Digital Gonioscopy Based on Three-dimensional Anterior-Segment OCT: An International Multicenter Study.

PURPOSE: To develop and evaluate the performance of a 3-dimensional (3D) deep-learning-based automated digital gonioscopy system (DGS) in detecting 2 major characteristics in eyes with suspected primary angle-closure glaucoma (PACG): (1) narrow iridocorneal angles (static gonioscopy, Task I) and (2) peripheral anterior synechiae (PAS) (dynamic gonioscopy, Task II) on OCT scans. DESIGN: International, cross-sectional, multicenter study. PARTICIPANTS: A total of 1.112 million images of 8694 volume scans (2294 patients) from 3 centers were included in this study (Task I, training/internal validation/external testing: 4515, 1101, and 2222 volume scans, respectively; Task II, training/internal validation/external testing: 378, 376, and 102 volume scans, respectively). METHODS: For Task I, a narrow angle was defined as an eye in which the posterior pigmented trabecular meshwork was not visible in more than 180° without indentation in the primary position captured in the dark room from the scans. For Task II, PAS was defined as the adhesion of the iris to the trabecular meshwork. The diagnostic performance of the 3D DGS was evaluated in both tasks with gonioscopic records as reference. MAIN OUTCOME MEASURES: The area under the curve (AUC), sensitivity, and specificity of the 3D DGS were calculated. RESULTS: In Task I, 29.4% of patients had a narrow angle. The AUC, sensitivity, and specificity of 3D DGS on the external testing datasets were 0.943 (0.933-0.953), 0.867 (0.838-0.895), and 0.878 (0.859-0.896), respectively. For Task II, 13.8% of patients had PAS. The AUC, sensitivity, and specificity of 3D DGS were 0.902 (0.818-0.985), 0.900 (0.714-1.000), and 0.890 (0.841-0.938), respectively, on the external testing set at quadrant level following normal clinical practice; and 0.885 (0.836-0.933), 0.912 (0.816-1.000), and 0.700 (0.660-0.741), respectively, on the external testing set at clock-hour level. CONCLUSIONS: The 3D DGS is effective in detecting eyes with suspected PACG. It has the potential to be used widely in the primary eye care community for screening of subjects at high risk of developing PACG.

Development of angle closure and associated risk factors: The Handan eye study.

PURPOSE: To investigate the development of angle closure from baseline open angle and associated risk factors in a rural Chinese population through a longitudinal study over a 5-year period. METHODS: Subjects aged ≥30 years and older with bilateral open angles at baseline of the Handan Eye Study who participated in the follow-up and had undergone both baseline and follow-up gonioscopic examinations were included. Subjects with any form of angle closure, glaucoma, incisional ocular surgery or other conditions that could influence the results were excluded. The development of angle closure was defined as the presence of primary angle closure suspect (PACS) or primary angle closure (PAC)/primary angle closure glaucoma (PACG) during the follow-up in normal subjects with baseline bilateral open angles. Logistic regression was performed to identify the baseline risk factors for the development of angle closure. RESULTS: A total of 457 subjects with bilateral open angles at baseline aged 53.0 (45.5, 58.0) years were enrolled. 94.7% of the included cases developed PACS, 5.3% developed PAC and no one developed PACG after 5 years. In logistic regression, significant risk factors for the development of angle closure were shallower central anterior chamber depth (ACD) (p = 0.002) and narrower mean angle width (p < 0.001). CONCLUSIONS: This study reports the development from baseline open angle to angle closure after a 5-year follow-up. We confirm that the mean angle width and central ACD were independent predictive risk factors for the development of any form of angle closure.

