Pregnancy outcomes in the medical management of glaucoma: An international multicenter descriptive survey.

PURPOSE: To determine if glaucoma medications are associated with pregnancy and/or postnatal complications. METHODS: Multicenter descriptive survey. Subjects were female patients 18-45 years who were previously pregnant with a diagnosis of glaucoma or ocular hypertension prior to pregnancy. Chart review queried diagnosis, glaucoma severity, and race. Survey questions were asked for each pregnancy and queried pregnancy age, medications used, and pregnancy outcomes/complications. RESULTS: 114 pregnancies of 56 patients (mean 2.0 pregnancies per patient) were included. Three pregnancies with therapeutic abortion were excluded from further analysis. Mean age during pregnancy was 29.1 ± 5.7 years. Of the 111 pregnancies, 20 (18.0%) used no medications and 91 (82.0%) used at least one medication. Medications were topical carbonic anhydrase inhibitors (n = 45), beta-blockers (n = 55), alpha-agonists (n = 56), and prostaglandin analogues (n = 28). Outcomes were: preterm contractions/labour (6.3%), miscarriage (4.5%), stillbirth (4.5%), induction of labour (11.9%), emergency/unplanned caesarean delivery (13.9%), neonatal intensive care unit (NICU) stay (15.8%), congenital anomalies (8.1%), and low birth weight (10.9%). Fisher exact test assessed outcome associations with individual agents, use of any agent, and different number of agents. Alpha-agonist use was associated with NICU stay: 25.5% rate (p = 0.012) in alpha-agonist use. Most of the alpha-agonist use NICU stays occurred in pregnancies with third trimester use. All other associations were not statistically significant. CONCLUSIONS: The data from this survey suggest an overall favourable safety profile for topical glaucoma medications in pregnancy, but further investigation is needed. Caution should be employed regarding third trimester alpha-agonist use owing to association with NICU stay.

Experience with netarsudil 0.02% and latanoprostene bunod 0.024% as adjunctive therapy for glaucoma.

PURPOSE: To assess the effectiveness and safety of adjunctive topical netarsudil 0.02% and latanoprostene bunod 0.024% in patients with glaucoma. METHODS: A retrospective, multi-center, cohort study of patients with glaucoma treated with netarsudil 0.02% or latanoprostene bunod from five tertiary care centers. Inclusion criteria included patients with glaucoma treated with either medication as adjunctive therapy. Outcomes included mean absolute intraocular pressure (IOP) reduction and relative IOP reduction from baseline. Adverse reactions and reasons for discontinuation were reported. One-way analysis of variance, Kruskal-Wallis rank sum test, and Mann Whitney U test compared the outcomes. RESULTS: A total of 95 eyes (95 patients) on netarsudil and 41 eyes (41 patients) on latanoprostene bunod were analyzed. Mean duration of use was 54.3 ± 28 days for netarsudil and 82.9 ± 51.2 days for latanoprostene bunod. At the final visit, mean IOP reduction was 3.9 ± 4.6 mmHg (17.5 ± 6.0%) (p < 0.0001) with netarsudil and 2.9 ± 3.7 mmHg (13.6 ± 16.3%) (p < 0.0001) with latanoprostene bunod. IOP lowering did not depend on baseline number of IOP-lowering medications. The most common reason for discontinuation was non-effectiveness in both groups. CONCLUSION: Similar to monotherapy, netarsudil and latanoprostene bunod demonstrated efficacy in lowering IOP when used as adjunctive therapy.

M&S Smart System Contrast Sensitivity Measurements Compared With Standard Visual Function Measurements in Primary Open-Angle Glaucoma Patients.

