Efficacy of gonioscopy-assisted transluminal trabeculotomy in advanced-age glaucoma patients.

BACKGROUND: The prevalence and severity of many etiologies of glaucoma increase with age, often requiring surgery later in life. Surgery in the most aged demographic, however, poses multiple unique physiologic and psychosocial challenges with variable outcomes. In this study, we evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in an advanced-age population (>85 years of age). METHODS: This is a single-centre retrospective cohort study of consecutive patients who underwent GATT at or above 85 years of age. This included patients with GATT of any circumferential extent (90°-360°) with or without concurrent phacoemulsification cataract surgery. The primary outcome measure was proportion of successful surgeries at 1 year by the "complete success" criteria (intraocular pressure [IOP] <17 mm Hg on no medications 3 months after surgery with no additional interventions). Secondary outcomes included proportion of successful surgeries by alternative criteria, cross-sectional analyses of IOPs and medication use, and analyses of postoperative complications and interventions. RESULTS: Forty eyes of 31 patients were included in the study. Mean baseline IOP was 16.75 ± 7.33 mm Hg on 1.60 ± 1.43 classes of medication. At 1 year, the cumulative survival by Kaplan-Meier analysis was 46.6%. There was a statistically significant reduction in IOP at all postoperative time points to a mean of 11.78 ± 3.07 mm Hg at the last follow-up. There were postoperative complications in 18 eyes, with hyphema and corneal edema accounting for the majority. CONCLUSIONS: This study provides evidence that GATT is a safe and effective intervention in advanced-age glaucoma populations.

Safety and efficacy of micropulse transscleral cyclophotocoagulation: 2-year follow-up in a tertiary Canadian centre.

OBJECTIVE: To describe the long-term results of patients undergoing micropulse cyclophotocoagulation (MPCPC). METHODS: Retrospective review of patients undergoing MPCPC with 1 surgeon between July 2016 and January 2017. Data collected included preoperative intraocular pressure (IOP), number of medications, daily acetazolamide use, and whether inferior, superior, or circumferential MPCPC was performed. This was assessed at postoperative week 1 and postoperative months 1, 3, 6, 12, 18, and 24. RESULTS: A total of 49 patients undergoing MPCPC with 2-year follow-up data was included. Ages ranged from 20 to 91 years (mean age, 69 years; 50% female). Following MPCPC, IOP was significantly lower at all points of follow-up (p < 0.05). At 2-year follow-up, the average IOP was 15 mm Hg (35% reduction). Six patients remained on acetazolamide (average daily dose, 333 mg). Average number of medications had decreased to 2.6 (p > 0.05). No significant structural complications occurred, but 53% required repeat MPCPC applications. The most common complication was failure requiring a secondary IOP-lowering surgical procedure. This occurred in 33% of patients. Subsequent glaucoma surgeries included gonioscopy-assisted transluminal trabeculotomy, iStent, Xen glaucoma implant, and Ahmed glaucoma valve. CONCLUSIONS: MPCPC was successful in reducing IOP in conjunction with a nonsignificant reduction in topical glaucoma medications. However, a large proportion of patients required repeat micropulse applications or invasive glaucoma surgery to achieve IOP control. These results suggest that the clinical efficacy of MPCPC may be lower than that reported in the literature.

Analysis of Efficacy and Safety of Pediatric Ahmed Glaucoma Valve (FP8) in Advanced Age Populations.

PRECIS: The FP8 glaucoma valve was demonstrated to be reasonably safe with reliable results in an advanced age patient population. PURPOSE: As life expectancy increases, a growing number of patients with glaucoma are of an advanced age. There are little to no data looking at glaucoma surgical treatment options in patients over the age of 85. Our study describes the safety and efficacy of the FP8 Ahmed glaucoma valve in this patient population. MATERIALS AND METHODS: This was a retrospective study of patients over 85 years of age undergoing FP8 Ahmed glaucoma valve implantation. Preoperative age, sex, intraocular pressure (IOP), and number of glaucoma medications were recorded. Primary outcome variables were IOP and number of medications. Secondary outcome variables included any intraoperative or postoperative complications. RESULTS: Mean IOP preoperatively was 26 mm Hg on an average of 3 glaucoma medications (n=56). IOP was significantly reduced at all time points in follow-up for an overall reduction of 42% at 1 year and 46% at 2 years. Mean IOP at 1 year follow-up was 15 mm Hg and 14 mm Hg at 2 years follow-up. Glaucoma medications were reduced from a mean of 3 preoperatively to 2 postoperatively. CONCLUSIONS: Implantation of an FP8 Ahmed glaucoma valve is a relatively safe procedure to achieve satisfactory IOP and decreased reliance on glaucoma medications in an advanced age population.

Utilizing a responsive web portal for studying disc tracing agreement in retinal images.

