Managing primary open-angle glaucoma in the setting of suboptimal surgical outcomes in the fellow eye.

A 62-year-old woman with mild myopia presented to her local optometrist for a routine examination and was found to have intraocular pressure (IOP) of 30 mm Hg in both eyes and cupped nerves. She had a family history of glaucoma in her father. She was started on latanoprost in both eyes and was referred for a glaucoma evaluation. On initial evaluation, her IOP was 25 mm Hg in the right eye and 26 mm Hg in the left eye. Central corneal thickness measured 592 µm in the right eye and 581 µm in the left eye. Her angles were open to gonioscopy without any peripheral anterior synechia. She had 1+ nuclear sclerosis with a corrected distance visual acuity (CDVA) of 20/25 in the right eye and 20/30- in the left eye and uncorrected near visual acuity of J1+ in each eye. Her nerves were 0.85 mm in the right eye and 0.75 mm in the left eye. Optical coherence tomography (OCT) showed retinal nerve fiber layer thinning and a dense superior arcuate scotoma into fixation in her right eye, and superior and inferior arcuate scotomas in her left eye (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202307000-00019/figure1/v/2023-06-26T195222Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202307000-00019/figure2/v/2023-06-26T195222Z/r/image-tiff, Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A882 and http://links.lww.com/JRS/A883). She was successively trialed on fixed combination brimonidine-timolol, dorzolamide, and netarsudil, in addition to her latanoprost, but her IOP remained in the mid- to upper 20s in both eyes. The addition of acetazolamide lowered the pressure to 19 mm Hg in both eyes, but she tolerated it poorly. Methazolamide was also attempted with similar side effects. We elected to perform left eye cataract surgery combined with 360-degree viscocanaloplasty and insertion of a Hydrus microstent (Alcon Laboratories, Inc.). Surgery was uncomplicated with IOP of 16 mm Hg on postoperative day 1 with no glaucoma medications. However, by postoperative week 3, IOP returned to 27 mm Hg, and despite restarting latanoprost-netarsudil and finishing her steroid taper, IOP remained at 27 mm Hg by postoperative week 6. Brimonidine-timolol was added back to her left eye regimen and at postoperative week 8, IOP had elevated to 45 mm Hg. Maximizing her therapy with the addition of topical dorzolamide and oral methazolamide brought her IOP back down to 30 mm Hg. At that point, the decision was made to proceed with trabeculectomy of the left eye. The trabeculectomy was uneventful. However, postoperative attempts to augment filtration were rendered less successful by extremely thick Tenon layer. At her most recent follow-up the pressure in the left eye was mid-teens with brimonidine-timolol and dorzolamide. Her right eye IOP is in the upper 20s on maximum topical therapy. Knowing her postoperative course in the left eye, how would you manage the right eye? In addition to currently available options, would you consider a supraciliary shunt such as the MINIject (iSTAR) if such a device were U.S. Food and Drug Administration (FDA)-approved?

Cost comparison of different treatment approaches of dacryocystitis and dacrocystocele.

PURPOSE: Congenital dacrocystocele with potential for dacryocystitis are common ophthalmic findings in children. There are multiple surgical approaches to open the mucocele. In this study, we look at the financial impact of these different approaches. METHODS: A retrospective chart review of 17 patients with dacrocystocele or dacryocystitis was performed. We examined four approaches: (1) bedside nasal endoscopy with marsupialization of nasolacrimal duct (NLD) cyst, (2) surgically performed nasal endoscopy with marsupialization of NLD cyst, (3) NLD probe, and (4) a combination of procedures. Cost of the procedure and length of anesthesia were collected. Reoccurrence of symptoms and disease post-procedure were also collected. RESULTS: The lowest cost billed procedure was bedside nasal endoscopy performed by an otolaryngologist (US$435; n = 1). A nasal endoscopy (n = 2) performed in the operating room (OR) had an average OR fee of US$14,557 [standard deviation (SD): US$7598] for 108.5 (SD: 87.0) min of operating time. An NLD probe (n = 5) performed by pediatric ophthalmologists resulted in an average OR fee of US$5540 (SD: US$1752) for 31.0 min (SD: 8.6 min) of operating time. A combination of both nasal endoscopy and NLD probing (n = 9) had an average OR fee US$10,325 (SD: US$4137) for 69 min (SD: 34.5 min) of operating time. CONCLUSION: This is the first study looking at cost benefit of four different approaches to treating dacrocystoceles/dacryocystitis. A NLD probe was a low-cost OR intervention and had the shortest operating time. The combination procedure was more cost-effective than nasal endoscopy or NLD probing alone.

Comparison of Different Surgical Approaches to Inferior Oblique Overaction.

BACKGROUND: The purpose of this study is to compare surgical outcomes of recession, anteriorization, and myotomy for the treatment of inferior oblique overaction (IOOA). METHODS: A retrospective chart review of all patients undergoing IOOA correction from July 2010 to March 2017 at the Children's Hospital of Colorado was performed. Preoperative grading of IOOA (+0.5 to +4.0) was compared to post-operative IOOA (0 to +4.0). The goal was reduction of IOOA to 0, but any decrease in IOOA was measured. RESULTS: There were a total of 260 patients with 357 eyes. Gender and age were similar across surgery types. A 94.6% of eyes had a decrease in IOOA with recession (n = 165) of the inferior oblique while 86.1% decreased to no IOOA. Anteriorization of the inferior oblique (n = 115) decreased overaction in 97.4% of eyes with 81.7% improving to zero degree of IOOA. Myotomy of the inferior oblique (n = 77) was found to decrease overaction in 98.7% of eyes and reduce IOOA to zero in 88.3%. There was no significant difference among type of surgery and outcome. CONCLUSION: All three surgical interventions were found to be equally successful in reducing the amount of IOOA.

