Clinicians' Use of Quantitative Information while Assessing the Rate of Functional Progression in Glaucoma.

PURPOSE: Clinicians use both global and point-wise information from visual fields to assess the rate of glaucomatous functional progression. We asked which objective, quantitative measures best correlated with subjective assessment by glaucoma experts. In particular, we aimed to determine how much that judgment was based on localized rates of change vs. on global indices reported by the perimeter. DESIGN: Prospective cohort study. PARTICIPANTS: Eleven academic, expert glaucoma specialists independently scored the rate of functional progression, from 1 (improvement) to 7 (very rapid progression), for a series of 5 biannual clinical printouts from 100 glaucoma or glaucoma suspect eyes of 51 participants, 20 of which were scored twice to assess repeatability. METHODS: Regression models were used to predict the average of the 11 clinicians' scores based on objective rates of change of mean deviation (MD), visual field index (VFI), pattern standard deviation (PSD), the Nth fastest progressing location, and the Nth fastest progressing of 10 anatomically defined clusters of locations after weighting by eccentricity. MAIN OUTCOME MEASURES: Correlation between the objective rates of change and the average of the 11 clinicians' scores. RESULTS: The average MD of the study eyes was -2.4 dB (range, -16.8 to +2.8 dB). The mean clinician score was highly repeatable, with an intraclass correlation coefficient of 0.95. It correlated better with the rate of change of VFI (pseudo-R2 = 0.73, 95% confidence interval [CI, 0.60-0.83]) than with MD (pseudo-R2 = 0.63, 95% CI [0.45-0.76]) or PSD (pseudo-R2 = 0.41, 95% CI [0.26-0.55]). Using point-wise information, the highest correlations were found with the fifth-fastest progressing location (pseudo-R2 = 0.71, 95% CI [0.56-0.80]) and the fastest-progressing cluster after eccentricity weighting (pseudo-R2 = 0.61, 95% CI [0.48-0.72]). Among 25 eyes with an average VFI of > 99%, the highest observed pseudo-R2 value was 0.34 (95% CI [0.16-0.61]) for PSD. CONCLUSIONS: Expert academic glaucoma specialists' assessment of the rate of change correlated best with VFI rates, except in eyes with a VFI near the ceiling of 100%. Sensitivities averaged within clusters of locations have been shown to detect change sooner, but the experts' opinions correlated more closely with global VFI. This could be because it is currently the only index for which the perimeter automatically provides a quantitative estimate of the rate of functional progression.

Clinicians' Use of Quantitative Information When Assessing the Rate of Structural Progression in Glaucoma.

PURPOSE: OCT scans contain large amounts of information, but clinicians often rely on reported layer thicknesses when assessing the rate of glaucomatous progression. We sought to determine which of these quantifications most closely relate to the subjective assessment of glaucoma experts who had all the diagnostic information available. DESIGN: Prospective cohort study. PARTICIPANTS: Eleven glaucoma specialists independently scored the rate of structural progression from a series of 5 biannual clinical OCT printouts. METHODS: A total of 100 glaucoma or glaucoma suspect eyes of 51 participants were included; 20 were scored twice to assess repeatability. Scores ranged from 1 (improvement) to 7 (very rapid progression). Generalized estimating equation linear models were used to predict the mean clinician score from the rates of change of retinal nerve fiber layer thickness (RNFLT) or minimum rim width (MRW) globally or in the most rapidly thinning of the 6 sectors. MAIN OUTCOME MEASURES: The correlation between the objective rates of change and the average of the 11 clinicians' scores. RESULTS: Average RNFLT within the series of study eyes was 79.3 µm (range, 41.4-126.6). Some 95% of individual clinician scores varied by ≤ 1 point when repeated. The mean clinician score was more strongly correlated with the rate of change of RNFLT in the most rapidly changing sector in %/year (pseudo-R2 = 0.657) than the rate of global RNFLT (0.372). The rate of MRW in the most rapidly changing sector had pseudo-R2 = 0.149. CONCLUSIONS: The rate of change of RNFLT in the most rapidly changing sector predicted experts' assessment of the rate of structural progression better than global rates or MRW. Sectoral rates may be a useful addition to current clinical printouts.

Metastatic paraganglioma presenting as ajunctional scotoma.

PURPOSE: To report a unique case of metastatic paraganglioma presenting as a junctional scotoma. OBSERVATIONS: A 38-year-old Caucasian man with a history of abdominal paraganglioma presented with minimally blurred vision 20/25 visual acuity in the left eye. The patient was found to have a junctional scotoma upon visual field testing. Cranial MRI revealed a large peri-clival mass compressing the pre-chiasmal optic nerves and other loci of metastatic disease. Intracranial masses, including metastases, can present with a relatively intact central acuity and nonspecific visual symptoms. CONCLUSIONS AND IMPORTANCE: To the best of our knowledge, this is the first report of metastatic paraganglioma causing a junctional scotoma. In cases with junctional scotoma, careful neuro-ophthalmic assessment and imaging are of paramount importance, even in patients with excellent visual acuity.

Intraoperative suprachoroidal hemorrhage during Xen gel stent implantation.

