Micropulse cyclophotocoagulation compared to continuous wave cyclophotocoagulation for the management of refractory pediatric glaucoma.

INTRODUCTION: Micropulse cyclophotocoagulation (MPCPC) has been shown in adults to offer a favorable post-operative safety profile compared to continuous wave transscleral cyclophotocoagulation (CWCPC) in the management of glaucoma. The purpose of this study is to evaluate the long term efficacy, safety, and effectiveness of MPCPC in the management of pediatric glaucoma when compared to CWCPC. METHODS: IRB approved retrospective chart review of patients with pediatric glaucoma that underwent MPCPC and CWCPC at 2 separate institutions. Success was defined as intraocular pressure (IOP) between 5 and 21mmHg on any number of topical glaucoma medication without requiring additional surgical intervention or oral IOP lowering medication. RESULTS: Of the 48 patients in the study, 22 (26 eyes) underwent MPCPC and 26 (30 eyes) underwent CWCPC. At 1 year, 7 out of 26 eyes (26.9%) achieved success in the MPCPC group compared to 13 out of 30 eyes (43.3%) in the CWCPC group. Survival analysis unveiled a statistically significant difference in success between the two groups (p = 0.03). CONCLUSION: In pediatric glaucoma patients undergoing cyclophotocoagulation procedures, CWCPC outperformed MPCPC using default settings in terms of achieving long-term IOP control. Additional studies are required to evaluated augmented MPCPC settings in pediatric glaucoma patients.

Iris atrophy after administration of Dexycu: Additional evidence and possible mechanism for a rare complication.

Purpose: To report the observation of iris atrophy with the use of Dexycu in cataract surgery and describe a possible mechanism for this complication. Observations: Between 2020 and 2021, 2 patients underwent cataract surgery procedures with the use of Dexycu and experienced iris atrophy. The first case of iris atrophy was discovered by 6-month follow-up and the second case by 2-month follow-up. The timing and nature of this complication possibly represent more than steroid-induced hypopigmentation. Conclusions and Importance: This publication adds further evidence of iris atrophy and a proposed mechanism associated with the use of Dexycu. Surgeons should be aware of this complication, especially when operating on eyes with dark irides.

Relationship of degrees of gonioscopy assisted transluminal trabeculotomy and trabecular shelf to success using a marker suture technique.

OBJECTIVE: To evaluate the safety and efficacy of gonioscopy-assisted transluminal trabeculotomy (GATT) using a marker suture which could be a viable low cost alternative to an illuminated micro catheter, by helping the surgeon identify obstruction to suture passage, and estimate the degree of Schlemm's canal cannulated. SUBJECT/METHODS: Thirty four eyes with 360° of open angles with uncontrolled IOP despite maximal medical therapy, non-compliant to medical therapy or failed incisional glaucoma surgery underwent GATT. 5-0 or 6-0 Prolene® suture was used to cannulate Schlemm's canal. An 8-0 Vicryl® suture was tied around the trailing portion of the Prolene® suture and acted as a guide to estimate the length of Schlemm's canal negotiated. The degree of trabecular shelf seen was noted postoperatively. RESULTS: Mean baseline IOP was 24.7 ± 8.8 mm Hg (range 13-54 mmHg). Six patients had appositional angle closure and the rest had open angles. Patients were followed up for a period of 45.0 ± 14.6weeks (range 6 weeks-2 years). The mean IOP 6 weeks after surgery was 13 ± 3.3 mm Hg, and at 1 year was 13.5 ± 2.6 mm Hg. Mean degrees of cannulation achieved was 264.5 ± 84.0˚ (90-360˚). The mean number of medications prior to surgery was 2.1 ± 1.0 and at 6 months review was 0.15 ± 0.3. The absolute success was 92.6% 1 year after surgery. Nine patients lost some of their trabecular shelf in the postoperative period, but this did not seem to affect the short term success rate. DISCUSSION: Suture GATT is a safe and effective procedure to lower IOP even in patients with partial cannulation. Adding a marker suture is a useful adjunct to help identify the length of Schlemm's canal successfully cannulated and monitor progress of the Prolene® suture.

