Deadbolt cataract due to misplanted minishunt.

A 62-year-old woman with stable unilateral glaucoma in the left eye presented for a cataract consultation. In 2010, laser peripheral iridotomies (LPI) were performed on both eyes by a different provider. Her postoperative course was complicated by a recalcitrant steroid response with a highest intraocular pressure (IOP) of 65 mm Hg in the left eye. A trabeculectomy with a glaucoma minishunt (EX-PRESS, Alcon) was then performed by that provider (Supplemental Figure 1, http://links.lww.com/JRS/A603). Thereafter, IOP control of the left eye was normalized and maintained without topical antiglaucoma medications. Historically, her right eye has been always her better eye. Recently, she noticed metamorphopsia in her left eye. Her ocular history was also notable for high refractive errors requiring continuous spectacles wear, possible mild refractive amblyopia of the left eye, history of submacular choroidal nevus with drusen in the right eye, and an epiretinal membrane (ERM) with macular pucker in the left eye. Her husband is an optician. Both inquire about refractive cataract surgery options to correct astigmatism and presbyopia; both have reservations regarding cost and visual quality associated with diffractive optic intraocular lenses (IOLs). Her deteriorating visual acuity in both eyes affects her ability to work. Her corrected distance visual acuity was 20/40 in both eyes (pinhole, no help) while wearing spectacles according to a prescription of -8.50 diopters (D) +1.50 D × 106 for the right eye and -13.00 D +3.25 D × 057 for the left eye. Her corrected near visual acuity was 14/14 in both eyes with the abovementioned prescription and a +3.00 D add. Central corneal thickness was 618 µm in the right eye and 631 µm in the left eye. IOP was 20 mm Hg in the right eye and 10 mm Hg in the left eye on no antiglaucoma medications. Pertinent findings on slitlamp examination included bilateral dermatochalasis, a shallow diffuse thick bleb superiorly in the left eye only, patent LPI superiorly in both eyes, nuclear sclerotic and cortical cataracts in both eyes (with prominent focal spoke superiorly left eye only) (Figure 1, A-C). Fundus photos show posterior vitreous detachment in both eyes, ERM with macular pucker in the left eye, and submacular choroidal nevus (2.5 × 3.0 disc diameter size) with overlying drusen in the right eye (Supplemental Figure 2, A, http://links.lww.com/JRS/A604). Gonioscopy revealed open angles in both eyes, albeit with focal narrowing without synechiae superiorly in the left eye only (Figure 1, D-FJOURNAL/jcrs/04.03/02158034-202207000-00020/figure1/v/2022-06-24T130746Z/r/image-tiff). Most importantly, however, the distal tip of the minishunt was not positioned as expected in the anterior chamber; rather, it was noted to pierce the peripheral iris near the iris root superiorly. Most of the minishunt shaft and spur were positioned in the posterior chamber with the distal tip penetrating into the superior aspect of the capsular bag and cataract in the left eye-like a deadbolt. Visual field testing showed a full field in the right eye and an inferior nasal step in the left eye (Supplemental Figure 2, B, http://links.lww.com/JRS/A604). In addition to slitlamp, gonioscopic, and fundus photos, we also obtained optical coherence tomography of the macula and nerve (Supplemental Figure 2, C, http://links.lww.com/JRS/A604), optical biometry, ultrasound biomicroscopy, endothelial cell counts, and corneal topography (Supplemental Figure 3, http://links.lww.com/JRS/A605). How would you counsel this patient regarding her glaucoma condition, the misplanted minishunt, and her cataract surgery and IOL options? How would you manage the misplanted minishunt? What surgical approaches or specific techniques would you consider for cataract removal and visual rehabilitation?

Cyclodialysis cleft repair with goniotomy for the control of post-operative ocular hypertension.

PURPOSE: In this case of iatrogenic cyclodialysis cleft, we describe a technique in which a nasal goniotomy is coupled with indirect cyclodialysis cleft (CDC) repair in order to minimize acute post-operative ocular hypertension, which is common following cyclodialysis cleft closure. OBSERVATIONS: This novel technique was simple, convenient, and effective in controlling intraocular pressure (IOP) for the patient. CONCLUSIONS AND IMPORTANCE: IOP frequently spikes to dangerously high levels following CDC closure. Pairing CDC repair with goniotomy may help prevent acute post-operative ocular hypertension in these patients.

Urinary ß2-microglobulin and disease activity in patients with tubulointerstitial nephritis and uveitis syndrome.