PURPOSE: To evaluate the nature and extent of letter contrast sensitivity (CS) deficits in glaucoma patients using a commercially available computer-based system (M&S Smart System II) and to compare the letter CS measurements to standard clinical measures of visual function. METHODS: Ninety-four subjects with primary open-angle glaucoma participated. Each subject underwent visual acuity, letter CS, and standard automated perimetry testing (Humphrey SITA 24-2). All subjects had a best-corrected visual acuity (BCVA) of 0.3 log MAR (20/40 Snellen equivalent) or better and reliable standard automated perimetry (fixation losses, false positives, and false negatives <33%). CS functions were estimated from the letter CS and BCVA measurements. The area under the CS function (AUCSF), which is a combined index of CS and BCVA, was derived and analyzed. RESULTS: The mean (± SD) BCVA was 0.08±0.10 log MAR (∼20/25 Snellen equivalent), the mean CS was 1.38±0.17, and the mean Humphrey Visual Field mean deviation (HVF MD) was -7.22±8.10 dB. Letter CS and HVF MD correlated significantly (r=0.51, P<0.001). BCVA correlated significantly with letter CS (r=-0.22, P=0.03), but not with HVF MD (r=-0.12, P=0.26). A subset of the subject sample (∼20%) had moderate to no field loss (≤-6 dB MD) and minimal to no BCVA loss (≤0.3 log MAR), but had poor letter CS. AUCSF was correlated significantly with HVF MD (r=0.46, P<0.001). CONCLUSIONS: The present study is the first to evaluate letter CS in glaucoma using the digital M&S Smart System II display. Letter CS correlated significantly with standard HVF MD measurements, suggesting that letter CS may provide a useful adjunct test of visual function for glaucoma patients. In addition, the significant correlation between HVF MD and the combined index of CS and BCVA (AUCSF) suggests that this measure may also be useful for quantifying visual dysfunction in glaucoma patients.

Morphologic Patterns Formed by the Anomalous Fibers Occurring Along the Anterior Capsule of the Crystalline Lens in People With the Long Anterior Zonule Trait.

People with the long anterior zonule (LAZ) trait, which may have prevalence near 2%, have zonular fibers that extend more central than usual along the anterior capsule of the crystalline lens. The anomalous fibers can be observed in vivo with clinical slit lamp biomicroscopy after pharmacologic pupil dilation, and although minimally studied, the LAZ trait may have importance to glaucoma, retinal degeneration, and cataract surgery. To further characterize LAZ morphology, a custom computer program was used to trace LAZ fibers seen on retro-illumination photos acquired during previous study at an academic, urban eye care facility in Chicago, IL. There were 59 African-Americans (54 female; median age = 70 years, 53-91 years) included in the analysis. After initial review of the zonule tracings, we identified three basic LAZ patterns. We called one pattern (47% of right eyes) a "non-segmental LAZ pattern," which was predominated by fibers that could be visually traced to the dilated pupil border where they became obscured by the iris. Another pattern (35% of right eyes), the "segmental LAZ pattern," was predominated by fibers that appeared to terminate abruptly without detectable extension to the pupil border. The third pattern (18% of right eyes), the "mixed LAZ pattern," had a more equivalent mixture of the other two fiber morphologies. Compared to the "non-segmental" group, the "segmental" LAZ eyes had smaller central zonule-free zones (P < 0.0001), and they tended to exhibit fewer LAZ fibers (P = 0.07). These data improve understanding of LAZ clinical anatomy and may be helpful to future investigation. Anat Rec, 300:1336-1347, 2017. © 2017 Wiley Periodicals, Inc.

Anterior Chamber Depth, Lens Thickness, and Related Measures in African American Females With Long Anterior Zonules: A Matched Study With Control for Refractive Error.

PURPOSE: To investigate anterior chamber depth (ACD), lens thickness (LT), vitreous body length (VBL), and axial length (AL) in African American females with long anterior zonules (LAZ) while controlling for refractive error. METHODS: The eyes of 50 African American females with LAZ were compared with 50 controls matched with age, race, sex, and refractive error. Central ACD, LT, VBL, and AL measurements were obtained in a masked manner using a-scan ultrasonography. RESULTS: LAZ cases had a mean age±SD of 67.1±7.6 years (range, 52 to 85 y) and a mean refractive error of +1.85±1.41 D (-1.75 to +4.75 D). Parameters were similar for controls. Mean ACD for cases was 2.45±0.34 mm and 2.57±0.38 mm for controls. Mean LT for cases was 4.94±0.43 mm and 4.83±0.45 mm for controls. Mean VBL for cases was 15.00±0.72 mm and 15.17±0.76 mm for controls. Mean AL for cases was 22.39±0.82 mm and 22.57±0.76 mm for controls. Using multiple logistic regression to control for any residual differences in age and refractive error, no significant differences were present between LAZ eyes and control eyes relative to the a-scan variables (P>0.1). CONCLUSIONS: When refractive error was controlled for, this group of African American females with LAZ did not exhibit clinically significant differences in ACD, LT, VBL, and AL as compared with controls.

Innovative approaches to glaucoma management of Boston keratoprosthesis type 1.

