Ethnic Differences in the Rates of Posterior Capsule Rupture and Long-Term Sequelae in Phacoemulsification Cataract Surgery.

Purpose The purpose of this study is to investigate the rates of posterior capsular rupture (PCR) and its sequelae during phacoemulsification across different ethnicities. Methods This is a retrospective cohort study of all consecutive phacoemulsification cases complicated by PCR that met the inclusion criteria over a four-year period at a single tertiary eye centre in the United Kingdom (UK). Results PCR occurred in 0.85% of cases overall (157/18,481). PCR rates were 1.8% (26/1485), 1.2% (51/4350), and 0.7% (75/10,927) in African-Caribbean, Indian subcontinent, and Caucasian patients, respectively (p < 0.001). Mean final corrected distance visual acuity improved (p < 0.05) in all ethnic groups (0.40 ± 0.57 logMAR) compared to pre-op (0.78 ± 0.61 logMAR). Post-operative cystoid macular oedema and unstable intraocular pressure rates following PCR did not statistically differ amongst ethnicities (p = 0.37 and p = 0.75, respectively). However, post-operative uveitis rates significantly differed at 11.5%, 15.7%, and 1.3% amongst the three ethnic groups, respectively (p = 0.01). Conclusion This is the first study to highlight a possible link between patient ethnicity and the risk of PCR during phacoemulsification cataract surgery. We observed significantly greater numbers of PCR cases amongst certain ethnic groups (highest in African-Caribbean eyes, then Indian subcontinental eyes, and lowest in Caucasian eyes) within the same multi-cultural urban population. Ethnicity may therefore be a contributing factor for PCR and should potentially be taken into consideration during preoperative risk stratification.

Use of Ocular Response Analyzer Output Data in the Management of Low Intraocular Pressure after Glaucoma Filtration Surgery.

Aim: To highlight potential benefits of using Reichert's ocular response analyzer (ORA) for intraocular pressure (IOP) measurement following glaucoma filtering surgery (GFS), especially in cases of low IOP. Background: Goldmann applanation tonometry (GAT) is widely regarded as the gold standard of IOP measurement in clinical practice. The ORA also calculates corneal biomechanics, which is used in the calculation of the cornea-compensated IOP (IOPcc).1 This useful, previously unknown information can be used to guide management in challenging clinical cases. Case description: A 78-year-old lady underwent right trabeculectomy with mitomycin C. During the first 9 months postoperatively, IOP's when measured with GAT, were found to be low (ranging between 2 mm Hg and 5 mm Hg). The patient displayed no clinical features of hypotony and visual acuity remained stable throughout. IOP was also measured with Reichert's ORA, which gives readings for corneal hysteresis (CH), corneal resistance factor and corneal corrected IOP. IOPcc measurements obtained with ORA were consistently higher, ranging from 6.7 mm Hg to 9.3 mm Hg and were more in keeping with the clinical features of the case. Conclusion: This case highlights the possibility that GAT can underestimate the true IOP in eyes with low IOP following GFS, as it does not account for corneal biomechanical properties. Clinical significance: Ocular response analyzer (ORA)-measured IOPcc may be a useful adjunct in reassuring surgeons to manage postoperative numerical hypotony conservatively in the absence of any clinical signs of hypotony. How to cite this article: Dawson S, Mohite A. Use of Ocular Response Analyzer Output Data in the Management of Low Intraocular Pressure after Glaucoma Filtration Surgery. J Curr Glaucoma Pract 2023;17(2):104-105.

A Novel Tube Insertion Technique for Glaucoma Drainage Device Implantation.

