Intraocular pressure profile following selective laser trabeculoplasty in pigmentary and primary open-angle glaucoma.

PURPOSE: To compare the intraocular pressure (IOP) profile and the incidence of IOP spikes following selective laser trabeculoplasty (SLT) between pigmentary glaucoma (PG) and primary open-angle glaucoma (POAG). MATERIALS AND METHODS: Retrospective comparative study of 65 PG eyes of 51 patients matched with 65 POAG eyes of 65 patients who received SLT. Matching was done based on age, gender, glaucoma severity, pre-laser IOP, and number of medications. Post-SLT IOP spike was defined as IOP elevation ≥5mmHg, 30-45 min after the laser. RESULTS: In PG and POAG groups, the average age was 62.33 ± 9.18 and 62.58 ± 9.19 years (p = 0.95). The glaucoma severity (p = 0.708), baseline IOP (PG = 21.61 ± 1.34mmHg vs. POAG = 21.13 ± 5.09mmHg, p = 0.943), and number of topical glaucoma medications(PG = 2.34 ± 1.34 vs. POAG = 2.1 ± 1.41, p = 0.342) were comparable. More PG patients were on oral acetazolamide (PG = 26.15% vs. POAG = 1.5%, p < 0.001). Average logMAR visual acuity was significantly higher in the POAG group (0.207 ± 0.3 vs. 0.192 ± 0.37, p = 0.012). Eyes with PG received lower laser energy (POAG = 63.65 ± 22.03 mJ vs. PG = 43.71 ± 25.68 mJ, p < 0.001). IOP spikes were recorded in 5 PG eyes (7.6%) and none in the POAG group (p = 0.058). Failure rates were similar (PG = 50.7% and POAG = 43.1%, p = 0.205). In multivariable analysis, only pre-laser IOP (coefficient = 2.154 [CI: 0.765-3.543], p = 0.003) was a significant predictor of IOP change percentage after 12 months. CONCLUSIONS: SLT was comparably effective in both PG and POAG. IOP spikes were observed only in the PG group, though the total laser energy was lower in this group compared with POAG.

Long-Term Surgical Outcomes of Glaucoma Drainage Implants in Eyes with Preoperative Intraocular Pressure Less than 19 mmHg.

Background: This retrospective review reports on patients who underwent glaucoma drainage implant (GDI) surgery and had baseline intraocular pressure (IOP) of ≤18 mmHg with at least one year of follow-up. Methods: Clinical data of 67 eyes of 67 patients were collected from patients' charts, and the outcomes of GDI were evaluated until 7 years. GDI failure was defined as IOP reduction of less than 20% from the baseline at two consecutive visits three months after surgery, decline to no light perception, or if additional glaucoma surgery was performed. Results: The average age was 65.9 ± 13.2 years. Most cases were male (52.2%), White (53.7%), and had primary open-angle glaucoma (62.7%). Forty-four eyes had prior glaucoma surgery (68.6%) and 46 (68.6%) had severe glaucoma. Though postoperative (postop) IOP changes were insignificant, the average postop number of medications dropped from 2.4 ± 1.4 to 1.9 ± 1.2 medications two years after surgery (p = 0.0451). Postop complications (23.9%) included GDI exposure (7.5%), inflammation (4.5%), shallow anterior chamber (4.5%), and strabismus (1.5%). Hypotony was observed in 4 eyes (5.9%), none of which developed hypotony maculopathy. The cumulative one-year failure rate was 56.7%, most of which were due to failure to lower IOP. Conclusion: In patients with baseline IOP ≤18 mmHg who had GDI surgery, though the change in IOP was not statistically significant, the number of medications dropped and visual field progression slowed in a subset of patients with adequate perimetric data. Due to a relatively high rate of complications and limited effectiveness in lowering IOP, GDI should be cautiously used in these eyes.

Empowering Family Glaucoma Risk Communication Using QR-Code-Mediated Online Intervention.