Glaucoma remains a prevalent disorder and visual limiting factor after Boston keratoprosthesis type 1 implantation. Patients with glaucoma have worse initial and late visual acuity outcomes after otherwise successful keratoprosthesis implantation. Management of glaucoma in the setting of a keratoprosthesis is challenging because of relatively rapid progression and an inability to accurately measure intraocular pressure (IOP). In addition, there are no standard guidelines for glaucoma surveillance and monitoring after keratoprosthesis surgery. This report provides a review of the current literature and offers innovative strategies that will overcome the challenges in managing glaucoma in the setting of a Boston keratoprosthesis type 1 implant. The topics that will be discussed in this section include alternative methods for IOP measurement, rationales and surgical techniques for a pars plana tube placement for glaucoma drainage device, effective medical and laser treatment, the risk for IOP elevations after YAG laser, and practical guides to glaucoma surveillance and monitoring.

Remnants of the anterior tunica vasculosa lentis and long anterior lens zonules.

PURPOSE: To investigate presence of remnants of the tunica vasculosa lentis, a possible indication of anterior segment dysgenesis, in subjects with the long anterior zonule (LAZ) trait. METHODS: Retroillumination photographs of the pupil region had been collected in earlier study of the LAZ trait in African Americans. Secondary image analysis was performed to assess the frequency of intact persistent pupillary membrane iris strands (PPMIS). RESULTS: The analysis included 148 subjects, comprised of 74 LAZ subjects (median age=70 y; range, 50 to 91 y; 64 females) and 74 controls (68 y; 50 to 83 y; 64 females). While controlling for age and sex, analysis showed that LAZ subjects were 3.1 times more likely than controls (odds ratio=3.1; 95% confidence interval, 1.4-6.7; P=0.004) to exhibit PPMIS in at least one of their eyes. CONCLUSION: The LAZ trait, which is being studied as a potential risk factor for glaucoma, was associated with presence of PPMIS in our study population.

Ocular pulse amplitude in patients with descemet stripping endothelial keratoplasty.

PURPOSE: To study the relationship of ocular pulse amplitude (OPA) and intraocular pressure (IOP) in eyes that have undergone successful Descemet stripping endothelial keratoplasty (DSEK). PATIENTS AND METHODS: Fifty eyes of 38 patients with successful DSEK at a single tertiary referral center were followed up for at least 3 months. At the time of the study all patients were carefully examined to rule out any clinically detectable corneal edema. IOP was measured by Goldmann applanation tonometry (GAT), pneumotonometry (PT), and dynamic contour tonometry (DCT). IOP, OPA, and quality measurements were recorded. Central corneal thickness (CCT) was measured by ultrasonic pachymetry. RESULTS: Mean IOP was 15.9±4.9 mm Hg by GAT, 20.3±4.6 mm Hg by PT, and 19.8±4.4 mm Hg by DCT. Mean OPA was 2.53±1.24 mm Hg. OPA was correlated with GAT (r=0.357, P=0.011) and PT (r=0.316, P=0.026). The correlation of OPA and DCT approached significance (r=0.270, P=0.058). Mean CCT was 701±65 µm (range, 529 to 928 µm). OPA was not associated with CCT (r=0.238, P=0.096). CONCLUSIONS: In eyes with DSEK, our results showed that OPA was similar to that reported in normal eyes. Comparable with results in normal eyes, OPA was not associated with CCT but was associated with increasing IOP in DSEK eyes.

Effect of hemodialysis on intraocular pressure and ocular perfusion pressure.

