Glaucomatous aqueous humor vesicles are smaller and differ in composition compared to controls.

Cells communicate with each other using vesicles of varying sizes, including a specific repertoire known as exosomes. We isolated aqueous humor (AH)-derived vesicles using two different methods: ultracentrifugation and an exosome isolation kit. We confirmed a unique vesicle size distribution in the AH derived from control and primary open-angle glaucoma (POAG) patients using various techniques, including Nanotracker, dynamic light scattering, atomic force imaging, and electron microscopy. Bonafide vesicle and/or exosome markers were present by dot blot in both control and POAG AH-derived vesicles. Marker levels differed between POAG and control samples, while non-vesicle negative markers were absent in both. Quantitative labeled (iTRAQ) proteomics showed a reduced presence of a specific protein, STT3B, in POAG compared to controls, which was further confirmed using dot blot, Western blot, and ELISA assays. Along the lines of previous findings with AH profiles, we found vast differences in the total phospholipid composition of AH vesicles in POAG compared to controls. Electron microscopy further showed that the addition of mixed phospholipids alters the average size of vesicles in POAG. We found that the cumulative particle size of type I collagen decreased in the presence of Cathepsin D, which normal AH vesicles were able to protect against, but POAG AH vesicles did not. AH alone had no effect on collagen particles. We observed a protective effect on collagen particles with an increase in artificial vesicle sizes, consistent with the protective effects observed with larger control AH vesicles but not with the smaller-sized POAG AH vesicles. Our experiments suggest that AH vesicles in the control group provide greater protection for collagen beams compared to POAG, and their increased vesicle sizes are likely contributing factors to this protection.

Delayed Suprachoroidal Hemorrhage After Xen45 Gel Stent.

PRCIS: In patients with significant preoperative comorbidities, prolonged activity restrictions beyond 2 weeks after Xen45 surgery may mitigate the risks of delayed SCH. PURPOSE: To report the first case to date of delayed suprachoroidal hemorrhage (SCH) not associated with hypotony 2 weeks after the placement of the Xen45 gel stent. CASE SUMMARY: An 84-year-old white man with significant cardiovascular comorbidities underwent uneventful ab externo implantation of a Xen45 gel stent for asymmetric progression of severe primary open angle glaucoma. The patient had a reduction in intraocular pressure by 11 mm Hg on postoperative day 1 and maintained preoperative visual acuity. The intraocular pressure remained stable at 8 mm Hg on multiple postoperative visits until the patient developed a SCH at postoperative week 2 immediately after a light session of physical therapy. The patient was treated medically with topical cycloplegic, steroid, and aqueous suppressants. He maintained preoperative visual acuity throughout the postoperative course and had resolving SCH without the need for surgical intervention. CONCLUSIONS: This is the first report of a delayed presentation of SCH in the absence of hypotony after ab externo implantation of the Xen45 device. The possibility of this vision-threatening complication should be considered as part of the risk assessment and included in the consent process for the gel stent. In patients with significant preoperative comorbidities, prolonged activity restrictions beyond 2 weeks after Xen45 surgery may mitigate the risks of delayed SCH.

The Effect of Changing Fellowship Interview Format on Candidate Ranking Variabilities: The COVID-19 Experience.