PURPOSE: To report a rare case of intraoperative suprachoroidal hemorrhage during Xen gel stent implantation with accompanying surgical video and subsequent 6-month follow-up. OBSERVATIONS: Our patient required incisional glaucoma surgery after inadequate pressure reduction with four classes of topical medication, methazolamide, and selective laser trabeculoplasty. The patient underwent Xen gel stent implantation and developed an intraoperative suprachoroidal hemorrhage, which was managed in the operating room. The patient recovered his baseline visual acuity with a functioning bleb out to 6 months postoperatively. CONCLUSIONS AND IMPORTANCE: Micro-invasive glaucoma surgeries offer a new repertoire of surgical options, purportedly with safer and less invasive techniques. Xen gel stent implantation may be a promising alternative to traditional trabeculectomies and tube shunt implants, providing similar IOP lowering results with potentially lower risk for complications. However, rare and severe complications such as suprachoroidal hemorrhage may still occur. Recognizing a suprachoroidal bleed, particularly intraoperatively, will still be necessary to help minimize the potential vision threatening sequelae often associated with this severe complication.

Review of the Xen Gel Stent and InnFocus MicroShunt.

PURPOSE OF REVIEW: Two new translimbal glaucoma devices (Xen Gel Stent and InnFocus MicroShunt) have been developed with the goal of optimizing the predictability and safety for subconjunctival glaucoma surgery. RECENT FINDINGS: The new subconjunctival glaucoma implants are manufactured from nonsilicone, biocompatible materials, which may reduce the postoperative inflammatory and fibrotic reactions that can lead to failure. Early data suggests a favorable safety profile with significant reductions in intraocular pressure (IOP). The prevention of chronic hypotony has been a hallmark of the devices, which utilize an intrinsic flow-limiting design based on the tube length and internal lumen diameter. SUMMARY: Early data with the XEN Gel Stent and InnFocus MicroShunt show promising results. Prospective comparative studies comparing these devices with tube shunt and trabeculectomy will be needed.

Patch graft materials for glaucoma tube implants.

PURPOSE OF REVIEW: Patch graft materials serve multiple purposes in glaucoma surgery. There are several choices of patch graft materials from which the surgeon can choose. Therefore, knowledge as to the choices and the potential risks and benefits of patch graft materials is imperative for the glaucoma surgeon. RECENT FINDINGS: Recent studies evaluate both patch graft materials and techniques. This evaluation is timely as facility reimbursement changes may also impact utilization and technique. SUMMARY: Successful operative outcomes require profound understanding of all potential risks and benefits of patch graft materials and surgical techniques.

Assessment of risk factors for oxacillin-resistant ocular flora in eyes having cataract surgery.

PURPOSE: To assess the risk factors for eyes of cataract surgery patients harboring oxacillin-resistant Staphylococcus species on the ocular surface. SETTING: Ambulatory surgical center, Saint Louis University, Saint Louis, Missouri, USA. DESIGN: Prospective in vitro laboratory study of a patient cohort. METHODS: Conjunctival cultures were obtained on the day of surgery from eyes scheduled for cataract surgery. Patients answered a questionnaire about risk factors that might lead to having oxacillin-resistant Staphylococcus organisms in their eyes. The factors tested were age, sex, race, recent systemic and topical antibiotic usage, recent hospitalization, and exposure to healthcare and institutional settings. Logistic regression analysis was performed. RESULTS: Of the 183 eyes cultured, 128 (70.0%) tested positive for Staphylococcus organisms, of which 70 (54.7%) were oxacillin-resistant. Only recent antibiotic usage was statistically significantly associated with the presence of oxacillin-resistant organisms (odds ratio, 8.2; 95% confidence interval, 2.2-30.5; P=.002). The other risk factors were not statistically significantly associated: age (P=.06), sex (P=.33), race (P=.34), recent hospitalization (P=.94), and exposure to healthcare and institutional settings (P=.10). CONCLUSIONS: Although the nonophthalmic literature has reported various risk factors for the harboring of oxacillin-resistant organisms, in the eyes in this study, only antibiotic usage within 30 days preoperatively was significantly associated with the colonization of oxacillin-resistant organisms on the ocular surface. This finding is important to ophthalmic surgeons when considering perioperative antibiotic prophylaxis. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Ocular flora and their antibiotic resistance patterns in the midwest: a prospective study of patients undergoing cataract surgery.