Avaliação da eficácia da trabeculotomia transluminal assistida por gonioscopia em glaucoma avançado e não avançado / Evaluation of efficacy of gonioscopy-assisted transluminal trabeculotomy in advanced-stage and non-advanced stage glaucoma

RESUMO Objetivo Avaliar a eficácia da trabeculotomia transluminal assistida por gonioscopia correlacionada com a gravidade do glaucoma. Métodos Análise restrospectiva de prontuários de pacientes que foram submetidos à trabeculotomia transluminal assistida por gonioscopia no período de 2019 a 2021 em um hospital privado. Resultados Vinte olhos foram submetidos à trabeculotomia transluminal assistida por gonioscopia (dois olhos) ou facectomia e trabeculotomia transluminal assistida por gonioscopia (18 olhos). Pacientes portadores da doença avançada obtiveram redução de 5mmHg (26,5%) na pressão intraocular, com redução de 2,3 drogas, e olhos com glaucoma leve ou moderado apresentaram redução de 8mmHg (40%) na pressão intraocular média e 2,1 drogas. Metade dos olhos operados teve hifema nos primeiros dias como principal complicação cirúrgica. Conclusão A trabeculotomia transluminal assistida por gonioscopia é um procedimento eficaz na redução da pressão intraocular e na redução da quantidade de drogas em uso, apresentando maior redução da pressão intraocular em olhos com glaucoma leve/moderado.

ABSTRACT Objective To evaluate efficacy of gonioscopy-assisted transluminal trabeculotomy and relate to severity of glaucoma. Methods A retrospective analysis of medical records of patients submitted to gonioscopy-assisted transluminal trabeculotomy, at a private hospital, from 2019 to 2021. Results A total of 20 were submitted to gonioscopy-assisted transluminal trabeculotomy (2 eyes) or facectomy and gonioscopy-assisted transluminal trabeculotomy (18 eyes). Patients with advanced-stage disease achieved a decrease by 5 mmHg (26.5%) in IOP, with a reduction of 2.3 drugs, and eyes with mild or moderate glaucoma showed a drop by 8 mmHg (40%) in mean IOP and of 2.1 drugs. Half of the operated eyes had hyphema in the first days as the main surgical complication. Conclusion Gonioscopy-assisted transluminal trabeculotomy is an effective procedure to reduce IOP and the number of drugs being used, with greater IOP decrease in eyes with mild/moderate glaucoma.

Progression of Primary Angle Closure Suspect to Primary Angle Closure and Associated Risk Factors: The Handan Eye Study.

Purpose: To investigate the progression of angle closure from primary angle closure suspect (PACS) and associated risk factors over five years in rural Chinese adults. Methods: In this population-based cohort study, subjects aged ≥30 years old with unilateral or bilateral PACS at baseline of the Handan Eye Study who participated in the follow-up and had undergone baseline and follow-up gonioscopic examinations were included. The progression of angle closure was defined as the presence of primary angle closure (PAC)/primary angle-closure glaucoma (PACG) during the follow-up in subjects with PACS at baseline. Ocular data from the right eye were used for cases with bilateral PACS and unilateral PACS in the right eye at baseline. For those with unilateral PACS in the left eye at baseline, ocular data from the left eye were used. Demographic information, ocular conditions, personal history, and systemic comorbidities were compared between the progression and nonprogression groups. Univariate and multivariate logistic regression was performed to identify the baseline risk factors for progression of angle closure. Results: In total, 526 subjects (111 male, 415 female) with baseline PACS were finally enrolled. The overall progression of PACS to angle closure was 32 cases (31 PAC, 1 PACG). Logistic regression analysis identified narrower mean angle width (P < 0.001) to be associated with the progression. Conclusions: We report the progression from baseline PACS to PAC/PACG after five years. And baseline mean angle width was determined to be independent predictive risk factor for the progression of angle closure.

Intraobserver and interobserver agreement among anterior chamber angle evaluations using automated 360-degree gonio-photos.