Glaucoma is a leading cause of blindness worldwide whose detection is based on multiple factors, including measuring the cup to disc ratio, retinal nerve fiber layer and visual field defects. Advances in image processing and machine learning have allowed the development of automated approached for segmenting objects from fundus images. However, to build a robust system, a reliable ground truth dataset is required for proper training and validation of the model. In this study, we investigate the level of agreement in properly detecting the retinal disc in fundus images using an online portal built for such purposes. Two Doctors of Optometry independently traced the discs for 159 fundus images obtained from publicly available datasets using a purpose-built online portal. Additionally, we studied the effectiveness of ellipse fitting in handling misalignments in tracing. We measured tracing precision, interobserver variability, and average boundary distance between the results provided by ophthalmologists, and optometrist tracing. We also studied whether ellipse fitting has a positive or negative impact on properly detecting disc boundaries. The overall agreement between the optometrists in terms of locating the disc region in these images was 0.87. However, we found that there was a fair agreement on the disc border with kappa = 0.21. Disagreements were mainly in fundus images obtained from glaucomatous patients. The resulting dataset was deemed to be an acceptable ground truth dataset for training a validation of models for automatic detection of objects in fundus images.

CONVERSION OF FOCAL CHOROIDAL EXCAVATION WITH THE ONSET OF CENTRAL SEROUS CHORIORETINOPATHY: REPORT OF 2 CASES AND REVIEW OF THE LITERATURE.

PURPOSE: To describe two cases of focal choroidal excavation (FCE) conversion in patients with central serous chorioretinopathy. METHODS: Case report and literature review of cases of FCE conversion. RESULTS: A 35-year-old asymptomatic pregnant patient was found to have conforming FCE on spectral domain optical coherence tomography of the right eye during hydroxychloroquine screening. Three months later, she presented with decreased vision in the right eye and subretinal fluid in both eyes secondary to central serous chorioretinopathy. Spectral domain optical coherence tomography revealed that her FCE had changed to nonconforming type. A 40-year-old male patient was found to have nonconforming FCE and subretinal fluid in his right eye on spectral domain optical coherence tomography. On follow-up, spectral domain optical coherence tomography demonstrated resolution of subretinal fluid and conversion of nonconforming FCE to conforming type. Literature review showed that most cases of FCE remain stable over time. Conversion from nonconforming FCE to conforming type has been described after photodynamic therapy or anti-vascular endothelial growth factor therapy. Conversion from conforming to nonconforming type has been described in 2 cases that developed subretinal fluid in the setting of acute central serous chorioretinopathy. CONCLUSION: Our cases and literature review suggest that nonconforming FCE is the result of persistent subretinal fluid. Further studies are necessary to determine whether symptomatic nonconforming SRF needs treatment to reduce subretinal fluid.

Face and content validity of an artificial eye model for Ab-Interno Goniotomy.

PURPOSE: To determine the face and content validity of an artificial eye model for ab-interno goniotomy (SimulEYE KDB model, InsEYEt, Westlake Village, CA) by surveying ophthalmologists with varying experience using a Kahook Dual Blade (KDB; New World Medical, Rancho Cucamonga, CA, USA) following a 90-min wet-lab course using the model. PARTICIPANTS: Overall 13 ophthalmologists participated following a surgical simulation session on goniotomy using the goniotomy blade at the 2019 Canadian Ophthalmological Society annual meeting. METHODS: A 17-question survey to assess the face and content validity of the model was given immediately following the surgical simulation session on goniotomy using the goniotomy blade. Responses to each survey question were recorded on a 5-point Likert scale ranging from (1) strongly agree to (5) strongly disagree. RESULTS: Respondents rated statements regarding the model with a median response of 1 (Strongly Agree) to 3 (Neither agree or disagree). Mann-Whitney U nonparametric analysis revealed no significant difference in responses between instructor vs. non-instructor or between prior experience vs. no prior experience for any of the survey statements. The model received highest survey ratings for utility in training residents, acquisition of surgical skills, accessibility, and higher likelihood of success with the procedure than theory and observation alone. Lowest ratings were for realism of the model compared to a human cadaveric eye. CONCLUSION: Our results suggest the SimulEYE KDB model is a reasonably cost-effective solution for simulating angle-based surgeries. Additionally, our project shows that experienced ophthalmologists found the artificial eye models useful and helpful for angle-based surgery training.

Ab Interno Canaloplasty in Open-angle Glaucoma Patients Combined With In Vivo Trypan Blue Aqueous Venography.

