (VA) at the final follow-up visit. RESULTS: There were 71 patients and 70 patients in the SD and LD groups, respectively. The mean IOP±SD pretreatment baseline was 33±10 versus 36±10 mm Hg for SD and LD groups, respectively (P>0.05). At 1 year postoperatively, the IOP decreased significantly in both groups (16.7 vs. 17.4 mm Hg for SD and LD, respectively; P<0.0001). This decrease in IOP was comparable between groups (P=0.5). The average number of IOP lowering medications were 2.5 and 2.9 at baseline in the SD and LD groups, respectively, and decreased to 1.3 in both groups (P=0.83). The mean LogMAR VA decreased significantly from 1.87 at baseline to 1.96 at 1 year in the SD group (P=0.276), and 2.03 to 2.3 (P≤0.001) in the LD group, this change was comparable (0.19; P=0.075) between the 2 groups. Complications were also comparable. CONCLUSIONS: Both LD and SD burns during cyclophotocoagulation effectively lowered IOP at 1 year. Neither treatment resulted in a greater reduction of IOP. LD treatment appeared to result in a decrease in VA and greater postoperative inflammation.

Lymphatic and Blood Vessel Density in Human Conjunctiva After Glaucoma Filtration Surgery.

PURPOSE: To investigate the lymphatic vascular microvessel density (LVD) and the blood vascular microvessel density (MVD) and their distribution in excised leaking blebs after mitomycin C trabeculectomy and normal conjunctiva specimens. MATERIALS AND METHODS: LVD and MVD in normal human conjunctiva (n=8) and excised blebs in the hypocellular stroma and peribleb tissue (conjunctiva adjacent to hypocellular bleb tissue) (n=8) were evaluated by immunohistochemistry using antibodies raised against Lymphatic Vessel Endothelial Receptor 1 (D2-40, lymphatic endothelium) and CD34 (vascular endothelium). LVD and MVD counts were performed by light microscopy in 5 fields at ×20 magnification by 3 observers. Differences were determined using Mann-Whitney U test (P<0.05 was considered significant). RESULTS: The leaking blebs showed typical epithelial-stromal domes with areas of acellular stroma covered by attenuated epithelium and surrounded by normal conjunctival epithelium and a dense scar-like matrix replacing the substantia propria. The LVD and MVD were significantly reduced to nil in the hypocellular conjunctival stroma of the excised blebs compared with normal conjunctiva (21.42 vs. 1.16, P<0.002 and 24.28 vs. 1, P<0.008, respectively). The LVD and MVD was also reduced (2- to 2.5-fold) in the peribleb stroma when compared with normal conjunctiva specimens. CONCLUSIONS: In this study we show reduced LCD and MVD in the hypocellular and peribleb stroma. These results may suggest a role of these vessels in an altered immune response in leaking blebs leading to an increased risk for blebitis.

Altered expression of fibrosis genes in capsules of failed Ahmed glaucoma valve implants.

PURPOSE: Ahmed glaucoma valve (AGV) implant is an aqueous shunt device used to control intraocular pressure in glaucoma. Implant failure results from impervious encapsulation of the shunt plate causing increased hydraulic resistance and raised intraocular pressure. We hypothesized that deregulation of fibrosis pathway contributes to capsular resistance. We tested this by studying fibrosis related gene expression in failed AGV implants. METHODS: Differential gene expression was examined in failed AGV capsules and compared to normal control tenon. Following total RNA extraction, 84 key genes in fibrosis pathway were examined by real-time PCR using RT2 Profiler PCR Array. Relative gene expression was calculated using ΔΔCt method. Gene specific TaqMan assays were used to validate select genes with ≥2 fold differential expression in the array expression profile. RESULTS: We observed differential expression in several genes in the fibrosis pathway. Almost half (39/84) of examined genes showed ≥2 fold differential expression in majority of capsules examined on the array. TaqMan assays for select genes including CCN2 (CTGF), THBS1, SERPINE1, THBS2, COL3A1, MMP3, and IL1A in an increased validation sample set showed significant changes in expression (p value from <0.001 to 0.022) at a high frequency in concurrence with our array results. CONCLUSIONS: Pathway-focused analyses identified candidate genes with altered expression providing molecular evidence for deregulation of the fibrosis pathway in AGV failure.

Intraocular Pressure Following Phacoemulsification and Endoscopic Cyclophotocoagulation for Advanced Glaucoma: 1-Year Outcomes.