PURPOSE: To investigate the reproducibility for the iridocorneal angle evaluations using the pictures obtained by a gonioscopic camera, Gonioscope GS-1 (Nidek Co., Gamagori, Japan). METHODS: The pragmatic within-patient comparative diagnostic evaluations for 140 GS-1 gonio-images obtained from 35 eyes of 35 patients at four ocular sectors (superior, temporal, inferior, and nasal angles) were conducted by five independent ophthalmologists including three glaucoma specialists in a masked fashion twice, 1 week apart. We undertook the observer agreement and correlation analyses of Scheie's angle width and pigmentation gradings and detection of peripheral anterior synechia and Sampaolesi line. RESULTS: The respective Fleiss' kappa values for the four elements between manual gonioscopy and automated gonioscope by the glaucoma specialist were 0.22, 0.40, 0.32 and 0.58. Additionally, the respective intraobserver agreements for the four elements by the glaucoma specialist each were 0.32 to 0.65, 0.24 to 0.71, 0.35 to 0.70, and 0.20 to 0.76; the Fleiss' kappa coefficients for the four elements among the three glaucoma specialists were, respectively, 0.31, 0.38, 0.31, and 0.17; the Fleiss' kappa coefficients for the angle width and pigmentation gradings between the two glaucoma specialists each were 0.30 to 0.35, and 0.29 to 0.43, respectively. Overall, the Kendall's tau coefficients for the angle gradings reflected the positive correlations in the evaluations. CONCLUSION: Our findings suggested slight-to-substantial intraobserver agreement and slight-to-fair (among the three) or fair-to-moderate (between the two each) interobserver agreement for the angle assessments using GS-1 gonio-photos even by glaucoma specialists. Sufficient training and a solid consensus should allow us to perform more reliable angle assessments using gonio-photos with high reproducibility.

One-year results of gonioscopy-assisted transluminal trabeculotomy: Evaluation of prognostic factors.

PURPOSE: To present the results and complications of gonioscopy-assisted transluminal trabeculotomy in adults with open-angle glaucoma using our different approaches during and after surgery. METHOD: A retrospective comparative study was designed. Patients with regular 12-month follow-up history were included. Two groups were defined: group 1 comprised patients with open-angle glaucoma who underwent gonioscopy-assisted transluminal trabeculotomy surgery alone; group 2 included patients with open-angle glaucoma who underwent combined gonioscopy-assisted transluminal trabeculotomy and cataract extraction. A 30% reduction in preoperative intraocular pressure or postoperative intraocular pressure below 18 mm Hg was considered as surgical success. The success rate, alteration in intraocular pressure, alteration in best-corrected visual acuity, alteration in the need for antiglaucomatous medications, surgical complications, and the need for additional glaucoma surgery were evaluated and compared between the groups. Multivariate logistic regression analysis was used to show the association between the surgical success and possible prognostic factors. RESULTS: A total of 37 eyes fulfilled the inclusion criteria and were analyzed in this study. An overall mean decrease in intraocular pressure of 11.3 ± 9.3 mm Hg was shown at 12 months (p < 0.001). The medication-free surgical success rate was 37.8% (14/37), and the surgical success rate with medication was 91.8% (33/37) at 12 months. Surgical outcomes were similar between patients who underwent gonioscopy-assisted transluminal trabeculotomy alone and those who had combined gonioscopy-assisted transluminal trabeculotomy and cataract extraction (p > 0.05). The most common postoperative complication was hyphemia (89.1%). There were no complications that threatened best-corrected visual acuity. Multivariate logistic regression analysis revealed one significant association between the presence of blood in Schlemm's canal and surgical success (odds ratio = 1.47; 95% confidence interval = 1.25-1.68; p = 0.047). CONCLUSION: This study showed that the gonioscopy-assisted transluminal trabeculotomy procedure is an effective and minimally invasive form of glaucoma surgery. Its effect was related to intraoperative blood in Schlemm's canal.

Detection of primary angleclosure suspect with different mechanisms of angle closure using multivariate prediction models.