Purpose: This study investigated the effect of interview format changes (in-person to virtual, one-to-one to multiple-to-one) necessitated by the COVID-19 travel restrictions on preliminary fellowship candidate ranking variabilities. Design: Cross-sectional observational study. Method: In 2018 and 2019, the glaucoma fellowship interviews were conducted in-person in a one-to-one format, whereas in 2020, interviews were virtual and in a multiple (interviewers)-to-one (candidate) format. We compared ranking ranges of interviewers within the same virtual room (WSR) and not within the same virtual room (NWSR) to assess the effect of WSR versus NWSR on ranking variabilities. We also compared ranking categories ("accept," "alternate," and "pass") agreements between 2018, 2019, and 2020 to assess the effect of virtual versus in-person interviews on ranking variabilities. Results: NWSR and WSR mean rankings differed by 1.33 (95% confidence interval difference 0.61 to 2.04, p = 0.0003), with WSR interviewers having less variability than NWSR pairs. The variability between 2018/2019 (in-person interviews) and 2020 (virtual interviews) showed no differences between in-person and virtual interviews (weighted Kappa statistic 0.086 for 2018, 0.158 for 2019, and 0.101 for 2020; p < 0.05 for all years). The overall least attractive candidate has the lowest variability; the most attractive candidate has the second lowest variability. Conclusion: Grouping interviewers WSR during the interview decreased ranking variabilities compared to NWSR, while a change from in-person to virtual interview format did not increase the ranking variabilities. This suggests that the decreased nonverbal interactions in virtual interviews do not decrease interviewers' perceptions as applied to preliminary rankings.

Proteomics of pseudoexfoliation materials in the anterior eye segment.

Pseudoexfoliation syndrome (PEX) is characterized by the production of white extracellular fluffy clumps of microfibrillar material that aggregates in various organs throughout the body but is known to cause disease in the eye. The accumulation of PEX material (PEXM) in the anterior segment ocular structures is believed to cause an increase in intraocular pressure (IOP) resulting in pseudoexfoliation glaucoma (PEXG). The onset of PEXG is often bilateral but asymmetric-one eye often presents with glaucoma prior to the other eye. Proteomics has been used to identify key proteins involved in PEXM formation with the end goal of developing effective treatments for PEX and PEXG which may act through inhibiting the formation of the PEX aggregates. To date, a variety of proteins with various molecular functions have been identified from extracted anterior segment structures and fluids, such as aqueous humor (AH) and blood serum of patients affected by PEX. From past studies, some proteins identified in AH, lens capsule epithelium, iris tissue, and blood serum samples include vitamin D binding protein (GC), apolipoprotein A4 (APOA4), lysyl oxidase like-1 (LOXL1), complement C3, beta-crystalline B1, and B2, and antithrombin-III (SERPINC1). Each of these proteins have been observed in eyes with PEX at varying levels within the different eye structures. In this review, we further examine the anterior segment ocular proteomics of PEXM from past studies to better understand the mechanism of PEX and PEXG development. Both genetic and environmental risk factors have been implicated to be involved in the development of PEX and PEXG. This field is at an early stage of investigation identifying how these factors modify proteins both at the expression and functional level to cause changes leading to the pathophysiology of PEX glaucoma.

Virtual Versus In-Person Surgical Fellowship Interviews and Ranking Variability: the COVID-19 Experience.

Objective: To investigate the effect of interview format changes (in-person to virtual, one-to-one to multiple-to-one) necessitated by the COVID-19 travel restrictions on candidate ranking variabilities. Method: In 2018/2019, the glaucoma fellowship interviews were conducted in-person and one-to-one, whereas in 2020, interviews were virtual and multiple (interviewers)-to-one (candidate). We compared ranking ranges of interviewers within the same virtual room (WSR) and not within the same virtual room (NWSR) to assess the effect of this change on ranking variabilities. We also compared ranking categories ("accept," "alternate," and "pass") agreements between in-person and virtual interviews to assess the effect of this change on ranking variabilities. Results: NWSR and WSR mean rankings differed by 1.33 (95% confidence interval difference 0.61 to 2.04, p = 0.0003), with WSR interviewers having less variability than NWSR pairs. The variability of in-person interviews and later virtual interviews showed no differences (weighted Kappa statistic 0.086 for 2018, 0.158 for 2019, and 0.101 for 2020; p < 0.05 for all years). The overall least attractive candidate has the lowest variability; the most attractive candidate has the second lowest variability. Conclusion: Grouping interviewers decreased ranking variabilities, while a change from in-person to virtual interview format did not increase the ranking variabilities.

XEN Gel Stent Implantation Following Encircling Scleral Buckle Surgery.