PURPOSE: Early hypotony after non-valved glaucoma drainage device (GDD) implantation for complex glaucomatous eyes with labile aqueous production can lead to significant visual morbidity. We therefore sought to report the early postoperative outcomes of a novel surgical technique that allows atraumatic insertion of non-valved GDDs through a much smaller 25-gauge scleral track, to minimize entry site leakage and improve safety. METHODS: Retrospective case series of 15 consecutive cases undergoing non-valved GDD insertion into the anterior chamber using a previously unreported technique. RESULTS: All eyes underwent successful GDD insertion using our novel technique, with no intraoperative complications. The mean preoperative intraocular pressures (IOP), at day 1, week 1 and week 3 were 31.4, 22.4, 23.7, and 25.6 mm Hg, respectively. A statistically significant IOP reduction was achieved at day 1, week 1 and week 3 postoperatively ( P <0.05) without any observed leakage at the scleral entry site. One eye (6.7%) with complex panuveitic glaucoma developed early hypotony (5 mm Hg) with shallow choroidal detachments on day 1. This was successfully managed with 1 intracameral ophthalmic viscoelastic device injection given at the slit-lamp and no further intervention. CONCLUSIONS: This novel single needle-docking intraocular insertion manoeuvre is an easily adoptable technique to make GDD insertion through a smaller 25-gauge water-tight scleral track more efficient and less traumatic. The technique reduces scleral distortion and therefore improves surgical safety particularly in eyes with complex secondary glaucoma.

Glaucoma control after phacoemulsification in eyes with functioning glaucoma filtration surgeries: trabeculectomies versus glaucoma drainage devices.

PURPOSE: Several studies have demonstrated decompensation of intraocular pressure (IOP) control following phacoemulsification in eyes with a functioning trabeculectomy. Limited evidence base suggests that this effect is minimal in eyes with functioning glaucoma drainage devices (GDD). The aim of this study was to report on glaucoma control after phacoemulsification in eyes with a functioning GDD compared to eyes with a functioning trabeculectomy. METHODS: Single-centre retrospective comparative study of patients with a functioning non-valved GDD (Baerveldt 350; Johnson & Johnson Surgical Vision) or trabeculectomy undergoing phacoemulsification. Glaucoma outcomes including IOP, cup:disc ratio (CDR), global retinal nerve fibre layer (RNFL) thickness and visual field mean deviation (MD) are reported. Failure was defined as IOP rise > 20% from baseline. RESULTS: Fifteen eyes with a functioning trabeculectomy and twenty-three eyes with a functioning GDD with 24-month post-phacoemulsification data were identified. Mean IOPs were significantly lower in the trabeculectomy group at month 24 compared to the GDD group, 9.5 and 15.9 mmHg (p = 0.001) respectively. At month 12, there was significant worsening on MD in GDD group compared to trabeculectomy group, - 20.0 dB and - 11.3 dB respectively (p = 0.03). A greater proportion of eyes failed in the GDD group compared to the trabeculectomy group, N = 15 (65%) and n = 7 (47%), p = 0.26. CONCLUSION: As with functioning trabeculectomies, phacoemulsification should be approached with similar caution in eyes with functioning GDD. An existing GDD is at least as likely to fail following clear corneal phacoemulsification as an existing trabeculectomy and non-augmented GDDs may be at greater risk.

Does prior endoscopic cyclophotocoagulation (ECP) affect subsequent trabeculectomy outcomes?