PURPOSE: Attempts at engaging relatives of glaucoma patients in education and screening have had limited success. This study explores the feasibility of an electronic intervention to facilitate direct yet reliable glaucoma risk communication between open-angle glaucoma patients (probands) and their first-degree relatives (FDRs). DESIGN: Prospective survey and assessment of intervention. PARTICIPANTS: Fifty adult probands, engaging 140 FDRs. METHODS: Phase I was an iterative process involving creating a customized website and Quick Response (QR)-code-based intervention designed with input from probands, FDRs of patients, community members, and researchers. In phase II, the intervention was deployed in a clinical setting; this involved recruiting probands who had a smartphone and were willing to use the QR-code to message their FDRs a standard message, including a website link about glaucoma risk in FDRs and the importance of getting examined. Follow-up interviews were conducted with probands 1 to 2 weeks after their clinic visit to assess the impact of the intervention. Demographic data, website analytics, and participant feedback were collected and analyzed. MAIN OUTCOME MEASURES: Increased awareness of glaucoma risk among FDRs and enhanced discussions. RESULTS: At the time of the first interview, probands reported that 70% of the FDRs were aware of the probands' glaucoma diagnosis, but only 26% had undergone glaucoma screening. Ninety percent of probands had no issues using the QR-codes. Website analytics recorded 73 visits from 51 distinct internet protocol addresses (IPs). After receiving the standard message, 95% of FDRs followed up with the probands, actively discussing glaucoma. Of the probands, 84% completed the follow-up interview 1 to 2 weeks after enrollment. Fifty-nine percent of the FDRs were reported to have scheduled screening appointments. The collected feedback revealed that 96% of probands found the intervention helpful, fostering glaucoma discussions with their FDRs and improving probands' comfort level in discussing health issues with FDRs from baseline (very comfortable: 88%, comfortable: 8%, neutral: 2%, and very uncomfortable: 2%) to the follow-up interview (very comfortable: 98% and comfortable: 2%). CONCLUSIONS: This innovative online method of communicating the risk of glaucoma to FDRs of probands prompted and increased the comfort level of familial discussions of glaucoma. More than half of FDRs reported making an appointment to get screened for glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Early Postoperative Aqueous Suppression Therapy and Surgical Outcomes of Ahmed Tube Shunts in Refractory Glaucoma.

PURPOSE: To compare early vs. delayed use of aqueous suppressants on Ahmed glaucoma valve (AGV) outcomes. DESIGN: Single-center retrospective comparative case series. PARTICIPANTS: Patients who underwent AGV surgery at Wills Eye Hospital in the period between 2016 and 2021. METHODS: Retrospective review of AGV surgery at Wills Eye Hospital 2016 to 2021 for refractory glaucoma. Two groups were created: group 1 or those who received early aqueous suppressant therapy in the first 2 weeks postoperatively whenever the intraocular pressure (IOP) was > 10 mmHg, and group 2 or those who received delayed treatment after 2 weeks whenever the IOP exceeded the target pressure. Aqueous suppressant therapy included topical beta blockers, carbonic anhydrase inhibitors, and/or alpha agonists. MAIN OUTCOME MEASURES: The primary outcome measures were the frequency of hypertensive phase (HP) defined as IOP > 21 mmHg in first 3 months after an initial reduction to 21 mmHg or less in the first postoperative week not caused by tube obstruction or retraction, and month-12 surgical failure defined as 5 ≥ IOP > 21 mmHg on 2 consecutive visits, vision decline to no light perception (NLP), or glaucoma reoperation. Secondary outcome measures included changes in visual acuity (VA), IOP, and glaucoma medications at 12 months. Predictive factors for surgical failure were also identified. RESULTS: A total of 407 eyes of 391 patients (260 in group 1, 147 in group 2) with similar baseline characteristics were included. Hypertensive phase was more common in group 2 than 1 (41.5% vs. 18.5%; P < 0.001). At month 12 (N = 303 eyes), group 1 was less likely to fail than group 2 (21.2% vs. 36.8%, P = 0.003). Multivariate regression analysis showed that HP (odds ratio [OR] = 10.47, P < 0.001), delayed aqueous suppression use (OR = 2.17, P = 0.003), and lower baseline VA (OR = 1.56, P = 0.015) were the strongest predictors of month-12 failure. CONCLUSIONS: Early use of aqueous suppressants may lower the risk of HP and improve AGV outcomes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Hemorrhagic Complications Following Trabecular Bypass Microstent Surgery in the Setting of Antithrombotic Therapy.