PURPOSE: To determine the spectrum of conjunctival flora and the antibiotic susceptibility profiles of patients undergoing cataract surgery at a Midwestern university. DESIGN: Prospective in vitro laboratory investigation of a patient cohort. METHODS: Conjunctival cultures were obtained from patients undergoing cataract surgery at a single ambulatory center on the day of surgery before the instillation of any ophthalmic medications. Isolates and antibiotic susceptibility profiles were identified using standard microbiological techniques. RESULTS: A total of 183 eyes were cultured, yielding 225 isolates. Twenty-seven eyes (14.8%) showed no growth. Coagulase-negative staphylococci (CNS) were the most commonly isolated organisms (74.8%). Overall susceptibility was highest for gentamicin (94%), which was also true of the CNS isolates (95.0%). A total of 64.5% of CNS isolates were sensitive to ciprofloxacin; 30.1% of CNS isolates were resistant to ≥3 classes of antibiotics; 46.6% of CNS isolates were oxacillin-resistant, and they were more resistant to antibiotics than their oxacillin-sensitive counterparts (P < .001), including fluoroquinolones (P < .001). Among eyes with multiple CNS strains, 41.4% had different antibiotic susceptibility profiles even though they were the same species. CONCLUSIONS: Our cohort harbored organisms with similar rates of antibiotic resistance as elsewhere in the country, including oxacillin resistance; however, the rate of fluoroquinolone resistance was less than in other reports. A surprisingly large proportion of different CNS strains from the same eye harbored different antibiotic susceptibility profiles. Our in vitro results, along with those of other investigators, should prompt further dialogue regarding antibiotic of choice for perioperative surgical prophylaxis in ophthalmic surgery.

Surgical management of non-traumatic pediatric ectopia lentis: A case series and review of the literature.

PURPOSE: To report a small series of pediatric patients with ectopia lentis that underwent limbal-approach lensectomy and vitrectomy and scleral-fixated intraocular lens implantation and to review the literature on the topic of surgical management of ectopia lentis. METHOD: A retrospective review of 13 eyes of seven patients that underwent lensectomy, vitrectomy, and scleral-fixated intraocular lens implantation and a review of the ophthalmic literature. RESULTS: In our series, the average age at surgery was 70.3 ± 13.8 months and the average length of follow-up was 23.8 ± 5.9 months. The mean pre-operative visual acuity was 0.86 ± 0.17 which improved to 0.23 ± 0.09 post-operatively (p < 0.001). No complications were encountered in our series. A review of the literature found that amblyopia was the biggest vision-limiting factor. In general, the literature suggested that a higher percentage of eyes that were left aphakic achieved better vision than those implanted with a scleral-fixated intraocular lens. However, there may be selection bias in that more eyes receiving an intraocular lens may have pre-existing amblyopia. The complication rates for lensectomy or scleral-fixated intraocular lens implantation were low in the literature. In the latter group, suture breakage and resultant intraocular lens dislocation is a worrisome late complication. CONCLUSION: Surgical intervention for ectopia lentis via vitrectomy techniques yields good result. In cases of unilateral aphakia or in settings where compliance with aphakic refractive correction is questionable and amblyopia is a constant threat, scleral-fixated intraocular lens implantation is highly encouraged. However, long-term follow-up is required due to the risk of suture breakage and resultant intraocular lens dislocation over time.

Nondisplacement of descemet stripping automated endothelial keratoplasty lenticule after traumatic rupture of the globe.

PURPOSE: The purpose of this study was to report a case of nondisplacement of an endothelial keratoplasty (EK) lenticule after traumatic rupture of the globe. METHODS: The authors conducted a review of the clinical course of a 35-year-old woman who sustained a traumatic rupture of the globe 4 months after Descemet stripping endothelial keratoplasty. RESULTS: The rupture did not involve the 4-month-old temporal scleral tunnel wound used for the EK. The lenticule was attached despite the injury and remained so in the postoperative course. CONCLUSIONS: Blunt trauma after endothelial keratoplasty can result in the disruption of the operative wound and lenticule dislocation. However, in our case, the rupture site did not involve the surgical wound, and the lenticule remained attached throughout the trauma, the surgical repair of the ruptured globe, and the postinjury course. This case illustrates the potential strength of EK wounds and the strength of adhesion of the transplanted lenticule and poses unanswered questions about the process of wound healing and attachment of donor lenticules in EK cases.

Clinical experience with the Baerveldt 250-mm2 Glaucoma Implant.

PURPOSE: To report the intermediate-term results of the Baerveldt 250-mm2 Glaucoma Implant for treatment of adult glaucoma. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: One hundred eight adult patients (108 eyes) with glaucoma who received a Baerveldt 250-mm2 Glaucoma Implant. INTERVENTION: Implantation of the Baerveldt 250-mm2 Glaucoma Implant. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), visual acuity, number of glaucoma medications, and surgical complications. Success was defined as IOP > or = 6 mmHg and < or = 21 mmHg (with or without antiglaucoma medications), without further glaucoma surgery, devastating complication, or loss of light perception attributable to drainage implantation. RESULTS: Mean age was 63.8+/-16.5 years. Mean postoperative follow-up was 22.8 months (range, 0.2-84.9; interquartile range, 3.9-36.3). Mean preoperative IOP was 36.3+/-13.0 mmHg, on 2.9+/-1.1 antiglaucoma medications. The mean postoperative IOP at final visit was 15.8+/-7.6 mmHg (P<0.0001, paired t test), on 0.8+/-1.0 antiglaucoma medications (P<0.0001, Wilcoxon test). Kaplan-Meier success rates were 0.92 (6 months, n = 81), 0.88 (12 months, n = 75), 0.84 (18 months, n = 68), and 0.79 (24 months, n = 61). CONCLUSIONS: The Baerveldt 250-mm2 Glaucoma Implant provides good intermediate-term success for the treatment of adult refractory glaucoma.