PURPOSE: To evaluate changes in intraocular pressure (IOP), vision, and medications at least 1 year after phacoemulsification combined with endocyclophotocoagulation for advanced glaucoma and cataract. METHODS: A retrospective chart review was conducted on patients with advanced glaucoma who underwent phacoemulsification combined with endocyclophotocoagulation at King Khaled Eye Specialist Hospital between 2005 and 2012. Data were collected on patient demographics, type of glaucoma, IOP over time, best-corrected visual acuity, number of glaucoma medications, comorbidities, and previous surgeries. Absolute success was defined as IOP≤15 mm Hg without medication and qualified success was IOP≤15 mm Hg with medications. Statistical significance was indicated by P<0.05. RESULTS: The study sample comprised 104 eyes (104 patients). Mean follow-up was 17.3±1.8 months. Mean IOP decreased from 17±1.4 mm Hg preoperatively to 14.7±1.3 mm Hg at the last postoperative visit. Absolute success was achieved in 11.9% (95% confidence interval, 5.6-18.2) of the eyes. Qualified success was achieved in 72.3% (95% confidence interval, 63.5-81.0) of the eyes. Best-corrected visual acuity improved by ≥2 lines in 76 (73%) eyes. Eyes with primary open-angle glaucoma had the higher absolute and qualified success rates compared with primary angle-closure and pseudoexfoliation glaucoma (P>0.05). Only 48 (46%) patients required >3 medications for IOP control compared with 78 (75%) patients before surgery. CONCLUSIONS: At ≥1 year postoperatively, the absolute success rate of treating advanced glaucoma by endocyclophotocoagulation and phacoemulsification was low. However, medication burden was reduced. Owing to the significant variation in the success rate based on the type of glaucoma, patients with advanced glaucoma should be carefully selected and counseled.

A novel CYP1B1 mutation with congenital glaucoma and total aniridia.

PURPOSE: Primary congenital glaucoma is a common disorder in the Middle East mainly caused by mutations in the the CYP1Bl gene. We report a family with three siblings that presented with recalcitrant childhood glaucoma, aniridia in two siblings with a novel CYP1B1 gene mutation. MATERIALS AND METHODS: Review of pedigree, clinical history and clinical course of the family. Genetic testing in the affected family members. RESULTS: Three sisters presented with clinical findings of severe congenital glaucoma and a positive family history. Clinical examination of two of sisters revealed corneal scarring, bilateral aniridia with severe glaucoma that required multiple surgical procedures to control intraocular pressure. The third sibling presented with garden-variety primary congenital glaucoma. Genetic analysis revealed a novel CYP1B1 gene mutation (g.8291 C > T; p.S485F). CONCLUSION: CYP1B1 mutation related congenital glaucoma can present with an extreme form of anterior segment dysgenesis that includes recalcitrant glaucoma, corneal opacification and aniridia.

Comparison of the anterior capsulotomy edge created by manual capsulorhexis and 2 femtosecond laser platforms: Scanning electron microscopy study.

PURPOSE: To compare the scanning electron microscopy (SEM) features of the anterior capsule edge created by continuous curvilinear capsulorhexis (CCC) and femtosecond laser-assisted capsulotomy using angular second moment and contrast. SETTING: King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia. DESIGN: Prospective comparative series. METHODS: Anterior capsule specimens following CCC (n = 10) or femtosecond laser-assisted capsulotomy using 2 platforms (Lensx, n = 9, and Victus, n = 10) were studied by SEM. Irregularity of the capsule edge was quantified using 2 parameters (angular second moment and contrast) using ImageJ software. The clinical features and laser parameters were correlated with angular second moment and contrast. RESULTS: By SEM, the femtosecond laser-assisted capsulotomy edge surfaces created by both lasers showed marked irregularity compared with the smooth edge of the CCC. The angular second moment and contrast measures for both lasers differed significantly from those obtained for CCC (P<.001). There was no between-laser difference in angular second moment and contrast measures. The angular second moment showed only a weak negative correlation with increasing laser power, whereas contrast showed a weak positive correlation with increasing power. CONCLUSIONS: Both laser platforms created an irregular capsulotomy edge. The angular second moment and contrast quantified capsule edge irregularities for further comparisons. These measures could be used to quantify efforts to reduce capsule-edge irregularity from femtosecond laser-lens capsule interaction.