PURPOSE: To demonstrate canalogram patterns observed when trypan blue tracer is combined with oculoviscoelastic device during ab interno canaloplasty, and discuss surgical results and potential implications for diagnosis, prognosis, and treatment. METHODS: This is a retrospective small case series study. RESULTS: The authors performed this procedure on 5 patients with informed consent with 4 to 18 months of follow-up. All procedures have been complication free. The average preoperative intraocular pressure was 16.4 mm Hg with an average number of topical glaucoma medications being equal to 3.6. Postoperatively, the average intraocular pressure for the group was reduced to 13 mm Hg with a concurrent drop in the average number of topical medications used equaling 1.8. CONCLUSIONS: Currently, there are limited practical options to evaluate the patency of the aqueous outflow system in our patients. The primary purpose of this paper is to describe canalogram patterns observed during ab interno canaloplasty with trypan blue. This technique may allow us to further our understanding of the aqueous outflow system and its role in the underlying pathophysiology of glaucoma. Further research is required to evaluate the prognostic and diagnostic significance of this technique.

EN FACE OPTICAL COHERENCE TOMOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF INNER RETINAL DIMPLES AFTER INTERNAL LIMITING MEMBRANE PEELING FOR FULL-THICKNESS MACULAR HOLES.

PURPOSE: To quantitatively and qualitatively evaluate the microvascular and structural abnormalities associated with inner retinal dimpling after internal limiting membrane peeling for full-thickness macular holes using sequential en face optical coherence tomography (OCT) and OCT angiography. METHODS: Thirteen eyes of 13 patients with idiopathic full-thickness macular holes were enrolled in the study. Patients were treated with pars plana vitrectomy, internal limiting membrane peeling, and gas tamponade. Subjects were evaluated preoperatively and at postoperative Months 1, 3, and 6. At each visit, patients underwent a comprehensive ophthalmologic examination, en face OCT and OCT angiography. The morphology and number and proportionate area of inner retinal dimples were analyzed. Vessel density of the superficial vascular complex at all visits was also measured. RESULTS: Inner retinal dimples were identified 1 month after surgery in all cases. The number and proportionate area of inner retinal dimples significantly increased over the follow-up period (P = 0.05). Preoperative vessel density of the superficial vascular complex was 17.9 ± 1.9 and did not change significantly over the follow-up period (P = 0.15). CONCLUSION: Inner retinal dimples are identified with en face OCT as early as the first month after internal limiting membrane peeling for idiopathic full-thickness macular holes and progressively increase in number and proportionate area in the subsequent 3 to 6 months after surgery. This may be the result of progressive deturgescence of the nerve fiber layer in the postoperative period.

INCREASED PHOTORECEPTOR OUTER SEGMENT VOLUME FOLLOWING SYSTEMIC TREATMENT OF BIRDSHOT CHORIORETINOPATHY.

PURPOSE: Retinal degeneration in birdshot chorioretinopathy can be quantified using spectral domain optical coherence tomography by measuring the photoreceptor outer segment (PROS) volume. The purpose of this study was to determine if the PROS volume in BSCR responds to systemic immunomodulatory therapy (IMT). METHODS: Retrospective chart review with analysis of PROS volume derived from spectral domain optical coherence tomography. RESULTS: We identified a total of three patients who met our inclusion criteria. At baseline, all patients had abnormal PROS and/or ellipsoid layer findings on spectral domain optical coherence tomography. After systemic immunomodulatory therapy, these abnormalities improved, and PROS volume increased, in all patients (P < 0.05). CONCLUSION: PROS volume can increase after systemic treatment of birdshot chorioretinopathy. This SD-OCT parameter may serve as a useful marker of retinal degeneration in BSCR, and may be a useful outcome measure in monitoring treatment response in birdshot chorioretinopathy.

Dural carotid cavernous fistula following hypertensive emergency.

A 58-year-old woman was referred to the outpatient ophthalmology clinic with progressive bilateral eye redness and vision loss. She had presented 2 weeks earlier with an episode of hypertensive emergency. CT angiography revealed bilateral superior ophthalmic vein (SOV) dilation, prompting further workup with a cerebral angiogram. Subsequent imaging revealed an indirect (type D) carotid-cavernous fistula (CCF) with venous drainage into both SOVs and cavernous sinuses. Successful treatment of the CCF with coil embolisation required interdisciplinary teamwork between ophthalmologists and interventional neuroradiologists. The patient made a substantial visual recovery following treatment.

Retrospective analysis of ophthalmology consults to a tertiary academic teaching centre.