IMPORTANCE: Elevated intraocular pressure (IOP) and decreased ocular perfusion pressure (OPP) are risk factors for glaucoma development and progression. Unrecognized significant IOP elevation or OPP reduction during hemodialysis (HD) could lead to glaucomatous optic nerve damage and subsequent visual loss. OBJECTIVE: To evaluate changes in IOP and OPP during HD. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional observational study was conducted in patients undergoing HD at an ambulatory care clinic at the University of Illinois at Chicago. EXPOSURES: Forty-nine patients (97 eyes) undergoing HD were enrolled. Exclusion criteria included preexisting corneal abnormalities, history of corneal surgery, allergy to topical anesthetic agents, and current eye infection. Nine patients had previous diagnoses of open-angle glaucoma (OAG) or suspected glaucoma. At 3 time points, IOP was measured using a pneumatonometer and blood pressure was recorded. Measurements were made with the patient in a seated position approximately 15 minutes before starting HD (T1), approximately 2 hours after starting HD (T2), and approximately 15 minutes after ending HD (T3). Mean arterial pressure (MAP) and OPP (systolic, diastolic, and mean OPP) were calculated. MAIN OUTCOMES AND MEASURES: Intraocular pressure and OPP. RESULTS: From T1 to T3, IOP significantly increased by 3.1 mm Hg (both eyes, P < .001), MAP significantly decreased by 5.8 mm Hg (P = .05), and all OPP measures significantly decreased from baseline (all P ≤ .02). Using previously reported thresholds of increased glaucoma development and progression risk, 53% of the right eyes (26 of 49) and 46% of the left eyes (22 of 48) had a systolic OPP of 101 mm Hg or less, 71% of the right eyes (35 of 49) and 73% of the left eyes (35 of 48) had a diastolic OPP of 55 mm Hg or less, and 63% of the right eyes (31 of 49) and 65% of the left eyes (31 of 48) had a mean OPP of 42 mm Hg or less. CONCLUSIONS AND RELEVANCE: Significantly increased IOP and decreased OPP occur during HD, bringing both to levels that increase the risk of glaucoma development and progression. Clinicians should consider HD history in patients who have glaucoma progression, even when IOP has been well controlled. Such patients may benefit from IOP and blood pressure monitoring during HD sessions to minimize OPP changes resulting from IOP spikes and/or suboptimal blood pressure.

Investigating ocular dimensions in African Americans with long anterior zonules.

PURPOSE: To investigate ocular dimensions in African Americans with the long anterior zonule (LAZ) trait. METHODS: A total of 61 African American LAZ subjects and 61 age-matched, race-matched, and sex-matched controls were compared with respect to central corneal thickness, central corneal curvature, axial length (AL), and subjective refraction. RESULTS: LAZ right eyes had a mean SR=+1.75±1.82 D and were 1.58 D (95% confidence interval, 0.83-2.31 D, P<0.0001) more hyperopic on average when compared with the control right eyes. LAZ right eyes also had an AL that was 0.69 mm (95% confidence interval, 0.34-1.04 mm, P<0.001) shorter on average than control right eyes. Similar results were found for left eyes. No differences were found with respect to central corneal curvature and central corneal thickness (P>0.05). CONCLUSIONS: In this data set, LAZ eyes tended to be more hyperopic and had ALs that were shorter than control eyes, characteristics that are consistent with elevated risk for angle-closure glaucoma.

Surgical technique for excisional bleb revision using a rotational conjunctival flap for a large conjunctival defect.

Bleb dysesthesia is a common but under recognized late complication of trabeculectomy, sometimes requiring surgical revision if conservative measures fail. We describe in detail a surgical technique for closure of a large conjunctival defect following bleb excision for refractory dysesthesia. Two subconjunctival 5-fluorouracil injections were given to improve bleb function. Eight months post-operatively, the intraocular pressure is well controlled on two agents, and the patient has had resolution of dysesthesia.

Quantification of pupil parameters in diseased and normal eyes with near infrared iris transillumination imaging.

BACKGROUND AND OBJECTIVE: To investigate near infrared iris transillumination (NIRit) imaging as a new method to quantify pupil shape, size, and position because the imaging modality can uniquely provide simultaneous information regarding iris structural details that influence pupil characteristics and because exploration of related techniques could promote discovery helpful to clinical research and care. PATIENTS AND METHODS: Digital NIRit images of normal and diseased eyes were used along with computer-assisted techniques to quantify four primary pupil parameters, including pupil roundness (PR), pupil ovalness (PO), pupil size (PS), and pupil eccentricity (PE). A combined measure of PR and PO was also developed (the pupil circularity index [PCI]). Repeatability of the measures was studied and example analyses were performed. RESULTS: Pupil measures could be calculated for right eyes of 307 subjects (164 normal, 143 other), with fewer than 0.5% exclusions due to image quality. Repeatability study did not show significant bias (P < .05) for any of the four primary measures. Example analyses could show age-associated differences in pupil shape (≥ 50 year olds had less regular pupils than < 50 year olds: median PCI = 0.009 vs 0.006; P < .01) and that a group of pigment dispersion syndrome subjects (n = 27) had less regular pupils than a group of matched controls (PO = 0.9966 vs 0.9990; P < .05). CONCLUSION: Digital NIRit imaging can provide novel, reliable, and informative methods to quantify pupil characteristics while providing simultaneous information about iris structure that may influence these parameters.

Multispectral diagnostic imaging of the iris in pigment dispersion syndrome.

