Impact of glaucoma medications on subsequent Schlemm's canal surgery outcome: Cox proportional hazard model and propensity score-matched analysis.

PURPOSE: The impact of various preoperative glaucoma medications on Schlemm's canal surgery outcomes remains unclear. This study aimed to investigate the impact of preoperative glaucoma medications on the postoperative 1-year outcomes of µTLO. METHODS: We analyzed the medical records of 218 patients who underwent their first µTLO to investigate the 1-year postoperative outcomes. Cox proportional hazard regression analysis was performed with surgical failure as the dependent variable and each type of preoperative medication as the independent variable. We also compared the 1-year outcomes of µTLO between users and non-users of specific medications using propensity score matching. Surgical success was defined as a postoperative intraocular pressure ranging from 5 to 21 mmHg, a ≥20% reduction in IOP from baseline, and no additional glaucoma surgery within 1 year postoperatively. RESULTS: The Cox proportional hazard analysis showed that all drugs that do not increase the conventional outflow exhibited hazard ratios greater than 1.0, and the preoperative use of ß-blockers and oral CAI was a significant surgical risk factor (hazard ratio: 2.65 and 2.45, p = 0.04 and <0.001). In the propensity score matching analysis, success rates at 1 year postoperatively were 55/85, 54/79, 60/73, and 40/76% for users/non-users of ß-blockers, topical CAIs, an alpha-2 adrenergic agonist, and an oral CAI, respectively. Kaplan-Meier survival curves in these comparisons also demonstrated that preoperative ß-blockers and oral CAI use were significant surgical risks (p = 0.01, <0.001). CONCLUSION: Our study suggests that preoperative medications that do not involve conventional pathway outflow have a detrimental effect on subsequent Schlemm's canal surgery outcomes.

Detection of Relative Afferent Pupillary Defect and Its Correlation with Structural and Functional Asymmetry in Patients with Glaucoma Using Hitomiru, a Novel Hand-Held Pupillometer.

Patients with asymmetric glaucomatous optic neuropathy (GON) present a relative afferent pupillary defect (RAPD) in the eye with more advanced damage. Although useful, pupillometric RAPD quantification is not widely used as it is not portable. Whether asymmetry of the peripapillary capillary perfusion density (CPD) detected using optical coherence tomography angiography correlates with the severity of RAPD remains unknown. This study assessed RAPD in 81 patients with GON using Hitomiru, a novel hand-held infrared binocular pupillometer. The correlation and ability to detect clinical RAPD based on the swinging flash light test of two independent RAPD parameters (the maximum pupil constriction ratio and the constriction maintenance capacity ratio) were assessed. The coefficient of determination (R2) was calculated between each of the two RAPD parameters and asymmetry of the circumpapillary retinal nerve fiber layer thickness (cpRNFLT), ganglion cell layer/inner plexiform layer thickness (GCL/IPLT), and CPD. The two RAPD parameters showed a correlation coefficient of 0.86 and areas under the receiver operating characteristic (ROC) curve of 0.85-0.88, with R2 being 0.63-0.67 for the visual field, 0.35-0.45 for cpRNFLT, 0.45-0.49 for GCL/IPLT, and 0.53-0.59 for CPD asymmetry. Hitomiru has high discriminatory performance in detecting RAPD in patients with asymmetric GON. CPD asymmetry may better correlate with RAPD than cpRNFLT and GCL/IPLT asymmetry.

Intraoperative Three-Dimensional Fluorescein Angiography-Guided Pars Plana Vitrectomy for the Treatment of Proliferative Diabetic Retinopathy: The Maximized Utility of the Digital Assisted Vitrectomy.

PURPOSE: To show the usefulness of the intraoperative three-dimensional fluorescein angiography (3D-FA)-guided pars plana vitrectomy. METHODS: The NGENUITY 3D visualization system was used for the digital assisted vitrectomy. Three-dimensional fluorescein angiography-guided pars plana vitrectomy was performed in three patients with vitreous hemorrhage secondary to proliferative diabetic retinopathy. We investigated both whether several angiographic findings can be successfully displayed on the screen during 3D-FA and whether pars plana vitrectomy can be performed simultaneously on the same screen while implementing 3D-FA. RESULTS: In all cases, the abnormal FA findings including hypofluorescence due to non-perfusion areas, and the hyperfluorescence due to macular edema and fibrovascular proliferative membrane were successfully displayed on the screen. The segmentation and delamination of fibrovascular proliferative membrane and panretinal photocoagulation for detected non-perfusion areas were able to be performed on the same screen while implementing 3D-FA. CONCLUSION: Three-dimensional fluorescein angiography-guided pars plana vitrectomy is a novel approach that fully utilizes the advantages of digital assisted vitrectomy and a promising option for the treatment of proliferative diabetic retinopathy.