PRCIS: In this retrospective study, the use of chronic antithrombotic therapy (ATT) did not increase the risk of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification. Stent type and female sex were associated with hyphema. PURPOSE: To report the incidence of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification with and without (ATT). METHODS: Retrospective case series on glaucoma patients on chronic ATT who underwent trabecular bypass microstent surgery (iStent, iStent inject, and Hydrus) combined with phacoemulsification between 2013 and 2019 with ≥3-month follow-up. The primary outcome measure was the incidence of hemorrhagic complications within a 3-month postoperative period. Generalized estimating equations were created to account for inter-eye correlation and logistic regression analysis was performed to identify factors predictive of hemorrhagic complications. RESULTS: Of 333 patients (435 eyes), 161 patients (211 eyes) were on ATT and 172 patients (224 eyes) were not on ATT; both groups were similar in age and baseline ocular characteristics. The only hemorrhagic complication was hyphema, which occurred in 84 (19.3%) eyes (41 ATT, 43 non-ATT eyes; P = 1.00). Onset was at postoperative day 1 in 98.8% of eyes, with a duration of 1 week in 73.8% of eyes, without difference between ATT and non-ATT groups. Hyphema was most common with Hydrus microstent (36.4%) versus iStent (19.9%) and iStent inject (8.5%) ( P = 0.003). In the multivariate model, the female sex was a predictor of hyphema [hazard ratio (HR) = 2.062; P = 0.009], iStent inject was protective against hyphema (HR = 0.379; P = 0.033), whereas Hydrus did not reach statistical significance (HR = 2.007; P = 0.081). Age, systemic comorbidities, ATT use, and baseline ocular characteristics were not significant predictors. CONCLUSIONS: Hemorrhagic complications after trabecular bypass microstent surgery were limited to transient hyphema and were not associated with chronic ATT use. Stent type and female sex were associated with hyphema.

Glaucoma Surgical Outcomes in Patients with a History of Scleritis.

PURPOSE: To assess the outcomes of glaucoma surgery in patients with a history of scleritis at a tertiary medical center. METHODS: The retrospective case series included patients with a history of scleritis who required glaucoma surgery between 4/2006 and 8/2021. RESULTS: Two hundred and eighty-one eyes of 259 patients had glaucoma and scleritis with 28 eyes (10%) of 25 patients requiring glaucoma surgery. Post-operatively, one eye (4%) had infectious scleritis. Eleven (39%) surgeries failed: 5 tube shunts, 5 cyclophotocoagulation, and 1 gonioscopy-assisted transluminal trabeculotomy. Five (18%) eyes required tube revisions due to tube exposures without infection (3), iris blocking the tube (1), or to shorten tube length (1). CONCLUSIONS: Patients with a history of scleritis have a low risk of scleritis recurrence or scleral perforation after glaucoma surgery but should be counseled appropriately on the higher risk of reoperation.

What Glaucoma Patients Are Reading on the Internet: A Systematic Analysis of Online Glaucoma Content.

PURPOSE: To systematically assess the content, quality, accuracy, navigability, and readability of the highest ranked online information regarding glaucoma. DESIGN: Internet-based, cross-sectional study. PARTICIPANTS: Not applicable. METHODS: The top 15 Google websites that resulted from the search term "glaucoma" were independently evaluated by 3 glaucoma specialists for content, accuracy (1-4 scale), and navigability (1-3 scale) in March 2020. Content was evaluated by answers to 25 questions regarding information most relevant to glaucoma patients (0-2 scale). Readability (Flesch-Kincaid grade level) and quality (Quality Component Scoring System) were also analyzed. MAIN OUTCOME MEASURES: Overall content, accuracy, navigability, quality component scores, and reading grade level as described. Additional analyses included type of websites, presence and type of graphic content. RESULTS: The mean (standard deviation) content score for all websites was 28 (7.6) of 50 possible points (range, 15-45). Inter-rater reliability for content score was good (0.619, 0.746, 0.872 for 3 pairwise comparisons between graders). Mean accuracy score was 9.8 (2.2) of 12 possible points (range, 5-12). Mean navigability score was 7.5 (1.4) of 9 possible points (range, 5-9). Mean reading grade level was 9.3 (1.7) with a range of 7-13 reading grades. Mean quality component score was 7.7 (2.6) of 13 possible points (range, 3-11). Six websites (40%) attempted to visually simulate glaucoma symptoms as tunnel vision (n = 5) and black spots (n = 1). Google rank did not correlate with any of the measures. CONCLUSIONS: The most readily accessible online information about glaucoma varies in content, quality, accuracy, navigability, and readability. This systematic analysis identifies potential areas of improvement.