The utility of home tonometry for peri-interventional decision-making in glaucoma surgery: Case series.

Purpose: To describe twelve cases in which home intraocular pressure (IOP) monitoring complimented clinical decision-making in glaucoma management. Observations: Home IOP monitoring elucidated peaks and amplitudes of variation that were not captured by in-clinic IOP measurements during the pre- or post-interventional period. Conclusions & Importance: Home monitoring can establish pre-treatment IOP patterns that are not evident during in-clinic measurements. Home monitoring can also demonstrate response to treatment more quickly than in-clinic monitoring, and provide more information about nyctohemoral fluctuations than is ascertained by in-clinic tonometry.

Patterns of Blindness in the Navajo Nation: A 9-Year Study.

The Navajo Nation is the largest Native American reservation by area and citizenship. The study sought to provide the first large-scale examination of ocular pathology within this population. A retrospective review of all Navajo patients seen at Moran Eye Center Navajo Nation Outreach Clinics from 2013 to 2021 for demographics, visual acuity, refractive, and eye pressure data was undergone. Further variables included comorbidity and eye diagnoses among patients at these clinics. Results: First-time patient visits totaled 2251 from 2013 to 2021. The median age was 53 (range, 18 to 92), and clinics had a predominance of female patients (1387:864). Among patients presenting without glasses, 20.67% (198/958), 9.71% (93/958), and 3.13% (30/958) had mild visual impairment (VI), moderate to severe VI, and blindness, respectively. Cataracts were the most common cause of blindness in these patients (40%, 12/30) and the need for glasses was the second most common cause (33%, 10/30). From 2016 to 2021, 17.71% (48/271) of diabetic patients were diagnosed with diabetic retinopathy (DR). Within the subset of Navajo patients that presented without any correction, 73% of bilateral blindness was preventable via glasses prescription or cataract surgery. This study comments on questions of equitable care for Navajo patients.

Exfoliation Syndrome in Baja Verapaz Guatemala: A Cross-Sectional Study and Review of the Literature.

There are little epidemiologic data on exfoliation syndrome (XFS) or exfoliation glaucoma (XFG) in Guatemala, especially in the underserved Baja Verapaz region. This observational study assessing XFS/XFG and demographic factors of this region aims to better understand unique exogenous and endogenous risk factors associated with XFS/XFG in Guatemala. During Moran Eye Center's global outreach medical eye camps from 2016-2017, 181 patients age 15 years and older presented for complete eye exams. These individuals were screened for eye disease and evaluated for possible surgical interventions that could occur during the camps to improve eyesight. During the dilated exams, XFS was noted as missing or present. Of those 181, 10 had insufficient data and 18 lacked a definitive diagnosis of XFS or XFG, resulting in 153 evaluable patients; 46 XFS and 9 XFG were identified. Age, gender, hometown, ancestry (languages spoken by parents and grandparents), past medical history, family medical history, and occupational data (only 2017 trip) were obtained for each patient. The most common occupations of these individuals were farming and housekeeping. Higher rates of XFS/XFG were noted in individuals of rural compared to urban settings and Mayan speaking people compared with Spanish speakers. Based on this subset of patients, with various ocular pathologies being evaluated during medical eye outreach camps, the prevalence of XFS/XFG appeared to be 36%, a high prevalence compared to other world populations. Location and higher altitude, along with a farming occupation, may contribute to XFS development and subsequent progression to XFG. To our knowledge, this is the largest study looking at the epidemiology of XFS/XFG in the Baja Verapaz region of Guatemala for those over the age of 15 years seeking eye exams and interventions.