PURPOSE: We had found that a multivariate prediction model used for the detection of primary angle-closure suspects (PACS) by combining multiple static and dynamic anterior segment optical coherence tomography (ASOCT) parameters had an area under the receiver operating characteristic curve (AUC) of 0.844. We undertook this study to evaluate this method in screening of PACS with different dominant mechanisms of angle closure (AC). METHODS: The right eyes of subjects aged ≥40 years who participated in the 5-year follow-up of the Handan Eye Study and had undergone gonioscopy and ASOCT examinations under light and dark conditions were included. All ASOCT images were analysed by the Zhongshan Angle Assessment Program. The dominant AC mechanism in each eye was determined to be pupillary block (PB), plateau iris configuration (PIC) or thick peripheral iris roll (TPIR). Backward logistic regression (LR) was used for inclusion of variables in the prediction models. LR, Naïve Bayes' classification (NBC) and neural network (NN) were evaluated and compared using the AUC. RESULTS: Data from 796 subjects (413 PACS and 383 normal eyes) were analysed. The AUCs of LR, NBC and NN in the PB group were 0.920, 0.918 and 0.917. The AUCs of LR, NBC and NN in the PIC group were 0.715, 0.708 and 0.707. The AUCs of LR, NBC and NN in TPIR group were 0.867, 0.833 and 0.886. CONCLUSIONS: Prediction models showed the best performance for detection of PACS with PB mechanism for AC and have potential for screening of PACS.

Diagnosis of Pseudoexfoliation Syndrome in Pseudophakic Patients.

OBJECTIVE: The aim of this study was to evaluate the sensitivity and specificity of pseudoexfoliation syndrome diagnosis in pseudophakic patients and potential means of improving it. METHODS: This prospective, nonrandomized study comprised 41 consecutive patients (41 eyes) scheduled for cataract surgery at a tertiary medical center during 2016 and 2017. Preoperatively, all patients underwent a detailed slit-lamp examination, including gonioscopic assessment of the iridocorneal angle. The examination was performed by a glaucoma specialist who completed an assessment form documenting the presence/absence of clinical signs of pseudoexfoliation syndrome. It was repeated 1-2 weeks postoperatively by a second, masked, glaucoma specialist. RESULTS: Sixteen patients (39.0%) were diagnosed with pseudoex-foliation syndrome preoperatively. The diagnosis was confirmed postoperatively in 11/16 patients (68.8% sensitivity) and in an additional patient not diagnosed preoperatively (96% specificity). The ability to diagnose pseudoexfoliation syndrome postoperatively was significantly worse than preoperatively (Z = 12.161, p < 0.0001). Pupillary border deposits (75% of cases) and the Sampaolesi line (83.3%) were the cornerstones of the postoperative diagnosis; anterior capsular deposits were evident in only 41.6% of cases diagnosed postoperatively (31.3% of the originally diagnosed cases). CONCLUSIONS: Underdiagnosis of pseudoexfoliation syndrome is common in pseudophakic patients and may have significant implications for future management. Careful attention to pupillary border anatomy and meticulous gonioscopic assessment of the iridocorneal angle are essential for accurate diagnosis. Preoperative documentation of pseudoexfoliation syndrome could help prevent this diagnostic pitfall.

Outcomes of gonioscopy-assisted transluminal trabeculotomy in pseudoexfoliative glaucoma: 24-month follow-up.

AIM: To report on outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with pseudoexfoliative glaucoma (PXG). METHODS: Prospective, interventional, non-comparative case series. A total of 103 eyes from 84 patients with PXG were enrolled to undergo a 360-degree ab interno trabeculotomy with gonioscopic assistance using either a 5.0 polypropylene suture or an illuminated microcatheter with up to 24 months of follow-up. Main outcome measures were intraocular pressure (IOP), number of antiglaucoma medications, success rate (IOP reduction ≥20% from baseline or IOP between 6 and 21 mm Hg, without further glaucoma surgery) and complication rate. RESULTS: Mean preoperative IOP was 27.1 mm Hg (95% CI 25.5 to 28.7) using 2.9 (SD 1.1) glaucoma medications which decreased postoperatively to 13.0 mm Hg (95% CI 11.5 to 14.4) and 1.0 (SD 1.1) medications at 24 months (p<0.001). Success rate was 89.2% at 24 months of follow-up, and complication rate was 2.9%. CONCLUSION: At 24 months of follow-up, our results for GATT in PXG demonstrate that this conjunctival sparing procedure effectively lowers IOP and reduces the medications with a low complication rate, in this relatively aggressive glaucoma subtype.