PURPOSE: To report long-term outcomes of trabeculectomy following prior endoscopic cyclophotocoagulation (ECP). METHODS: Retrospective case-controlled comparative study reporting 2-year outcomes of eyes undergoing trabeculectomy following failed prior ECP (group 1), using eyes undergoing trabeculectomy as a primary glaucoma procedure as controls (group 2). RESULTS: Filtration surgery was required in only 19.4% (12/62) of eyes undergoing ECP. Of these, nine eyes that underwent trabeculectomies were included in group 1. Nine matched eyes were used as controls and included in group 2. Mean baseline IOPs were 23.7 ± 7.7 and 26.0 ± 6.7 mmHg (p = 0.452) in groups 1 and 2, respectively, on a mean of 3.4 ± 0.9 and 2.8 ± 1.4 medications, respectively (p = 0.274). The mean 2-year IOP was 10.6 ± 5.2 and 12.9 ± 4.0 mmHg (p = 0.285) in groups 1 and 2, respectively, on a mean of 0.1 ± 0.3 and 0.1 ± 0.4 medications (p = 0.931) respectively. Complete success rates were 77.8% and 88.9% in groups 1 and 2, respectively (p = 0.527). Qualified success rates were 11.1% in both groups. Combined success rates were 88.9% and 100.0% in groups 1 and 2, respectively (p = 0.318). There were no failures in group 2, compared to 11.1% in group 1 (p = 0.318). There were no significant between-group differences in hypotony, bleb needling, cystoid macular oedema, persistent uveitis, or repeat filtration surgery rates. CONCLUSIONS: ECP is a safe initial procedure in eyes with progressive glaucomas, and may substantially reduce the need for trabeculectomy without compromising outcomes in the minority that go on to require it.

Refractive Outcomes of Phacovitrectomy in Retinal Detachment Compared to Phacoemulsification Alone Using Swept-Source OCT Biometry.

BACKGROUND AND OBJECTIVE: To assess the refractive outcomes in patients who underwent combined phacovitrectomy for retinal detachment compared to phacoemulsification and intraocular lens (IOL) implant utilizing newer swept-source optical-coherence-tomography (SS-OCT) biometry and determine the requirement of an adjustment factor for superior predicted refractive outcomes. PATIENTS AND METHODS: Retrospective study of 95 eyes: 52 eyes that underwent phacovitrectomy and 43 eyes with phacoemulsification only that served as the control group. Mean refractive error (ME) and mean absolute error (MAE) were used to compare the groups. RESULTS: No statistically significant postoperative refractive shift was found between phacoemulsification and phacovitrectomy eyes for (1) ME (0.05 D [± 0.51 diopters (D)] and (0.03 [± 0.73 D], respectively; P = .348), (2) MAE (0.41 D ± 0.29 D and 0.60 ± 0.44 D, respectively), or (3) MAE of the control compared to macula-on/off eyes (P = .160 and P = .078, respectively). CONCLUSION: The authors do not recommend an adjustment factor for IOL selection when utilizing SS-OCT biometry, as it provided refractive outcomes superior to those found in previous studies utilizing a partial coherence interferometry system. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:432-437.].

Comparison of 1-year surgical outcomes of combined cataract surgery and gonioscopy-assisted transluminal trabeculotomy (GATT) versus cataract surgery and iStent Inject.

PURPOSE: Evaluate the efficacy, safety, and complication rates of phacoemulsification cataract surgery when combined with either gonioscopy-assisted transluminal trabeculotomy (GATT) or iStent Inject. METHODS: This is a retrospective case-control study to compare the surgical outcomes of combined phacoemulsification cataract surgery with either GATT (phaco-GATT) or iStent Inject (phaco-iStent). Both groups had at least 1-year follow-up. The primary outcome measures were IOP and number of glaucoma medications (NGMs) at 1 year. Secondary outcomes measures were best corrected visual acuity (BCVA) and intra- or postoperative complications within the first year of follow-up. Success was defined as intraocular pressure (IOP) < 21 mmHg and ≥ 20% reduction in IOP at 1 year regardless of the NGM. RESULTS: Each group included 37 patients. The median baseline IOP (24 vs 17) and NGM (3 vs 2) were higher in the phaco-GATT group (p < 0.001). Phaco-GATT achieved a 38% (p < 0.0001) reduction in IOP compared to 13.2% (p < 0.001) in the phaco-iStent group at 1-year follow-up. The reduction in IOP and NGM was significantly higher in the phaco-GATT group (p < 0.01). After adjusting for baseline IOP, the reduction in IOP at 12 months was still significantly higher in the phaco-GATT group (p = 0.042). At 1 year, 86.4% of patients in the phaco-GATT group met the success criteria compared to 35.1% in the phaco-iStent group. Safety outcomes were slightly favourable in the phaco-iStent group. CONCLUSION: Phaco-GATT and phaco-iStent showed a significant reduction in IOP and NGM, with phaco-GATT having a significantly higher reduction. Phaco-iStent appears to have a higher safety profile and is probably preferable in monocular patients and those with a high risk of bleeding.