Surgical Cancellations in Glaucoma Practice: Causes, Delays, and Effect on Patient Care and Revenue.

PURPOSE: To assess the incidence of glaucoma surgery cancellations, as well as their characteristics, underlying reasons, resultant surgical delay, and estimated lost potential reimbursement, at a tertiary eye hospital. DESIGN: Retrospective observational study of planned surgical procedures of 4 glaucoma specialists at a tertiary eye center over a 2-year period (May 2017-May 2019). An additional prospective survey of patients was conducted. PARTICIPANTS: Patients who canceled glaucoma surgeries. METHODS: Demographics and clinical information were recorded from the electronic medical record. A brief phone survey was implemented to determine the reason for cancellation and whether the patient rescheduled. Lost reimbursement was estimated assuming Medicare reimbursement rates for each procedure based on facility fee, surgeon fee, and anesthesia fee. MAIN OUTCOME MEASURES: Reasons for surgical cancellation, delay related to surgical cancellations, and annual lost reimbursement potential. RESULTS: One hundred twenty-three of 1384 glaucoma surgeries (8.9%) to be performed by 4 glaucoma specialists at Wills Eye Hospital during the 2-year study period were canceled. Among those canceled, the mean age ± standard deviation (SD) of the patients was 70.3 ± 14.4 years and 51% were men. Of the cancellations, 56.9% were made within 1 day of the planned date of surgery and 96.7% were canceled within 7 days. Of the reasons for surgical cancellation, 28% were considered preventable, 50% were considered unpreventable, and 23% were categorized as "no reason given." Most of the surgeries eventually were performed-to-date (64.2%); the mean ± SD delay in surgery was 63.4 ± 68.6 days. The 3 most common preventable reasons for cancellation were lack of transportation (34%), lack of timely clearance (26%), and insurance-related issues (14%). Assuming Medicare reimbursement rates, the estimated annual lost potential reimbursement from surgical cancellations of the 4 glaucoma specialists was $208 306. CONCLUSIONS: This study highlights a significant number of cancellations in a glaucoma practice, most of which occurred within 1 day of planned surgery. Minimizing preventable causes of cancellations could decrease the likelihood of surgical delays as well as lost reimbursement. Further comparison with patients who successfully underwent surgery performed without delay may identify predictive factors or interventions that could decrease the number of surgical cancellations.

Reoperation for complications within 90 days of minimally invasive glaucoma surgery.

OBJECTIVE: To describe reoperations that occurred within 90 days of minimally invasive glaucoma surgery (MIGS) at a single institution over a 30-month period. SETTING: Tertiary care hospital. DESIGN: Retrospective case series. METHODS: Charts of adult patients who underwent trabecular microbypass stents, gel microstents, and goniotomy procedures (including gonioscopy-assisted transluminal trabeculotomy) from October 1, 2017, to March 15, 2020, at Wills Eye Hospital were examined. Outcome measures were unanticipated reoperations within the first 90 days after MIGS procedures and the complications that led to these reoperations. RESULTS: A total of 448 MIGS procedures were performed on 436 eyes of 348 patients over a 30-month period by 6 glaucoma surgeons. Of these, 206 (46.0%) were trabecular microbypass stents (198 iStent/iStent inject and 8 Hydrus), 152 (33.9%) were gel microstents, and 90 (20.1%) were goniotomy procedures. Combined phacoemulsification took place in 256 eyes (58.7%). Reoperation within 90 days took place in 23 (5.3%) of 436 eyes, including 16 (10.5%) of 152 eyes in the gel microstent group, 4 (2.0%) of 198 eyes in iStent/iStent inject group, and 3 (3.3%) of 90 eyes in the goniotomy group. Indications for reoperation were elevated intraocular pressure (IOP) in 16 (69.6%) of 23 eyes, gel microstent tip exposure with wound leakage in 3 (13.0%) of 23 eyes, and early gel microstent encapsulation without elevated IOP in 1 (4.3%) of 23 eyes. Two (8.7%) of 23 eyes required reoperation for intraocular lens complications, whereas 1 (4.3%) of 23 eyes had elevated IOP and aphakia requiring reoperation. CONCLUSIONS: The rate of reoperation within the first 90 days after MIGS was low. Elevated IOP and complications associated with gel microstents were the main indications for reoperation.

Marijuana and Glaucoma: A Social Media Content Analysis.