Scleral buckling procedures create a challenge for intraocular pressure (IOP) control in the glaucoma patient. The encircling band is believed to compress vortex veins, causing increased episcleral venous pressure, a proposed mechanism for secondary glaucoma. Glaucoma drainage device implantation is preferred over trabeculectomy when medical management fails, but often involves modification of the glaucoma implant and manipulation of the fibrotic capsule surrounding the scleral buckle. This case demonstrates that ab externo XEN gel stent implantation may successfully reduce IOP without interfering with the previous scleral buckle, a major limitation of previous glaucoma filtering surgeries. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:289-292.].

Current Trends in Tonometry and Tonometer Tip Disinfection.

PRECIS: A survey among members of the American Glaucoma Society (AGS) and the American Optometry Association (AOA) on tonometer preference and tonometer disinfection indicates a shift to disposable tonometer tips compared with 1987. PURPOSE: This survey's purpose was to determine how eye care providers responded to the 2008 Centers of Disease Control (CDC) tonometer disinfection guidelines, which recommend 10% hypochlorite (dilute bleach) for reusable tonometers. Tonometers measure the eye pressure when they touch the cornea, an essential part of the eye examination. METHODS: AGS and AOA members were surveyed on tonometer preference, tonometer use, disinfection process, disinfectants, disinfection timing, and tonometer damage. RESULTS: Survey responses from 79 AOA members and 197 AGS members are included. The Goldmann tonometer is considered most accurate (70, 89% AOA and 161, 82% AGS). It is preferred by 54 (70%) AOA and 193 (98%) AGS members. Many providers (165) use reusable Goldmann tonometer tips (77, 79% AOA, 88, 45% AGS), and most clean with 70% isopropyl alcohol wipes 59 (77%) AOA and 54 (61%) AGS. In summary, 126 of 276 participants (8, 10% AOA and 118, 60% AGS) follow CDC guidelines by using disposable tips (2 AOA and 109 AGS) or disinfecting reusable tips with 10% hypochlorite (6 AOA and 9 AGS). CONCLUSIONS: The majority of AGS providers follow current CDC tonometer disinfection guidelines by shifting to disposable Goldmann tonometer tips. Only a minority of providers who use reusable tonometer tips disinfect with dilute bleach. Continued education on proper tonometer disinfection is critical to prevent eye-care related infection due to improper disinfection.

Differentiation of soluble aqueous humor metabolites in primary open angle glaucoma and controls.

We report an analysis of the aqueous humor (AH) metabolome of primary open angle glaucoma (POAG) in comparison to normal controls. The AH samples were obtained from human donors [control (n = 35), POAG (n = 23)]. The AH samples were subjected to one-dimensional 1H nuclear magnetic resonance (NMR) analyses on a Bruker Avance 600 MHz instrument with a 1.7 mM NMR probe. The same samples were then subjected to isotopic ratio outlier analysis (IROA) using a Q Exactive orbitrap mass spectrometer after chromatography on an Accela 600 HPLC. Clusterfinder Build 3.1.10 was used for identification and quantification based on long-term metabolite matrix standards. In total, 278 metabolites were identified in control samples and 273 in POAG AH. The metabolites identified were fed into previously reported proteome and genome information and the OmicsNet interaction network generator to construct a protein-metabolite interactions network with an embedded protein-protein network. Significant differences in metabolite composition in POAG compared to controls were identified indicating potential protein/gene pathways associated with these metabolites. These results will expand our previous understanding of the impeded AH metabolite composition, provide new insight into the regulation of AH outflow, and likely aid in future AH and trabecular meshwork multi-omics network analyses.

Aqueous humor metabolite profile of pseudoexfoliation glaucoma is distinctive.

