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.

Managing primary open-angle glaucoma in the setting of suboptimal surgical outcomes in the fellow eye.

A 62-year-old woman with mild myopia presented to her local optometrist for a routine examination and was found to have intraocular pressure (IOP) of 30 mm Hg in both eyes and cupped nerves. She had a family history of glaucoma in her father. She was started on latanoprost in both eyes and was referred for a glaucoma evaluation. On initial evaluation, her IOP was 25 mm Hg in the right eye and 26 mm Hg in the left eye. Central corneal thickness measured 592 µm in the right eye and 581 µm in the left eye. Her angles were open to gonioscopy without any peripheral anterior synechia. She had 1+ nuclear sclerosis with a corrected distance visual acuity (CDVA) of 20/25 in the right eye and 20/30- in the left eye and uncorrected near visual acuity of J1+ in each eye. Her nerves were 0.85 mm in the right eye and 0.75 mm in the left eye. Optical coherence tomography (OCT) showed retinal nerve fiber layer thinning and a dense superior arcuate scotoma into fixation in her right eye, and superior and inferior arcuate scotomas in her left eye (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202307000-00019/figure1/v/2023-06-26T195222Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202307000-00019/figure2/v/2023-06-26T195222Z/r/image-tiff, Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A882 and http://links.lww.com/JRS/A883). She was successively trialed on fixed combination brimonidine-timolol, dorzolamide, and netarsudil, in addition to her latanoprost, but her IOP remained in the mid- to upper 20s in both eyes. The addition of acetazolamide lowered the pressure to 19 mm Hg in both eyes, but she tolerated it poorly. Methazolamide was also attempted with similar side effects. We elected to perform left eye cataract surgery combined with 360-degree viscocanaloplasty and insertion of a Hydrus microstent (Alcon Laboratories, Inc.). Surgery was uncomplicated with IOP of 16 mm Hg on postoperative day 1 with no glaucoma medications. However, by postoperative week 3, IOP returned to 27 mm Hg, and despite restarting latanoprost-netarsudil and finishing her steroid taper, IOP remained at 27 mm Hg by postoperative week 6. Brimonidine-timolol was added back to her left eye regimen and at postoperative week 8, IOP had elevated to 45 mm Hg. Maximizing her therapy with the addition of topical dorzolamide and oral methazolamide brought her IOP back down to 30 mm Hg. At that point, the decision was made to proceed with trabeculectomy of the left eye. The trabeculectomy was uneventful. However, postoperative attempts to augment filtration were rendered less successful by extremely thick Tenon layer. At her most recent follow-up the pressure in the left eye was mid-teens with brimonidine-timolol and dorzolamide. Her right eye IOP is in the upper 20s on maximum topical therapy. Knowing her postoperative course in the left eye, how would you manage the right eye? In addition to currently available options, would you consider a supraciliary shunt such as the MINIject (iSTAR) if such a device were U.S. Food and Drug Administration (FDA)-approved?

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.

Exfoliation Syndrome and Exfoliation Glaucoma in the Navajo Nation.

(1) Background: Exfoliation syndrome (XFS) is a common cause of secondary open angle glaucoma. In 1971, Faulkner et al. estimated the prevalence of XFS among 50 Navajo Nation residents as 38%. Given that XFS can cause irreversible blindness secondary to glaucoma (XFG), this study aims to identify the current prevalence of XFS among Navajo Nation residents within the Four Corners region of the U.S. (2) Methods: A retrospective chart review was conducted from 2016 to 2021 for patients aged 18 and older. All patients with XFS or XFG diagnosed by slit lamp exam were identified through chart review. (3) Results: Of the 1152 patient charts available for review, eight patients (11 eyes) were diagnosed with XFS with three patients (4 eyes) demonstrating concomitant XFG. Within this XFS population, 50% of the patients identified as male, with a mean age of 73 years. The overall prevalence of XFS was 0.7% and the overall prevalence of XFG was found to be 0.26%. The rate of XFG among patients with XFS was 37.5%. (4) Conclusion: Compared to Faulkner's study of Navajo Nation residents in 1971, our findings show a considerably lower prevalence of XFS at 0.7%. We present the largest study to date of XFS among this population.

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.

Outcome of a low-cost glaucoma drainage device with posterior chamber/pars plana insertion of the tube.