ASSESSING REFRACTIVE OUTCOMES AND ACCURACY OF BIOMETRY IN PHACOVITRECTOMY AND SEQUENTIAL OPERATIONS IN PATIENTS WITH RETINAL DETACHMENT COMPARED WITH ROUTINE CATARACT SURGERY.

PURPOSE: To compare refractive outcomes and accuracy of modern optical biometry, swept-source optical coherence tomography, ultrasound biometry, and effect of the macula status in rhegmatogenous retinal detachment managed with either combined phacovitrectomy or sequential vitrectomy and cataract surgery compared with a control, phacoemulsification alone. METHODS: Retrospective, comparative, consecutive study of 154 eyes; Group 1 underwent phacovitrectomy (n: 70), Group 2 underwent vitrectomy with subsequent cataract surgery (n: 41), and Group 3 underwent cataract surgery alone (n: 43). RESULTS: No difference in the mean absolute error was found between Group 2 (0.41 ± 0.56) and Group 3 (0.41 ± 0.29); both were superior to Group 1 (0.74 ± 0.57). Between Group 1 and Group 2, no statistically significant difference in the mean absolute error was found between macula-on subgroups (P = 0.057), but this was statistically significant between macula-off subgroups (P = 0.009). Subgroup analysis by biometry showed that the difference in the mean absolute error between macula-off optical biometry Group 1 and Group 2 against our control, Group 3, were not significant (P = 0.078 and P = 0.119, respectively); the mean absolute error was significantly different when considering macula-off ultrasound biometry cases (P < 0.001 and P = 0.038, respectively). CONCLUSION: All three groups had comparable refractive outcomes when using optical biometry. However, phacovitrectomy macula-off cases had inferior refractive outcomes when the ultrasound biometry had to be used. In macula-off rhegmatogenous retinal detachment, when optical biometry is not reliable, it is preferable to perform sequential surgery rather than phacovitrectomy.

Secondary Glaucoma due to Iridescent Crystalline Particles Masquerading as Refractory Hypertensive Uveitis in an Eye With Irradiated Iris Melanoma.

PURPOSE: We report a previously unrecognized mechanism of secondary glaucoma due to iridescent crystalline particles released from an irradiated iris melanoma. It masqueraded as refractory hypertensive uveitis following uncomplicated phacoemulsification. MATERIALS AND METHODS: A 58-year-old gentleman had an iris melanoma that underwent successful regression following irradiation with proton beam radiotherapy. Three years later an uncomplicated phacoemulsification with intraocular lens implant was performed and subsequently the patient presented with apparently "refractory hypertensive uveitis." Closer examination identified unique iridescent crystalline particles originating from a disintegrating tumor and dispersing within the anterior chamber and drainage angle. The patient developed a unilateral secondary open-angle glaucoma attributable to these particles. Ultrasound biomicroscopy of the anterior segment confirmed absence of tumor recurrence or intrascleral spread and systemic investigations ruled out distant metastases. RESULTS: The intraocular pressure was refractory to maximal medical treatment, but was eventually controlled with trans-scleral diode laser cyclo-photocoagulation. CONCLUSIONS: This is the first report of a secondary glaucoma attributable to trabecular blockage with iridescent crystalline particulate material released from a disintegrating, previously irradiated, iris melanoma. Proton beam radiotherapy and possibly phacoemulsification may have played a role in triggering the release of these previously undescribed particles from the atrophied tumor surface. This unique mechanism of secondary glaucoma needs to be kept in mind in such rare cases. Trans-scleral cyclodiode laser may be used as a good initial option in such cases to minimize potential risk of tumor seeding with incisional glaucoma surgery.