Pseudoexfoliation (PEX) is a known cause of secondary open angle glaucoma. PEX glaucoma is associated with structural and metabolic changes in the eye. Despite similarities, PEX and primary open angle glaucoma (POAG) may have differences in the composition of metabolites. We analyzed the metabolites of the aqueous humor (AH) of PEX subjects sequentially first using nuclear magnetic resonance (1H NMR: HSQC and TOCSY), and subsequently with liquid chromatography tandem mass spectrometry (LC-MS/MS) implementing isotopic ratio outlier analysis (IROA) quantification. The findings were compared with previous results for POAG and control subjects analyzed using identical sequential steps. We found significant differences in metabolites between the three conditions. Principle component analysis (PCA) and partial least squares discriminant analysis (PLS-DA) indicated clear grouping based on the metabolomes of the three conditions. We used machine learning algorithms and a percentage set of the data to train, and utilized a different or larger dataset to test whether a trained model can correctly classify the test dataset as PEX, POAG or control. Three different algorithms: linear support vector machines (SVM), deep learning, and a neural network were used for prediction. They all accurately classified the test datasets based on the AH metabolome of the sample. We next compared the AH metabolome with known AH and TM proteomes and genomes in order to understand metabolic pathways that may contribute to alterations in the AH metabolome in PEX. We found potential protein/gene pathways associated with observed significant metabolite changes in PEX.

Supraciliary Microstent Revision in a Patient With Corneal Edema and Primary Open Angle Glaucoma: A Case Report.

A 56-year-old Hispanic male individual with moderate primary open-angle glaucoma on maximal tolerated topical therapy with recent visual field progression presented with excessive glare due to cataract in the right eye. The patient underwent uncomplicated phacoemulsification with supraciliary microstent implantation. Ten weeks postoperatively, he presented with global Descemet folds and focal corneal edema overlying the CyPass implant despite apparent adequate implant position (1 retention ring visible). The revision proved challenging as the anterior chamber portion of the implant was short. Nonetheless, the device was trimmed under gonioscopic view using intraocular lens cutting scissors and a Sinskey hook. Postoperatively, the implant was flush with the iris root with a patent lumen. Bilateral global guttae indicating unrecognized Fuchs endothelial corneal dystrophy diagnosed postoperatively may have contributed to the corneal edema that improved after the revision.

Visual and anatomic outcomes of cataract surgery with intraoperative or postoperative complications in a teaching institution.

OBJECTIVE: To review visual and anatomic outcomes after cataract surgery with complications in a teaching institution. METHODS: Consecutive case series. A chart review was conducted of patients who underwent phacoemulsification with intraoperative or postoperative complications, performed by ophthalmology residents under direct supervision of experienced ophthalmology attending physicians. Best corrected visual acuity (BCVA), OCT parameters, and postoperative treatments were reviewed at 1, 3, 6, and 12 months postoperatively. RESULTS: One hundred thirty-three eyes were analyzed. Mean BCVA was 50 ± 23 approximate Early Treatment Diabetic Retinopathy Study letters at the preoperative visit and improved by a mean of 8 letters (n = 128; p = 0.001), 16 letters (n = 117; p < 0.001), 14 letters (n = 79; p < 0.001), and 4 letters (n = 34; p = 0.37) at 1, 3, 6, and 12 months. The mean OCT central subfoveal thickness increased by less than 50 µm at all time points and this change was not statistically significant at 12 months. BCVA increased by 3 lines in 41%, 56%, 57%, and 44% of eyes at 1, 3, 6, and 12 months. Median BCVA was 20/40 or better at each follow-up period. Fifty-three (40%) eyes required a secondary surgical procedure due to intraoperative or postoperative complication. A significant proportion of eyes received anti-inflammatory drops through 1 year. CONCLUSIONS: After cataract surgery with intraoperative or postoperative complications, a majority of eyes experienced substantial visual gains and only mild retinal thickening while being managed with long-term anti-inflammatory drops and additional surgical procedures.