Intraocular Pressure Elevation Following Intravitreal Anti-VEGF Injections: Short- and Long-term Considerations.

Published studies agree that transient intraocular pressure (IOP) spikes are common after intravitreal injections of anti-vascular endothelial growth factor agents. Currently, there is no standard of care guiding if and when to prevent these IOP spikes. Furthermore, there are challenges in determining the impact of postinjection IOP elevation on the health of the retinal ganglion cells, particularly given the often-existing comorbidities of retinal and glaucoma pathology. This review highlights the current literature regarding both acute and chronic postinjection IOP elevations and discusses management of postinjection IOP elevation, especially in patients at high risk for glaucomatous damage.

Combined Phacoemulsification and Pars Plana Vitrectomy for the Treatment of Cataract in Patients With Noninfectious Uveitis.

Purpose: This work evaluates the role of combined phacoemulsification and vitrectomy surgery in the management of cataract associated with noninfectious uveitis. Methods: A retrospective chart review was conducted of all patients aged 7 years or older who underwent a combined surgical approach from 2005 to 2018. Results: Eighty-five eyes of 67 patients were included in the study; 10.7% of eyes had a best-corrected visual acuity (BCVA) of 20/40 or better at time of surgery. At 1-year follow-up, 63.4% of eyes had a BCVA 20/40 or better and 7.6% had a BCVA of 20/200 or worse. There was an overall decrease in cystoid macular edema after surgery compared with preoperatively (47.6% vs 34.5% presurgery and postsurgery, respectively). Complete inflammatory disease remission off immunomodulatory therapy and systemic steroids was achieved in 21.1% of patients. Conclusions: A combined surgical approach is effective in visual rehabilitation in patients with uveitic cataracts and may promote inflammatory disease remission specifically in intermediate uveitis.

Corneal edema and keratitis following selective laser trabeculoplasty.

PURPOSE: To describe three cases of keratitis following Selective Laser Trabeculoplasty (SLT). OBSERVATIONS: Three females with a history of glaucoma presented with corneal edema, keratitis (endothelial, epithelial) and decreased visual acuity shortly after SLT. There was variable resolution of symptoms after starting treatment with oral antiherpetics and topical steroids. CONCLUSIONS AND IMPORTANCE: With the increase in usage of SLT as a treatment for glaucoma and subsequent reports of keratitis, it is imperative for ophthalmic surgeons to be aware of herpes simplex as a possible risk factor. Prompt treatment with antivirals and steroids can potentially prevent scarring and permanent damage to the cornea.

A comparison of semiautomated versus manual Goldmann kinetic perimetry in patients with visually significant glaucoma.

PURPOSE: To determine if semiautomated kinetic perimetry (SKP) is reproducible and comparable to Goldmann manual kinetic perimetry (GVF). METHODS: Glaucoma patients were recruited to perform visual field testing using GVF and SKP. Specific isopters were tested, quantified, and compared. Visual field patterns were analyzed for shape and defect. RESULTS: Ten patients (16 eyes) underwent visual field studies using SKP and GVF, and 8 patients completed a second SKP on a different day. Individual isopter areas were similar between GVF and SKP, although 60% of isopters were larger on SKP by an average of 15%. This was statistically significant for the smaller isopters, I4e (P=0.02) and I2e (P=0.05). Retesting with SKP on a separate day, showed similar isopter areas (P values=0.3 to 1.0), however, the exact location of isopters in degrees from central fixation tended to vary with the smaller test object sizes. Isopter position in degrees from the central axis agreed in at least 3 quadrants in approximately 65% of fields compared. SKP visual field defects and patterns were similar between test strategies. CONCLUSIONS: SKP and GVF testing produce similar visual field results in glaucoma patients, and SKP testing seems to be reliable and reproducible in this population. However, overlapping isopters, typically associated with nonorganic vision loss, and jagged isopters were sometimes observed in SKP visual fields. Further study of SKP is needed to explore these findings.