OBJECTIVE: This study was conducted to analyse data from emergency ophthalmology referrals after-hours from different hospitals to identify the most common pathologies and compare accuracy of diagnoses. The primary objective was to identify common presenting entities and common causes of misdiagnosis in the emergency department to help guide education initiatives. DESIGN: This was a retrospective chart review that looked at consults occurring between September 1, 2015, and October 21, 2016. METHODS: Emergency ophthalmology consults were reviewed and the date, time, age, sex, and provisional diagnosis were recorded. Ophthalmic diagnosis was compared with provisional diagnosis to compare agreement rate. Diagnoses were categorized to determine most frequent etiologies presenting on an emergent basis. RESULTS: A total of 697 consults were reviewed. The most common consults by diagnostic category were anterior segment (36.4%) and posterior segment (27.4%) pathologies. Together, these categories accounted for over 60% of all consults. Agreement between provisional diagnosis and final ophthalmology diagnosis was 65.8%. CONCLUSIONS: There was a reasonable agreement rate between referring services diagnosis and ophthalmology diagnosis. The retrospective nature of this study and use of categories to determine agreement are potential biases and the agreement rate may not reflect clinical practice. Most common diagnoses were similar to previous studies. The authors noted several diagnostic categories that could be targeted as areas for medical education to help increase recognition in the primary care setting and facilitate appropriate ophthalmic referral.

Test Characteristics of Point-of-care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department.

BACKGROUND: Previous studies of point-of-care ultrasound (POCUS) have reported high sensitivities and specificities for retinal detachment (RD). Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. METHODS: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of emergency department (ED) patients presenting with flashes or floaters in one or both eyes. After standard ED assessment, EPs performed an ocular POCUS scan targeted to detect the presence or absence of RD. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CIs) using the retina specialist's final diagnosis as the reference standard. RESULTS: A total of 30 EPs enrolled 115 patients, with median age of 60 years and 64% female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD were 75% (95% CI = 48%-93%) and 94% (95% CI = 87%-98%), respectively. The positive likelihood ratio was 12.4 (95% CI = 5.4-28.3), and negative likelihood ratio was 0.27 (95% CI = 0.11-0.62). CONCLUSIONS: A large heterogeneous group of EPs can perform POCUS with high specificity but only intermediate sensitivity for RD. A negative POCUS scan in the ED performed by a heterogeneous group of providers after a 1-hour POCUS didactic is not sufficiently sensitive to rule out RD in a patient with new-onset flashes or floaters.

Prospective analysis of emergency ophthalmic referrals in a Canadian tertiary teaching hospital.

OBJECTIVE: This study was conducted to analyze data from emergency ophthalmology referrals after hours from different hospitals to identify the most common pathologies and compare accuracy of diagnoses. Additionally, examination findings, including visual acuity (VA), intraocular pressure (IOP), and pupils from referring service and ophthalmic examination, were compared to assess agreement. DESIGN: This was a prospective study that reviewed information collected from referring services to the emergency on-call ophthalmology service and compared it with ophthalmic examination between February 2017 and July 2017. METHODS: The number of referrals from each hospital was reviewed. Referring physician provisional diagnosis, VA, IOP, and pupil assessment were collected to analyze the agreement between ophthalmic examination and diagnosis. RESULTS: The observed agreement rate was 67.0% between referring source and ophthalmic diagnosis. Posterior vitreous detachment (12.2%) was the most common diagnosis, followed by corneal abrasion (7.4%) and retinal detachment (5.3%). Referring services measured VA to be worse than on-call ophthalmology service (right eye Z = -5.47, p < 0.001; left eye Z = -5.44, p < 0.001), and IOP measurement by referring services was significantly higher (p < 0.05). The observed agreement rate of pupillary assessment was 91% between referring services and ophthalmology services. CONCLUSION: Data suggest that there is moderate agreement for diagnostic category between referring service and ophthalmology examination in regard to provisional diagnosis and pupillary assessment. Both VA and IOP were measured to be higher by referring services. This study highlights common emergency ophthalmic referrals and suggests potential areas for teaching initiatives for primary care physicians assessing ophthalmic emergency patients.

Bilateral carotid cavernous sinus fistula: a case report and review of the literature.

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. They are commonly classified based on hemodynamics, etiology or anatomically. Hemodynamic classification refers to whether the fistula is high or low flow. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of aneurysm or medical conditions predisposing to arterial wall defects. Bilateral carotid cavernous fistulas are rare. We present a case of bilateral CCF secondary to trauma. Ophthalmology was urgently consulted to assess the patient in the intensive care unit (ICU) for red eye. The patient was found to have decreased vision, increased intraocular pressure, an afferent pupillary defect, proptosis, chemosis, and ophthalmoplegia. Subsequent neuro-imaging confirmed a bilateral CCF. The patient underwent two endovascular embolization procedures. Trauma is the most common cause of CCF and accounts for up to 75% of cases. Most common signs of CCF depend on whether it is high or low flow. High-flow CCF may present with chemosis, proptosis, cranial nerve palsy, increased intraocular pressure, diplopia, and decreased vision. Cerebral angiography is the gold standard diagnostic modality. First-line treatment consists of endovascular embolization with either a metallic coil, endovascular balloon or embolic agent. It is unclear in the literature if bilateral cases are more difficult to treat or have a different prognosis. Our patient required two endovascular procedures suggesting that endovascular intervention may have reduced efficacy in bilateral cases.