INTRODUCTION: The Aurolab aqueous drainage implant (AADI) is a low-cost glaucoma drainage device that is modelled on the Baerveldt glaucoma implant. Studies on AADI have reported absolute success rates of 41.8-93.1% at 1 year. Most studies report on tube placement in the anterior chamber. We report on results of tube insertion in the sulcus/pars plana. MATERIAL AND METHODS: A retrospective chart review of all patients who had undergone AADI implantation (with insertion of tube in the sulcus/posterior segment) between June 2015 and November 2018 was done. Patients were asked to stop anti-glaucoma medications on the 40th post-operative day. RESULTS: The mean age was 57.4 ± 13.8 years (n = 30). The mean IOP prior to surgery was 34.4 ± 6.1 mmHg which reduced to 15.4 ± 8.6 mmHg on the 45th post-operative day (p < 0.001). The absolute success at last review was 10% and the qualified success was 80%. The complication rate was 26.7%. Three patients had hypotony related complications noted at/after the 45th day review (none before 40th day). The incidence of ocular motility disturbances was 26.7% though none of the patients reported diplopia. One patient had sideways rotation of the scleral patch graft resulting in tube exposure. This complication was not seen after we shifted to using 9-0 nylon sutures to anchor the graft. Six patients had loss of best corrected visual acuity and one patient developed endophthalmitis. The endophthalmitis was preceded by conjunctival retraction and sloughing off of the scleral patch graft. DISCUSSION: AADI implantation results in a substantial drop in IOP. However, many patients continue to require anti-glaucoma medications. Allowing overlap of scleral/corneal patch graft onto the scleral flap may be effective in preventing peritubular leak. It may be advisable to use 9-0 nylon sutures to secure the scleral patch graft anti-glaucoma medications can be temporarily suspended after the 40th post-operative day to minimize hypotony related complications. Melting of the scleral patch graft may be an early sign of endophthalmitis. It would be prudent to specifically look for ocular motility problems in patients undergoing AADI implantation.

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.

Trabeculectomy With Mitomycin C or Ahmed Valve Implantation in Eyes With Uveitic Glaucoma.

PURPOSE: To report and compare the results of trabeculectomy with mitomycin C (MMC) and Ahmed valve implantation in the management of uveitic glaucoma. PATIENTS AND METHODS: The records of 41 eyes of 29 patients who underwent trabeculectomy with MMC or Ahmed valve implantation for uveitic glaucoma were retrospectively reviewed. Seventeen eyes underwent trabeculectomy with MMC, and 24 eyes underwent Ahmed valve implantation. Outcomes included postoperative intraocular pressure (IOP), percent reduction from preoperative IOP, postoperative number of medications, time to failure, and complications. RESULTS: Mean follow-up was 21.2 months in the trabeculectomy group and 23.8 months in the valve group (P=0.06). Mean IOP was reduced from 29.2 to 18.4 mm Hg in the trabeculectomy group (31.3%), compared with a reduction from 33.4 to 15.5 mm Hg in the Ahmed valve group (42.7%, P=0.53). Postoperatively, 1.76 medications were used in the trabeculectomy group, compared with 1.83 medications in the Ahmed valve group (P=0.89). Cumulative success at 1 year was 66.7% in the trabeculectomy group, compared with 100% in the Ahmed valve group (P=0.02). Mean time to failure was 8.36 months with trabeculectomy, and 21.8 months with Ahmed valve (P=0.02). Complications in both groups were typically rare and self-limited, with recurrent inflammation being most common. CONCLUSIONS: Although both trabeculectomy with MMC and Ahmed valve implantation are reasonable surgical options in the management of uncontrolled uveitic glaucoma, Ahmed valve implantation was associated with higher cumulative success rate at 1 year and a longer mean time to failure.

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.

Preferences among four combination nicotine treatments.

RATIONALE: Acute nicotine replacement treatments (NRTs) are disliked or misused, leading to insufficient nicotine intake and poor outcome. Patches provide steady nicotine but are slow and passive. Combining systems may improve efficacy with acute NRTs tailored for compliance. OBJECTIVE: To test initial reactions to and use preferences among combinations of NRTs. MATERIALS AND METHODS: Smokers (n=27) tested four combination NRTs in a 5-day crossover trial: 2/4-mg gum + 15-mg patch (G/P), 2/4-mg lozenges + 15-mg patch (L/P), inhaler + 15-mg patch (I/P), and 10 mg + 15-mg patches (P/P). Subjects rated an NRT combination each day after 5-6 h of use and ranked among the NRTs after testing all treatments. RESULTS: Double-patches (P/P) were ranked highest for "ease of use", "safety", and "use in public". However, for "help to quit", 70% preferred some form of acute-patch combination (A/P) compared to 30% choosing P/P. For "use under stress" (an immediate need), 93% preferred A/P systems compared to 7% choosing P/P. L/P ranked lowest for "ease of use", I/P and L/P were lowest on "safety", and I/P ranked lowest for "use in public". Expectations of NRTs changed with test experience for patches (better) and lozenges (worse). CONCLUSIONS: In brief testing, all combinations were acceptable. P/P was favored for ease, safety, and public use, but a majority chose A/P systems for help in quitting and use under stress. Combined use is viable and needs to be made known and accessible to smokers.

Thrombolytic therapy for massive pulmonary embolism in a patient with a known intracranial tumor.

The objective was to describe and review the use of thrombolytic therapy in a patient with an intracranial tumor and massive pulmonary embolism. This is the first reported case of a patient with a known glioblastoma multiforme and massive pulmonary embolism who was successfully treated with alteplase. Pulmonary embolism was demonstrated by a ventilation-perfusion scan and transthoracic echocardiogram with repeat studies demonstrating resolution of the thromboembolism and reperfusion of pulmonary vasculature. A review of the literature revealed that the incidence of intracranial hemorrhage with thrombolysis is <3% and compares favorably with the much higher mortality rate of 25% to >/=50% in patients with hemodynamically unstable pulmonary emboli. The benefit of thrombolysis may outweigh the risks of intracranial hemorrhage in these patients, and careful consideration for its use in these patients is warranted.