Caracterización clínica y epidemiológica del síndrome pseudoexfoliativo / Clinical and epidemiological characterization of pseudoexfoliation syndrome

Objetivo: Determinar las características clínicas y epidemiológicas del síndrome pseudoexfoliativo. Métodos: Se realizó un estudio de 109 ojos correspondientes a 55 pacientes atendidos en el Centro de Microcirugía Ocular y en el Servicio de Glaucoma del Instituto Cubano de Oftalmología "Ramón Pando Ferrer" entre julio del año 2016 y septiembre de 2017. Para su caracterización se realizaron determinaciones a través de la gonioscopia, la tonometría, la paquimetría, la microscopia endotelial, el fondo de ojo y la medición de la agudeza visual. Resultados: El promedio de edad fue de 74,6 años, con predominio del sexo masculino (60 por ciento) y la piel blanca (78,2 por ciento), con antecedentes frecuentes de enfermedad vascular, particularmente hipertensión arterial (65,5 por ciento). El 92,7 por ciento presentaba catarata bilateral con predominio nuclear. Todos los pacientes tenían ángulo camerular abierto y la presión intraocular era alta en el 36,4 por ciento de los casos. La presencia de glaucoma fue del 56,4 por ciento, más frecuente el unilateral (38,2 por ciento). En relación con el endotelio corneal, la celularidad estaba disminuida en el 40 por ciento, con polimegatismo (58,2 por ciento) y pleomorfismo (72,7 por ciento). Conclusión: No se encuentra relación entre las alteraciones corneales, la edad, la presión intraocular y la presencia de material pseudoexfoliativo(AU)

Objective: Determine the clinical and epidemiological characteristics of pseudoexfoliation syndrome. Methods: A study was conducted of 109 eyes of 55 patients attending the Ocular Microsurgery Center and Glaucoma Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology from July 2016 to September 2017. Characterization was based on determinations made by gonioscopy, tonometry, pachymetry, endothelial microscopy, funduscopy and visual acuity measurement. Results: Mean age was 74.6 years, with a predominance of the male sex (60 percent), white skin (78.2 percent) and frequent antecedents of vascular disease, particularly arterial hypertension (65.5 percent). All the patients had cataract, which was predominantly bilateral and nuclear in 92.7 percent. In all cases the chamber angle was open, whereas intraocular pressure was high in 36.4 percent. 56.4 percent of the patients had glaucoma, which was more commonly unilateral (38.2 percent). Regarding the corneal endothelium, cellularity was reduced in 40 percent, with polymegethism (58.2 percent) and pleomorphism (72.7 percent). Conclusion: No relationship was found between corneal alterations, age and intraocular pressure, and the presence of pseudoexfoliative material(AU)

Assessment of angle closure spectrum disease as a continuum of change using gonioscopy and anterior segment optical coherence tomography.

PURPOSE: Studies examining the anterior chamber angle and angle closure disease often compare quantitative angle information obtained using anterior segment optical coherence tomography (ASOCT) with one of several ordinal scales derived using gonioscopy. We test the assumption that the ordinal gonioscopic angle grades have equal step sizes and can be analysed using metric statistics. METHODS: The medical records of 214 consecutive patients who were referred for assessment of the anterior chamber angle were prospectively examined using gonioscopy and ASOCT (Spectralis Optical Coherence Tomography, OCT, www.heidelbergengineering.com). Anterior chamber angle parameters (angle opening distance, AOD, and trabecular-iris space area, TISA at 500 and 750 microns) were extracted from ASOCT images using a semi-automated segmentation algorithm written on MATLAB (www.mathworks.com). We first matched the quantitative values for each gonioscopic grade (0-4, from no structures visible to ciliary body visible) and described the frequency distributions to determine separability. We then applied a grade-agnostic clustering algorithm to determine the concordance between algorithm-clustered groups (using solely quantitative data) and those obtained using gonioscopy. RESULTS: The frequency distributions of the quantitative ASOCT parameters for each angle grade were mostly non-parametric and displayed unique distribution characteristics, with a floor effect seen for grade 0 and the lack of a ceiling effect seen for grades 3 and 4. Although we found significant differences in quantitative values across the five angle grades using the frequency distributions, some pairwise comparisons were indistinguishable (such as grades 0 and 1, and grades 3 and 4) due to the overlaps in distributions. On average, differences in quantitative values were consistent between gonioscopic grade steps, but there remained substantial variability that confounds prediction of change between ordinal steps. The clustering algorithm showed approximately 10% of cases with the same group assignment as that of the gonioscopic grade, improving slightly to 30% when the top 5% of quantitative data were excluded from analysis. CONCLUSIONS: Our results do not necessarily support the assumption that the ordinal scales used in gonioscopy can be interpreted using an interval scale. We highlight the need for better methods of describing the course and risk of angle closure spectrum disease to identify disease progression and conversion, where gonioscopy remains the gold standard.