Incidence of Leber hereditary optic neuropathy in 2019 in Japan: a second nationwide questionnaire survey.

BACKGROUND: Leber hereditary optic neuropathy (LHON) is an acute or subacute optic neuropathy that mainly affects young males. The first nationwide epidemiological survey of LHON was conducted in 2014 in Japan, and LHON was officially designated as a rare intractable disease by the Japanese government in 2015. We conducted a second survey of the annual incidence of LHON in 2019, and estimated the total number of patients with LHON in Japan. RESULTS: A questionnaire was sent to 997 facilities accredited by the Japanese Ophthalmological Society and/or affiliated with the councilors of the Japanese Neuro-Ophthalmology Society. Responses were received from 791 facilities, with a response rate of 79%. Fifty-five newly diagnosed cases (49 males and 6 females) of LHON were reported from 35 institutions in 2019, with a median age of 28.5 for males and 49.5 years for females. The total number of newly diagnosed cases was calculated as 69 (62 were males and 7 were females, 95% confidence interval 55-83), and the total number of patients was estimated to be 2491 (95% confidence interval: 1996-2986), suggesting a prevalence of LHON in Japan of 1:50,000. CONCLUSION: The incidence of LHON in 2019 was lower than the estimate in 2014, whereas its prevalence may be similar to that reported in other countries. The accurate estimation of the incidence and prevalence of patients with LHON requires prospective registration.

Risk of surgical failure and hemorrhagic complications associated with antithrombotic medication in glaucoma surgery.

PURPOSE: The purpose of this retrospective study was to determine the extent to which the use of antithrombotic drugs during glaucoma surgery contributes to surgical failure and postsurgical hemorrhagic complications. METHODS: Glaucoma surgeries were categorized into three groups: trabeculotomy (TLO), trabeculectomy (TLE), and long-Tube shunt surgery (Tube). At 1 year after surgery, the following criteria for surgical success were met: intraocular pressure (IOP) in the 5-21-mmHg range, IOP reduction of at least 20% from the preoperative level, and no additional glaucoma surgeries. We compared the percentages of the success rates and hemorrhagic complications between antithrombotic medication experiencers and non-experiencers. Furthermore, we adjusted the preoperative factors between the two groups using a propensity score analysis in TLO and TLE surgeries. RESULTS: A total of 910 glaucoma surgeries were included, with TLO, TLE, and Tube accounting for 353, 444, and 113 surgeries, respectively. Preoperative antithrombotic medications were administered to 149 patients in all glaucoma surgeries: 37 patients used only anticoagulants, 102 used only antiplatelets, and 10 used both. There was no significant difference in the success rates of any of the procedures. The hemorrhagic complications (hyphema and vitreous hemorrhage rate) were significantly higher in the patients who underwent TLE and Tube. The surgical success rates of TLO and TLE were not significantly different after the two groups were matched by propensity score. CONCLUSION: The perioperative use of antithrombotic drugs did not affect success for any of the procedures. However, it increased early postoperative hemorrhagic complications for TLE and Tube.

Association of the prolonged use of anti-glaucoma medications with the surgical failure of ab interno microhook trabeculotomy.

PURPOSE: This study examined the perioperative factors affecting surgical success in ab interno microhook trabeculotomy (µTLO). METHODS: A total of 146 consecutive patients who underwent µTLO were included in this retrospective study. We performed Cox proportional hazard modelling by setting surgical success at 1 year as an objective variable. The explanatory variables included age, sex, glaucoma type, preoperative intraocular pressure (IOP), glaucoma drug score, mean deviation (MD) of the Humphrey visual field test, duration of glaucoma drug use, antithrombotic drug use, combined cataract surgery, incision range and diabetes mellitus. Additionally, we performed 1:1 matching using propensity score analysis and compared the perioperative parameters between durations of glaucoma drug use of <4.5 years and ≥ 4.5 years (50 patients each). We defined surgical success as satisfaction of all three criteria: IOP 5-21 mmHg, IOP reduction of ≥20% from the preoperative IOP and no additional glaucoma surgery. RESULTS: The Cox proportional hazard model revealed that a longer duration of anti-glaucoma medication was significantly associated with surgical failure. Propensity score matching analysis showed that the <4.5-year users of anti-glaucoma drugs had significantly higher success rates than the ≥4.5-year users (72% versus 52%; p = 0.04). CONCLUSIONS: The prolonged use of multiple glaucoma drugs adversely affected the outcome of µTLO at least at 1 year postoperatively.