PURPOSE: To determine if wavelength selection with near infrared iris imaging may enhance iris transillumination defects (ITDs) in pigment dispersion syndrome. METHODS: An experimental apparatus was used to acquire iris images in 6 African-American (AA) and 6 White patients with pigment dispersion syndrome. Light-emitting diode probes of 6 different spectral bands (700 to 950 nm) were used to project light into patients' eyes. Iris patterns were photographed, ITD regions of interest were outlined, and region of interest contrasts were calculated for each spectral band. RESULTS: Contrasts varied as a function of wavelength (P<0.0001) for both groups, but tended to be highest in the 700 to 800 nm range. Contrasts were higher in Whites than AAs at 700 nm but the opposite was found at 810 nm (P<0.001). CONCLUSIONS: Optimized near infrared iris imaging may be wavelength dependent. Ideal wavelength to image ITDs in more pigmented eyes may be slightly longer than for less pigmented eyes.

Special considerations for pars plana tube-shunt placement in Boston type 1 keratoprosthesis.

The Boston type 1 keratoprosthesis has been successfully used in eyes with a poor prognosis for a conventional penetrating keratoplasty. The Boston Type 1 Keratoprosthesis Study Group reported significant postoperative vision improvement with a high rate of graft retention. However, glaucoma has significantly limited visual potential in patients with otherwise successful transplants. Given a crowded anterior chamber, scarring, and/or inability to visualize the anterior segment after the keratoprosthesis implantation, vitrectomy and pars plana tube placement is frequently necessary for intraocular pressure control. In addition, the need for optimal contact lens fitting after surgery necessitates a modified surgical technique for the combined procedure to avoid complications and to achieve optimal visual rehabilitation. We present our technique in a case series of combined vitrectomy and pars plana glaucoma shunt placement for the Boston type 1 keratoprosthesis.

Gender and glaucoma: what we know and what we need to know.

PURPOSE OF REVIEW: With growing aging populations and an increase in cases of glaucoma and glaucoma blindness worldwide, aging populations are particularly at higher risk of glaucoma and glaucoma blindness. Awareness of the gender differences might increase attention toward populations at risk. RECENT FINDINGS: Women not only outlive men, but also outnumber men in glaucoma cases worldwide. Women are at higher risks for angle closure glaucoma, but there is no clear gender predilection for open angle glaucoma. Of interest, there is some evidence suggesting that female sex hormones might be protective of the optic nerve. In addition, it is hypothesized that decreased estrogen exposure is associated with increased risk for open angle glaucoma, yet population-based studies present inconsistent results. Presently, there is insufficient evidence to support hormonal replacement therapy use in glaucoma prevention. In addition, it appears that women carry a larger burden of glaucoma blindness due to longevity and disadvantages in socioeconomic/health beliefs. SUMMARY: Current evidence suggests that older women are at risk for glaucoma and glaucoma blindness. Further interdisciplinary research involving investigators, specialized in glaucoma, women's health and health disparities, will lead to better understanding of gender health disparities in glaucoma and better targeting populations at risk.

Early results of Descemet-stripping and automated endothelial keratoplasty (DSAEK) in patients with glaucoma drainage devices.

PURPOSE: To evaluate the outcome of Descemet-stripping and automated endothelial keratoplasty (DSAEK) in patients with glaucoma tube shunts in the anterior chamber. METHODS: Retrospective review of 4 patients with a history of tube shunt placement that experienced corneal decompensation and subsequently underwent DSAEK at 1 institution. Details of the surgical procedures as well as postoperative features including graft attachment, visual acuity, intraocular pressure (IOP), graft clarity, and central corneal thickness were recorded. RESULTS: There were no graft detachments postoperatively. In all but 1 case, the corneal edema resolved with a corresponding decrease in corneal thickness. In 1 case, where there was excessive donor tissue manipulation intraoperatively, the edema failed to resolve. This patient underwent a repeat DSAEK with subsequent graft attachment and resolution of the corneal edema. In all 4 patients, the tube shunt was revised at the time of DSAEK. The tube was not tied or plugged in any of the patients. Except for 1 patient with fibrin reaction, there were no IOP spikes postoperatively. At the 6-month follow-up, the visual acuity had improved in all patients and the IOP had not changed significantly from preoperative levels. CONCLUSION: This small series suggests that DSAEK is a viable and effective option in patients with existing tube shunts. The presence of a tube did not affect the rate of graft dislocation; however, it appeared to increased the rate of complications postoperatively. These early outcomes support the use of DSAEK as an alternative to penetrating keratoplasty in this patient population.