Gonioscopy-assisted Transluminal Trabeculotomy in Uveitic Glaucoma Secondary to Juvenile Idiopathic Arthritis.

Gonioscopy-assisted transluminal trabeculotomy (GATT) is a minimally invasive ab interno procedure, performed with guidance of an illuminating microcatheter device (iTrack). The pathophysiology of raised intraocular pressure (IOP) in uveitic glaucoma is commonly due to increased resistance at the trabecular meshwork-Schlemm canal. By removing this resistance, GATT can potentially control the IOP. In addition, the ab interno approach avoids violating the conjunctiva and reduces the risk of complications including infection, leak, and hypotony. In this series, we discuss 3 uveitic glaucoma cases secondary to juvenile idiopathic arthritis (JIA) that underwent GATT. Case 1 was a 16-year-old phakic female with a preoperative IOP of 25 to 33 mm Hg had 360-degree GATT; her IOP remained stable at 6 to 10 mm Hg over 14 months. Case 2 was a 23-year-old pseudophakic female with a preoperative IOP of 28 to 34 mm Hg had 180-degree GATT; her IOP reduced to 8 mm Hg over 10 months. Case 3 was an 8-year-old aphakic male with a preoperative IOP of 21 to 32 mm Hg had 360-degree GATT; his IOP remained stable at 13 to 15 mm Hg over 21 months. In our limited case series, GATT is very successful in controlling IOP in young uveitic patients with JIA by surgically targeting the underlying pathophysiology.

Effect of Angle Narrowing on Sectoral Variation of Anterior Chamber Angle Width: The Chinese American Eye Study.

PURPOSE: To characterize the relationship between mean and sectoral variation of anterior chamber angle (ACA) width using anterior segment optical coherence tomography (AS-OCT). METHODS: Subjects aged 50 years or older were identified from the Chinese American Eye Study (CHES), a population-based epidemiological study in Los Angeles, CA. Each subject underwent a complete ocular examination including gonioscopy and AS-OCT imaging. Primary angle closure disease (PACD) was defined as inability to visualize pigmented trabecular meshwork in 3 or more quadrants. Four AS-OCT images from one eye per subject were analyzed and parameters describing ACA width were measured at 500 and 750 µm from the scleral spur: angle opening distance (AOD), trabecular iris space area (TISA), and scleral spur angle (SSA). The relationship between mean and sectoral variation of ACA width was assessed using locally-weighted scatterplot smoothing (LOWESS) regression and change-point analyses and Spearman correlation coefficients. RESULTS: 674 eyes (337 with PACD, 337 without PACD) from 674 subjects were analyzed. Overall, sectoral variation of ACA width decreased as mean ACA width decreased. This relationship was divided into two phases based on the change-point analysis. Sectoral variation of ACA width was strongly and significantly correlated (P < 0.001) with mean ACA width with below parameter-specific change points for most parameters: AOD500 (r = 0.599), AOD750 (r = 0.246), TISA500 (r = 0.734), TISA750 (r = 0.664), SSA500 (r = 0.661), SSA750 (r = 0.394). Correlations were weaker but still significant (P < 0.004) above these change points for most parameters: AOD500 (r = 0.321), AOD750 (r = 0.550), TISA500 (r = 0.122), TISA750 (r = 0.275), SSA500 (r = -0.036), SSA750 (r = 0.313). Correlations to the left and right of the change points strengthened when sectoral variation of ACA width was adjusted for mean ACA width. CONCLUSIONS: Correlations between mean and sectoral variation of ACA width strengthen as the severity of angle narrowing worsens. This relationship likely reflects anatomical changes related to chronic angle closure and may be relevant for refining current definitions and management of PACD.