Swept-Source OCT for Evaluating the Lamina Cribrosa: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the use of swept-source (SS) OCT for evaluating the lamina cribrosa in glaucoma. METHODS: A PubMed and Cochrane Library literature search initially conducted on March 3, 2017, and updated on June 26, 2018, yielded a total of 64 articles. Articles that were reviews or that were not published in English were excluded, and 29 were found to fit the inclusion criteria. The panel methodologist then assigned a level of evidence rating to each study. Fifteen studies were rated level III, 14 studies were rated level II, and no studies were rated level I. RESULTS: Different aspects of the lamina cribrosa were studied using SS-OCT, including the anterior lamina cribrosa curvature, anterior lamina cribrosa depth, anterior lamina cribrosa insertions, laminar thickness, focal lamina cribrosa defects (FLCDs), and lamina cribrosa microarchitecture. In general, imaging of the anterior lamina can be achieved reliably, although shadowing from blood vessels at the neuroretinal rim remains an issue. Imaging of the posterior lamina can be achieved with varying levels of success. In glaucoma, there is posterior migration of the anterior lamina cribrosa insertions as well as increased thinning and posterior curvature of the lamina cribrosa. Focal lamina cribrosa defects appear more commonly in glaucoma, and this may hint at the pathogenesis of axonal damage. In addition, there may be remodeling of the microarchitecture of the lamina, resulting in more variable laminar pores. There are limited studies comparing SS-OCT with spectral-domain (SD) OCT with regard to imaging of the lamina, but the difference in image quality between enhanced depth imaging (EDI) with SD-OCT and SS-OCT seems minimal. CONCLUSIONS: Imaging of the lamina cribrosa using SS-OCT has demonstrated that the lamina cribrosa is likely biomechanically active and that significant changes occur in glaucoma. The diagnostic utility of SS-OCT for lamina cribrosa imaging is promising, but standardized nomenclature, automated measurements, and longitudinal studies with larger and more diverse sample sizes are needed.

The Effect of Anti-Vascular Endothelial Growth Factor Agents on Intraocular Pressure and Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To assess the effect of intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents on immediate and long-term intraocular pressure (IOP) elevation and glaucoma. METHODS: Literature searches of the PubMed and Cochrane databases, last conducted in April 2018, yielded 253 unique citations. Of these, 41 met the inclusion criteria and were rated according to the strength of evidence. Two articles were rated level I, 17 were rated level II, and 15 were rated level III; an additional 7 were excluded because of poor study design and lack of relevance to the topic under evaluation. RESULTS: The studies that reported on short-term IOP elevation (i.e., between 0 and 60 minutes) showed that an immediate increase in IOP is seen in all patients when measured between 0 and 30 minutes of intravitreal injection and that the IOP elevation decreases over time. The data on long-term IOP elevation were mixed; 7 studies reported that between 4% and 15% of patients developed sustained elevation of IOP at 9 to 24 months after injection, whereas 6 studies found no long-term change in IOP from 1 to 36 months after injection. Pretreatment with glaucoma medications, anterior chamber tap, vitreous reflux, longer intervals between injections, and longer axial lengths were associated with lower IOP elevations after injection. Data were mixed on the relationship between IOP increase and the type of intravitreal injection, number of intravitreal injections, preexisting glaucoma, and globe decompression before injection. There were no data on the onset or progression of glaucoma in the studies reviewed in this assessment. CONCLUSIONS: Intravitreal injection of anti-VEGF agents results in an immediate and transient increase in IOP. A long-term increase in IOP also may be seen, and further studies are needed to determine at-risk populations. Although there is some suggestion in the literature, there is currently insufficient data to determine the impact of intravitreal anti-VEGF injections on glaucoma progression. Although pretreatment with glaucoma medications, performing anterior chamber paracentesis, or increasing the interval between injections may reduce the impact of transient IOP elevation, the clinical significance and associated risks of these interventions are unknown.