BACKGROUND: Urinary ß2-microglobulin (Uß2M) is elevated in tubulointerstitial nephritis and uveitis (TINU) syndrome and has emerged as an important diagnostic tool. This study aims to determine whether Uß2M correlates with uveitis activity in TINU. METHODS: Retrospective observational case series of nine patients with TINU and ≥ 30 days follow-up. Presenting symptoms, visual acuity, uveitis characteristics, follow-up, Uß2M, serum creatinine (SCr), urinalysis, and renal biopsy results were collected. RESULTS: A correlation between Uß2M and anterior chamber (AC) cell (r = 0.69, 95% CI 0.46-0.84), flare (r = 0.65, 95% CI 0.39-0.81), trended toward a stronger correlation than SCr and AC cell (r = 0.59, 95% CI 0.29-0.79), flare (r = 0.52, 95% CI 0.19-0.75). Uß2M decreased over 1-2 years while SCr returned to normal within a few months. CONCLUSIONS: Uß2M correlate with uveitis activity and trend down over the course of TINU. Uß2M may serve as a useful tool in determining where patients are in their systemic disease course.

Glaucoma-associated corneal endothelial cell damage: A review.

The corneal endothelium is critical in maintaining a healthy and clear cornea. Corneal endothelial cells have a significant reserve function, but preservation of these cells is paramount as they have limited regenerative capacity. Glaucoma is a prevalent disease, and damage to the corneal endothelium may be caused by the disease process itself as well as by its treatment. The mechanisms involved in glaucoma-associated damage to the corneal endothelium need further investigation. Understanding how glaucoma and glaucoma surgery impact the endothelium is important for protecting corneal clarity and visual acuity in all glaucoma patients, including those undergoing corneal transplant. We will discuss a range of identified factors that may impact corneal endothelial cell health in glaucoma, including intraocular pressure, glaucoma medications, surgical glaucoma management, mechanical forces, and alterations in the aqueous environment.

Upper Eyelid Splitting to Facilitate the Insertion of Glaucoma Drainage Devices.

PURPOSE: To describe a new application for vertical splitting of the upper eyelid, a technique traditionally used for orbital access, to facilitate glaucoma drainage device (GDD) implantation in patients with poor surgical exposure. METHODS: Case series. CASES: We present a case of Möbius syndrome with complete restriction of the extraocular muscles, followed by a case of cicatricial narrowing of the palpebral fissures due to chronic allergic dermatitis. Both patients had severe, medically uncontrolled glaucoma, but poor surgical exposure precluded implantation of a GDD. Both cases underwent vertical splitting of the upper eyelid, which allowed for adequate exposure of the superior globe quadrants and successful implantation of a GDD. CONCLUSIONS: A variety of congenital or acquired conditions result in narrowing of the palpebral fissure or restriction of extraocular motility. When these patients have concurrent advanced glaucoma, inadequate surgical exposure can impede necessary surgical intervention. Use of a vertical upper eyelid split technique allows for access to the superior globe and facilitates implantation of a GDD.

Idiopathic Bilateral Profound Hypotony in an Unknown Progressive Neurodegenerative Disorder.

PURPOSE: To present a unique case of idiopathic bilateral hypotony in a patient with progressive, undiagnosed neurological decline, possibly due to mitochondrial disease, and to explore mechanisms of disease and potential treatment options. METHODS: This is a case report. PATIENT: A 17-year-old boy with a history of chronic progressive bilateral vision loss and hypotony in the setting of progressive gait abnormalities, lower extremity spasticity, nystagmus, and urinary retention starting around age 8. Despite extensive biochemical and genetic evaluation, no systemic etiology has been identified. He had no history of ocular trauma or surgery. RESULTS: Examination confirmed the above history as well as decreased vision, significant bilateral astigmatism (7 D), short axial-eye-lengths, and disc edema with chorioretinal folds in the left eye. There was no inflammation or ciliary body detachment. We propose the etiology is similar to hypotony in myotonic dystrophy, in which low intraocular pressure may result from aqueous egress across the ciliary body face. The best treatment remains unclear, but surgical closure of the iridocorneal angle is under careful consideration. This may halt nonconventional (suprachoroidal) outflow. CONCLUSIONS: Management of ocular hypotony is typically directed at the underlying etiology. Idiopathic hypotony poses a unique treatment challenge. If excess aqueous flow across the ciliary body face is responsible, intentional closure of the iridocorneal angle may preserve vision.