Risk Factors for Complications and Failure after Gonioscopy-Assisted Transluminal Trabeculotomy in a Young Cohort.

PURPOSE: To determine the risk factors for failures and complications of gonioscopy-assisted transluminal trabeculotomy (GATT) in a young cohort. DESIGN: Retrospective case series. PARTICIPANTS: Eyes that underwent GATT at Bascom Palmer Eye Institute. METHODS: Preoperative and postoperative intraocular pressure (IOP), extent of angle treated, postoperative IOP spike, postoperative drop regimen, and postoperative failure were recorded. Failure was defined as (1) IOP of more than 21 mmHg or less than 5 mmHg after postoperative month 3, (2) absence of at least 20% reduction from the preoperative IOP baseline after postoperative month 3, or (3) performance of additional IOP-lowering surgery before postoperative month 3. Intraocular pressure spike complication was defined as an increase in IOP in the operated eye at any postoperative visit to higher than preoperative IOP within the first 3 months. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to assess the time to events (failure and IOP spike). MAIN OUTCOME MEASURES: Risk of failure associated with any of the preoperative, intraoperative, or postoperative variables. RESULTS: A total of 102 eyes of 88 patients were included. The median follow-up time was 7.4 months, with an interquartile range of 3.3 to 13.1 months (standard deviation, 8.7 months). Patients who used corticosteroids after surgery were more likely to experience IOP spikes than those using nonsteroidal anti-inflammatory drugs (NSAIDs) alone (hazard ratio, 3.34; P = 0.042), and patients who underwent noncircumferential trabeculotomy were 2.56 times more likely to experience treatment failure (P = 0.002) compared with those who underwent circumferential surgery. CONCLUSIONS: Eyes that received postoperative corticosteroids were more likely to experience an IOP spike complication than those that received postoperative NSAIDs alone, which may suggest corticosteroid-mediated outflow obstruction distal to the trabecular meshwork. Achieving a circumferential trabeculotomy and using only NSAIDs may be more likely to result in surgical success when compared with noncircumferential trabeculotomy or using postoperative corticosteroids.

Non-contact wide-angled visualization with chandelier-assisted scleral buckling for primary uncomplicated rhegmatogenous retinal detachment.

PURPOSE: To report our experience in non-contact wide-angled visualization with chandelier-assisted scleral buckling (SB) in uncomplicated primary rhegmatogenous retinal detachments (RRD). METHODS: Retrospective case series of 282 eyes that underwent non-contact wide-angled visualization with chandelier-assisted SB and were followed for a mean of 13.5 months. RESULTS: There were 160 male patients. The average age was 42.6 years old. There were 262 eyes that were phakic, 18 pseudophakic, and 2 aphakic. Two-thirds of eyes presented with the macula detached. Eyes had an average of 1.6 breaks. The single operation anatomic success rate was 85.1% (240/282). The pre-op visual acuity improved from 1.21 to 0.76 logMAR at 6 months (p < 0.0001). Complications included a case of scleral laceration, choroidal hemorrhage, 3 epiretinal membranes, 1 macular fold, and 4 eyes with buckle exposure. CONCLUSION: Non-contact wide-angled visualization with chandelier-assisted SB compares favorably with conventional SB for primary uncomplicated primary RRD.

Assessment of glaucoma referral letter for quality and accuracy among patients referred to a tertiary eye care center.

Purpose: To assess the quality and accuracy of glaucoma referrals from ophthalmologist. Methods: Retrospective review of patients chart with referral letter to a tertiary glaucoma center between January and December 2017. Patients aged <16 years, lens-induced glaucoma, uveitic glaucoma, and glaucoma following retinal and corneal surgery were excluded. Results: A total of 184 patients referred by 55 ophthalmologists were included. Mean patient age (SD) was 57.8 ± 14 years. Intraocular pressure was not documented in the referral letter in 113 (61%) patients, gonioscopy in 174 (95%) patients, disc findings in 149 (81%) patients, and visual fields in 175 (95%) patients. Thirteen (37%) of the 35 patients referred as open angle glaucoma were found to have angle closure glaucoma. Pseudoexfoliation glaucoma was diagnosed in 29 (16%) patients, of which 18 were missed by the referring ophthalmologist. Conclusion: In our study >90% of referral letter did not have the essential parameters. A standard template for glaucoma referral is suggested, which will help the patient to get better transfer of care.