Spectral-Domain OCT: Helping the Clinician Diagnose Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the current published literature on the use of spectral domain (SD) OCT to help detect changes associated with the diagnosis of glaucoma. METHODS: Searches of the peer-reviewed literature were conducted on June 11, 2014, November 7, 2016, August 8, 2017, and April 19, 2018, in the PubMed and Cochrane Library databases and included only articles published since the last glaucoma imaging Ophthalmic Technology Assessment, which included articles up until February 2006. The abstracts of these 708 articles were examined to exclude reviews and non-English articles. After inclusion and exclusion criteria were applied, 74 articles were selected, and the panel methodologist (K.N.-M.) assigned ratings to them according to the level of evidence. Two articles were rated level I, 57 articles were rated level II, and the 15 level III articles were excluded. RESULTS: Spectral-domain OCT is capable of detecting damage to the retinal nerve fiber layer (RNFL), macula, and optic nerve in patients with preperimetric and perimetric glaucoma (level I and II evidence). The most commonly studied single parameter was RNFL thickness. Of note, RNFL thickness measurements are not interchangeable between instruments. Various commercially available SD OCT instruments have similar abilities to distinguish patients with known glaucoma from normal subjects. Despite different software protocols, all SD OCT instruments are able to detect the same typical pattern of glaucomatous RNFL loss that affects primarily the inferior, inferior temporal, superior, and superior temporal regions of the optic nerve (level II evidence). Across many SD OCT instruments, macular imaging also can detect a preferential inferior, inferior temporal, and superior temporal thinning in patients with glaucoma compared with controls. Best disc parameters for detecting glaucomatous nerve damage are global rim area, inferior rim area, and vertical cup-to-disc ratio. Studies suggest that newer reference-plane independent optic nerve parameters may have the same or better detection capability when compared with older reference-plane dependent disc parameters (level II evidence). CONCLUSIONS: Structural glaucomatous damage can be detected by SD OCT. Optic nerve, RNFL, and macular parameters can help the clinician distinguish the anatomic changes that are associated with patients with glaucoma when compared with normal subjects.

Histologic Analysis of Trabecular Meshwork Obtained From Kahook Dual Blade Goniotomy.

PURPOSE: To determine whether there are identifiable, reproducible findings in the trabecular meshwork (TM) of patients with primary open-angle glaucoma (POAG) who underwent Kahook Dual Blade (KDB) goniotomy. DESIGN: Noncomparative retrospective case series. METHODS: Tertiary academic referral center, Veterans Affairs Medical Center. Thirteen patients (14 eyes) with POAG (100%) were treated with KDB goniotomy from May to December 2017. Isolated TM tissue was collected from 9 patients (10 eyes) and submitted for histologic analysis. Hematoxylin-eosin, periodic acid-Schiff, and elastin Van Gieson stains were completed, in addition to immunohistochemistry for collagen IV. RESULTS: Mean age of patients was 74.2 ± 6.7 years. Trabecular beams were identified in all 10 specimens, although distorted in 4 samples, of which 3 had a history of laser trabeculoplasty. Collagen IV staining was present in 10 of 10 samples, coating the trabecular beams. Elastin was present in 8 of 10 samples along the trabecular beams. Intraocular pressure and number of glaucoma medications decreased significantly in all cases postoperatively (P < .0001, P = .035, respectively). CONCLUSIONS: This pilot study demonstrates that tissue obtained during KDB goniotomy has a high yield of containing TM compared to reported yield of TM in specimens collected from traditional ab externo trabeculectomy (71% vs 20%, respectively). These goniotomy specimens possess sufficient anatomic preservation to be studied histologically. Trabecular meshwork obtained with this procedure may provide a novel modality to study TM dysfunction in open-angle glaucomas.

Laser Peripheral Iridotomy in Primary Angle Closure: A Report by the American Academy of Ophthalmology.