PURPOSE: This study analyzes the content quality and characteristics of the most popular and highly ranked search results on the internet related to glaucoma and medical cannabis (MC). DESIGN: Internet-based, cross-sectional study. PARTICIPANTS: Not applicable. METHODS: Google and 2 social media platforms (Facebook, YouTube) were used to identify online information most accessible to patients. Search criteria included "glaucoma" AND "marijuana" or "cannabinoid" or "CBD." The top 20 Google search and YouTube results for each search term and the posts from the top 9 patient-based glaucoma Facebook groups were aggregated and analyzed using the search criteria. MAIN OUTCOME MEASURES: The quality of the content was graded by 2 independent graders using a previously validated Sandvik score and previously reported risk score. The differing values were resolved by a final grader. Additional analysis included whether the source was professional (by physician or medical organization) or shared an opinion on MC (pro, mixed, or against) use in glaucoma. RESULTS: This search resulted in an aggregate of 51 websites on Google, 126 posts from Facebook groups, and 37 videos on YouTube. The mean (± standard deviation) Sandvik score and risk score were 11.0 (±2.23), 10.2 (±1.12), 10.6 (±1.89) and 0.27 (±0.49), 0.46 (±0.62), 0.97 (±0.90) for Google, Facebook, and YouTube, respectively. Analysis of variance showed statistically significant differences in Sandvik (P = 0.01) and risk (P < 0.0001) scores across the 3 platforms. A significant portion of online material was pro-MC use in the setting of glaucoma (24% of Google, 59% of YouTube, and 21% of Facebook results). Professional content had a significantly higher content quality score and a lower risk score, and was less likely to recommend MC use in glaucoma. CONCLUSIONS: Despite American Academy of Ophthalmology, Canadian Ophthalmological Society, and American Glaucoma Society statements against MC use in patients with glaucoma, a significant portion of online material recommends its use. With the wide variation in quality and content of online information, it is important for physicians to be aware of the different platforms and opinions that are readily available to patients.

Assessment of Firework-Related Ocular Injury in the US.

Importance: Fireworks are popularly used for recreation but can lead to potentially blinding injuries. Studies quantifying the trend and national prevalence of firework-related ocular injuries are limited. Objective: To characterize firework-related ocular injuries treated in emergency departments (EDs) in the US from 1999 to 2017. Design, Setting, and Participants: This cross-sectional study used the National Electronic Injury Surveillance System, a stratified probability sample of more than 100 hospital-affiliated US EDs representing more than 5300 nationwide hospitals. Deidentified individuals in the National Electronic Injury Surveillance System database who experienced eye injury due to fireworks between January 1, 1999, and December 31, 2017, were included. Analysis began February 2019. Main Outcomes and Measures: Annual prevalence of firework-related ocular injury, firework type stratified by demographic information, diagnosis, event location/date, and patient disposition. Results: A total of 34 548 firework-related ocular injuries were seen in US EDs during the 19-year study period (estimated from 1007 individuals in the National Electronic Injury Surveillance System database). Overall, 664 individuals (65.9%) were 18 years or younger, 724 (71.9%) were male, and 512 (50.8%) were white. Twenty-eight patients (2.8%) sustained a ruptured globe, while 633 (62.9%) sustained ocular burn injuries, 118 (11.7%) had ocular foreign bodies, 97 (9.6%) had conjunctival irritation, and 46 (4.6%) experienced other severe eye trauma. Of 1007 individuals, 911 (90.5%) were treated and released without transfer, while 87 (8.7%) required admission or transfer to another hospital. The most common specified firework types included firecrackers (193 [19.2%]), bottle rockets (177 [17.6%]), sparklers (88 [8.7%]), roman candles (66 [6.6%]), and novelty devices (65 [6.5%]) (eg, poppers and snappers). Bottle rockets disproportionately caused the most severe injuries, including ruptured globe (odds ratio, 5.82; 95% CI, 2.72-12.46; P < .001). A total of 411 cases (74.9%) occurred at home. Injuries most commonly occurred near the time of Independence Day and New Year's Day: 707 patients (70.2%) presented in July, 74 (7.4%) in June, 101 (10.0%) in January, and 47 (4.7%) in December. Conclusions and Relevance: These findings support that firework-related ocular injuries range from mild irritation to ruptured globe, and most occur frequently in those who are young, male, and white. Focused preventive methods and regulations may be imperative in decreasing fireworks-related ocular morbidity, namely from bottle rockets and especially near national holidays.