Nanophthalmos in children: morphometric and clinical characterization.

PURPOSE: To report clinical and morphometric characteristics of children with nanophthalmos and to identify possible risk factors associated with occludable angles. METHODS: The medical records of children (<18 years of age) with nanophthalmos examined from January 2016 to December 2016 were reviewed retrospectively. Demographic and examination details, including cycloplegic refraction, best-corrected visual acuity, intraocular pressure (IOP), gonioscopy, and fundus examination, were extracted for analysis. Biometric data included axial length, anterior chamber depth, and lens thickness. Subgroup data from children with occludable and open angles on gonioscopy were compared. RESULTS: A total of 75 children were included. Mean age at presentation was 10.92 ± 4.97 years. Mean spherical equivalent was +13.31 ± 2.69 D. Best-corrected visual acuity was 20/40 or better in 26 eyes (35%). Ametropic amblyopia was leading cause of visual impairment in our series. IOP was within normal limits (10-21 mm Hg) in 73 subjects and above normal in 2. Of the 75 children, 17 had occludable angles. Posterior segment anomalies were found in 28. Mean axial length was 16.88 ± 1.5 mm, mean anterior chamber depth was 3.00 ± 0.5 mm, and mean lens thickness was 3.9 ± 0.5 mm. The ratio of lens thickness to axial length was 0.253 ± 0.025 in subjects with occludable angles; 0.226 ± 0.038, in those with open angle. A ratio of >0.239 increased the risk of having angle closure by nearly three times. CONCLUSIONS: In this study cohort, nanophthalmos was characterized by short axial length and high hyperopia, with shallow anterior chamber. Nearly 20% of children had occludable angles requiring intervention. Clinicians should monitor the ratio of lens thickness to axial length to ensure that angle closure is prevented.

XEN gel implant versus gonioscopy-assisted transluminal trabeculotomy for the treatment of open-angle glaucoma.

OBJECTIVES: To compare successes and complications of XEN GEL Stent implantation and gonioscopy-assisted transluminal trabeculotomy (GATT) surgery in patients with open-angle glaucoma (OAG). METHODS: The multicentre, non-randomized, comparative, interventional, retrospective chart review study included 114 eyes undergoing XEN implantation and 107 eyes undergoing GATT for treatment of OAG. A comprehensive ophthalmic examination consisting of best-corrected LogMAR visual acuity (BCVA), Goldmann Applanation Tonometry, biomicroscopy, fundoscopy and gonioscopy was performed, and then, clinical findings, complications and number of antiglaucomatous medications were noted at the 3-, 6-, 12-, 18- and 24-month postoperative visits. Surgical success was defined as IOP ≤ 21 mmHg and 20% ≥ IOP reduction from baseline with (qualified success) or without (complete success) further medication, and without any further IOP-lowering surgery. RESULTS: The mean ages were 65.8 ± 10.6 and 59.1 ± 14.3 in XEN and GATT groups, respectively (p = 0.001). In XEN group, the percentage of IOP reduction and need of medication were significantly more improved than those in GATT group. The complete surgical success rates were 34.2% and 50.5% in XEN and GATT groups, respectively (p = 0.039), with a success rate of 41.1% in total. Qualified surgical success rates were 97.4% and 89.7% in XEN and GATT groups, respectively (p = 0.025), with a success rate of 93.7% in total. Transient hyphema, the most observed postoperative complication in both groups, cleared in a few days. CONCLUSIONS: Both MIGS have good efficacy and safety outcomes in lowering IOP and need of medication in patients with OAG. XEN Gel Stent implantation may be preferred in patients with lower IOP values targeted.