PURPOSE: To examine the efficacy and complications of laser peripheral iridotomy (LPI) in subjects with primary angle closure (PAC). METHODS: Literature searches in the PubMed and Cochrane databases were last conducted in August 2017 and yielded 300 unique citations. Of these, 36 met the inclusion criteria and were rated according to the strength of evidence; 6 articles were rated level I, 11 articles were rated level II, and 19 articles were rated level III. RESULTS: Reported outcomes were change in angle width, effect on intraocular pressure (IOP) control, disease progression, and complications. Most of the studies (29/36, 81%) included only Asian subjects. Angle width (measured by gonioscopy, ultrasound biomicroscopy, and anterior segment OCT) increased after LPI in all stages of angle closure. Gonioscopically defined persistent angle closure after LPI was reported in 2% to 57% of eyes across the disease spectrum. Baseline factors associated with persistent angle closure included narrower angle and parameters representing nonpupillary block mechanisms of angle closure, such as a thick iris, an anteriorly positioned ciliary body, or a greater lens vault. After LPI, further treatment to control IOP was reported in 0%-8% of PAC suspect (PACS), 42% to 67% of PAC, 21% to 47% of acute PAC (APAC), and 83%-100% of PAC glaucoma (PACG) eyes. Progression to PACG ranged from 0% to 0.3% per year in PACS and 0% to 4% per year in PAC. Complications after LPI included IOP spike (8-17 mmHg increase from baseline in 6%-10%), dysphotopsia (2%-11%), anterior chamber bleeding (30%-41%), and cataract progression (23%-39%). CONCLUSIONS: Laser peripheral iridotomy increases angle width in all stages of primary angle closure and has a good safety profile. Most PACS eyes do not receive further intervention, whereas many PAC and APAC eyes, and most PACG eyes, receive further treatment. Progression to PACG is uncommon in PACS and PAC. There are limited data on the comparative efficacy of LPI versus other treatments for the various stages of angle closure; 1 randomized controlled trial each demonstrated superiority of cataract surgery over LPI in APAC and of clear lens extraction over LPI in PACG or PAC with IOP above 30 mmHg.

Surgical Simulation Training Reduces Intraoperative Cataract Surgery Complications Among Residents.

INTRODUCTION: This retrospective consecutive case series examined whether training on a surgical simulator reduces intraoperative complication rates among novice ophthalmology residents learning cataract surgery. METHODS: Beginning July 2014, training on the Eyesi simulator became mandatory for novice postgraduate year 3 ophthalmology residents before live cataract surgery at our institution. Complication rates of the 11 simulator-trained residents (study group) were compared with their immediate 11 simulator-naive predecessors (comparison group). Only straightforward cataract cases (according to standardized preoperative criteria) where postgraduate year 3 residents served as the primary surgeon were included. Complication data were obtained from Morbidity and Mortality records and compared using Fisher exact test. A survey was administered to the residents to gauge the perceived utility of simulation training. RESULTS: The simulator-trained group (n = 501 cataract cases) and the simulator-naive comparison group (n = 454 cases) were analyzed. The complication rate in the simulator group was 2.4% compared with 5.1% in the comparison group (P = 0.037, Fisher exact test). Both the mean posterior capsule tear rate and vitreous prolapse rate in the simulator group were 2.2% compared with 4.8% in the comparison group (P = 0.032, Fisher exact test). The survey had a response rate of 100% (11/11), and 91% (10/11) of respondents felt that the training was "extremely worthwhile" and should be mandatory. CONCLUSIONS: The addition of surgical simulation training was associated with a significantly reduced rate of complications, including posterior capsule tears and vitreous prolapse, among novice postgraduate year 3 residents. There is a perceived utility among residents to incorporate virtual simulation into surgical training.

Disinfection of Tonometers: A Report by the American Academy of Ophthalmology.