Latanoprost Induced Iris Pigment Epithelial and Ciliary Body Cyst Formation in Hypermetropic Eyes.

PURPOSE: Latanoprost has become one of the most widely prescribed topical antihypertensive medications in recent years. Yet there have been few reports of secondary iris pigment epithelial (IPE) and ciliary body (CB) cyst formation to date and none, to our knowledge, reported in eyes predisposed to primary angle closure. METHODS: We report the first documented case of bilateral IPE and CB cysts in a hypermetropic patient with prior laser peripheral iridotomies (LPIs) as a rare, delayed side effect of topical Latanoprost treatment. The cysts subsided with discontinuation of Latanoprost, thereby demonstrating a causal relationship. We discuss the pathogenesis of such cysts and advocate using of serial ultrasound biomicroscopic (UBM) images to monitor them. RESULTS AND CONCLUSIONS: Latanoprost may cause iris pigment epithelial and ciliary body cysts that remain clinically undetected. In eyes predisposed to angle closure, such cysts may become clinically detectable and masquerade as iris tumours. Prior laser peripheral iridotomies in these eyes may delay or prevent the detection of these cysts. Ultrasound biomicroscopy (UBM) imaging is therefore a valuable tool in diagnosing and monitoring these cysts.

Accuracy of clinical diagnosis of benign eyelid lesions: Is a dedicated nurse-led service safe and effective?

This article compares an independent nurse-led benign lesion service with a doctor-led one, and assesses the impact of clinician seniority on diagnostic accuracy rates. Retrospective review of benign lesions referred to a teaching hospital and managed in either a doctor- or nurse-led lid service. All lesions were diagnosed clinically, excised and then sent for histological diagnosis. Lesions were categorized into subtypes. Pre-excision clinical diagnoses were compared with histological diagnoses. Sensitivity, specificity and missed malignancy rates were calculated for each subtype. Accuracy was compared between different grades of doctors and a specialist nurse. 264 and 332 lesions were managed in a doctor-led and nurse-led service, respectively. Rates of accurate sub-typing were 79.6% and 80.4% in the doctor- and nurse-led services, respectively (p > 0.05). Clinician seniority had no bearing. Missed malignancies or pre-malignancies accounted for 1.1% and 1.5% of lesions in the doctor and nurse-led services, respectively (p > 0.05). Overall, the remaining misdiagnoses were benign lesions of another subtype (13.6%) or non-specific histological findings (5.0%) and 98.6% of lesions were confirmed as benign on histology. Overall sensitivity and specificity values were: benign epithelial proliferations 95.6% and 92.2%, epidermal inclusion cysts 92.2% and 88.0%, xanthelasma 97.5% and 100.0%, cysts of Moll 66.7% and 96.6%, naevi 39.4% and 99.8% and molluscum 20.0% and 99.8%, respectively. A dedicated nurse-led service is as effective in managing a range of clinically benign lid lesions as a doctor-led one, and clinician seniority has little impact on the diagnostic accuracy of these lesions.

Chikungunya fever presenting with acute optic neuropathy.

Chikungunya fever is a vector borne virus that typically causes a self-limiting systemic illness with fever, skin rash and joint aches 2 weeks after infection. We present the case of a 69-year-old woman presenting with an acute unilateral optic neuropathy as a delayed complication of Chikungunya virus (CHIKV) infection contracted during a recent trip to the West Indies. She presented to our ophthalmology department with acute painless visual field loss in the right eye and a recent flu-like illness. She was found to have a right relative afferent pupillary defect (RAPD) with unilateral optic disc swelling. Serology confirmed recent CHIKV infection. Treatment with intravenous methylprednisolone was delayed while awaiting MRI scans and serology results. At 5-month follow-up, there was a persistent right RAPD and marked optic atrophy with a corresponding inferior scotoma in the visual field.