The beneficial impact of filtration surgery on antiviral therapy cessation in patients with cytomegalovirus-related secondary glaucoma.

PURPOSE: Cytomegalovirus (CMV)-related keratouveitis elevates intraocular pressure (IOP). Antiviral therapy does not always control IOP and some patients do not tolerate systemic antiviral therapy because of the side effects. The purpose of this study is to evaluate the clinical characteristics of patients with CMV-related keratouveitis and determine the impact of glaucoma surgeries on the postoperative antiviral therapy regimen. METHODS: We enrolled twenty-two patients with CMV-DNA-positive keratouveitis between June 2012 and July 2019 in Kobe University Hospital. The following clinical parameters were collected: gender, age, history of previous intraocular surgery, antiviral medications, visual acuity, IOP, glaucoma drug score, corneal endothelial cells density, and the mean deviation of a Humphrey visual field test at the first visit and before and 1 year after glaucoma surgery. RESULTS: All twenty-two patients started on oral and/or topical antiviral therapy. Eighteen patients needed glaucoma surgery despite their antiviral medications. Nine patients underwent trabeculotomy (TLO) and nine underwent trabeculectomy (TLE) as the first surgical intervention. Six of patients who initially underwent TLO and two of the patients who initially underwent TLE required additional TLE within 1 year. Each of the 15 patients who underwent at least 1 TLE showed a reduction in the magnitude and variation of IOP and glaucoma drug scores and 13 patients were able to discontinue antiviral therapy. For the remaining 4 patients, IOP and inflammation were controlled but with antiviral medications. CONCLUSIONS: In patients with CMV-related keratouveitis, TLE decreases and stabilizes IOP and contributes to withdrawal from antiviral medications.

Protocol to test the efficacy and safety of frequent applications of skin electrical stimulation for Leber hereditary optic neuropathy: a single-arm, open-label, non-randomised prospective study.

INTRODUCTION: Leber hereditary optic neuropathy (LHON) is an acute or subacute inherited optic neuropathy caused by mitochondrial mutations. More than 90% of patients with LHON have one of three point mutations (ie, G3460A, G11778A and T14484C). We previously reported that a 12-week session of skin electrical stimulation (SES) with a 2-week interval significantly improved visual acuity and field tests 1 week after the last stimulation and without adverse effects in 10 cases of LHON carrying the mt DNA G11778A mutation. In the present study, we will examine the magnitude and persistence of the efficacy and presence or absence of adverse events using SES with a more frequent stimulation protocol. METHODS AND ANALYSIS: This study will be a single-arm, open-labelled, non-randomised clinical study that analyses 15 cases of LHON with G11778A mutation. All participants will take a portable SES device home and perform SES by themselves every other day for 12 weeks. The logarithm for the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) at 1 week after the last SES will be measured as the primary outcome. LogMAR BCVA will be measured at four and 8 weeks after the last SES treatment. The Humphrey visual field sensitivity test using size V stimulation and critical fusion frequency at 1, 4 and 8 weeks after the last SES session will be secondary outcome measurements. Slit-lamp examination, optical coherence tomography and specular microscopy will also be performed to verify the safety of SES. ETHICS AND DISSEMINATION: The protocol was approved by the Institutional Review Board at Kobe University, Japan (Approval No.C190030). This study is in progress and deserves Pre-result. All documents communicating with the ethics committee will be reposited by the researcher. Modifications to the protocol will be reviewed by the ethics committee and implemented after approval. Data monitoring will be performed by a researcher who is not involved in the study every 6 months after approval. The research summary results will be registered in the Japan Registry of Clinical Trials (jRCTs) and made available to participants in accordance with the terms described in the documents. In addition, the results of this study will be presented at domestic and international meetings and published in peer-reviewed journals within a year after data is fixed. TRIAL REGISTRATION NUMBER: jRCTs052200033.