OBJECTIVE: To examine the efficacy of various disinfection methods for reusable tonometer prisms in eye care and to highlight how disinfectants can damage tonometer tips and cause subsequent patient harm. METHODS: Literature searches were conducted last in October 2016 in the PubMed and the Cochrane Library databases for original research investigations. Reviews, non-English language articles, nonophthalmology articles, surveys, and case reports were excluded. RESULTS: The searches initially yielded 64 unique citations. After exclusion criteria were applied, 10 laboratory studies remained for this review. Nine of the 10 studies used tonometer prisms and 1 used steel discs. The infectious agents covered in this assessment include adenovirus 8 and 19, herpes simplex virus (HSV) 1 and 2, human immunodeficiency virus 1, hepatitis C virus, enterovirus 70, and variant Creutzfeldt-Jakob disease. All 4 studies of adenovirus 8 concluded that after sodium hypochlorite (dilute bleach) disinfection, the virus was undetectable, but only 2 of the 4 studies found that 70% isopropyl alcohol (e.g., alcohol wipes or soaks) eradicated all viable virus. All 3 HSV studies concluded that both sodium hypochlorite and 70% isopropyl alcohol eliminated HSV. Ethanol, 70% isopropyl alcohol, dilute bleach, and mechanical cleaning all lack the ability to remove cellular debris completely, which is necessary to prevent prion transmission. Therefore, single-use tonometer tips or disposable tonometer covers should be considered when treating patients with suspected prion disease. Damage to tonometer prisms can be caused by sodium hypochlorite, 70% isopropyl alcohol, 3% hydrogen peroxide, ethyl alcohol, water immersion, ultraviolet light, and heat exposure. Disinfectants can cause tonometer tips to swell and crack by dissolving the glue that holds the hollow tip together. The tonometer tip cracks can irritate the cornea, harbor microbes, or allow disinfectants to enter the interior of the tonometer tip. CONCLUSIONS: Sodium hypochlorite (dilute bleach) offers effective disinfection against adenovirus and HSV, the viruses commonly associated with nosocomial outbreaks in eye care. Tonometer prisms should be examined regularly for signs of damage.

The Effect of Phacoemulsification on Intraocular Pressure in Glaucoma Patients: A Report by the American Academy of Ophthalmology.

OBJECTIVE: To examine effects of phacoemulsification on longer-term intraocular pressure (IOP) in patients with medically treated primary open-angle glaucoma (POAG; including normal-tension glaucoma), pseudoexfoliation glaucoma (PXG), or primary angle-closure glaucoma (PACG), without prior or concurrent incisional glaucoma surgery. METHODS: PubMed and Cochrane database searches, last conducted in December 2014, yielded 541 unique citations. Panel members reviewed titles and abstracts and selected 86 for further review. The panel reviewed these articles and identified 32 studies meeting the inclusion criteria, for which the panel methodologist assigned a level of evidence based on standardized grading adopted by the American Academy of Ophthalmology. One, 15, and 16 studies were rated as providing level I, II, and III evidence, respectively. RESULTS: All follow-up, IOP, and medication data listed are weighted means. In general, the studies reported on patients using few glaucoma medications (1.5-1.9 before surgery among the different diagnoses). For POAG, 9 studies (total, 461 patients; follow-up, 17 months) showed that phacoemulsification reduced IOP by 13% and glaucoma medications by 12%. For PXG, 5 studies (total, 132 patients; follow-up, 34 months) showed phacoemulsification reduced IOP by 20% and glaucoma medications by 35%. For chronic PACG, 12 studies (total, 495 patients; follow-up, 16 months) showed phacoemulsification reduced IOP by 30% and glaucoma medications by 58%. Patients with acute PACG (4 studies; total, 119 patients; follow-up, 24 months) had a 71% reduction from presenting IOP and rarely required long-term glaucoma medications when phacoemulsification was performed soon after medical reduction of IOP. Trabeculectomy after phacoemulsification was uncommon; the median rate reported within 6 to 24 months of follow-up in patients with controlled POAG, PXG, or PACG was 0% and was 7% in patients with uncontrolled chronic PACG. CONCLUSIONS: Phacoemulsification typically results in small, moderate, and marked reductions of IOP and medications for patients with POAG, PXG, and PACG, respectively, and using 1 to 2 medications before surgery. Trabeculectomy within 6 to 24 months after phacoemulsification is rare in such patients. However, reports on its effects in eyes with advanced disease or poor IOP control before surgery are few, particularly for POAG and PXG.