Rotary Chop: A New Technique for Teaching Chop and Tackling Mature Cataracts.

INTRODUCTION: Here we describe a new cataract chop technique that is most valuable for two groups of ophthalmologists: (1) experienced surgeons encountering challenging nuclear fragmentation due to mature cataracts or zonulopathies, and (2) inexperienced surgeons wishing to develop skills necessary for chopping techniques. METHODS: We have termed this new method "rotary chop," since the partial thickness pilot holes created by the phacoemulsification (phaco) tip around the periphery of the nucleus produce a rotary phone dial appearance on the surface of the cataract. By creating these pilot holes, the surgeon is able to easily place the chopper deep into the body of the nucleus, avoiding the need to apply vertical piercing force to the nucleus. RESULTS: The patient in the technical video had a 4+ nuclear sclerosis cataract. The preoperative vision in this eye was counting fingers at 2 feet with no improvement with refraction. On postoperative day 1, visual acuity had improved to 20/80 . By postoperative week 1, best-corrected visual acuity was 20/20 (20/25-2 uncorrected). CONCLUSION: This method avoids unnecessary zonular stress. Additionally, inexperienced surgeons using this technique during routine cataract surgery are able to quickly master the movements necessary for both vertical and horizontal chop in a safer environment.

Retinal artery occlusion followed by contralateral amaurosis fugax in association with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome).

PURPOSE: To describe two cases of retinal artery occlusion followed by contralateral amaurosis fugax associated with eosinophilic granulomatosis with polyangiitis (EGPA, formerly known as Churg-Strauss syndrome). OBSERVATIONS: Case 1 is a 57 year-old male who presented with transient vision loss in the right eye two weeks after a cilioretinal artery occlusion in the left eye. Evaluation eventually led to a diagnosis of EGPA. The patient was treated with high-dose steroids followed by systemic immunomodulatory therapy. Vision in the right eye recovered to 20/20 with no further episodes of vision loss. Case 2 is a 55 year-old male with a known diagnosis of EGPA who presented with transient vision loss in the right eye four weeks after a central retinal artery occlusion of the left eye. This patient also successfully recovered vision in the right eye after treatment with high-dose steroids following a change in his systemic immunomodulatory therapy. CONCLUSIONS AND IMPORTANCE: While ANCA-vasculitides are an uncommon cause of retinal artery occlusion and amaurosis fugax, it is important that they remain in the differential diagnosis, as good visual outcomes can be achieved with prompt initiation of appropriate therapies.

Refractive outcomes among glaucoma patients undergoing phacoemulsification cataract extraction with and without Kahook Dual Blade goniotomy.

BACKGROUND: Glaucoma patients undergoing phacoemulsification alone have a higher rate of refractive surprise compared to patients without glaucoma. This risk is further increased with combined filtering procedures. Indeed, there are few and conflicting reports on the effect of combined phacoemulsification and micro-invasive glaucoma surgery (MIGS). Here, we look at refractive outcomes of glaucoma patients undergoing phacoemulsification with and without Kahook Dual Blade (KDB) goniotomy. METHODS: Retrospective chart review of 385 glaucomatous eyes of 281 patients, which underwent either phacoemulsification alone (n = 309) or phacoemulsification with KDB goniotomy (n = 76, phaco-KDB) at the University of Colorado. The main outcome was refractive surprise defined as the difference in target and postoperative refraction spherical equivalent greater than ±0.5 Diopter (D). RESULTS: Refractive surprise greater than ±0.5 D occurred in 26.3% of eyes in the phaco-KDB group and 36.2% in the phacoemulsification group (p = 0.11). Refractive surprise greater than ±1.0 D occurred in 6.6% for the phaco-KDB group and 9.7% for the phacoemulsification group (p = 0.08). There was no significant difference in risk of refractive surprise when pre-operative IOP, axial length, keratometry or performance of KDB goniotomy were assessed in univariate analyses. CONCLUSION: There was no difference between refractive outcomes of glaucomatous patients undergoing phacoemulsification with or without KDB goniotomy.

Outcomes of Kahook Dual Blade Goniotomy with and without Phacoemulsification Cataract Extraction.

PURPOSE: To determine the effectiveness and safety of Kahook Dual Blade (KDB) goniotomy in reducing intraocular pressure (IOP) and medication need in glaucoma patients when combined with phacoemulsification or as a standalone procedure. DESIGN: Retrospective study. PARTICIPANTS: A total of 197 eyes from 143 patients were reviewed. METHODS: Thirty-two eyes underwent KDB goniotomy alone and 165 eyes underwent KDB goniotomy combined with phacoemulsification cataract surgery (phaco-KDB). MAIN OUTCOME MEASURES: Surgical success, defined as IOP reduction of at least 20% from baseline at 12 months, and/or reduction of at least 1 glaucoma medication. RESULTS: At 12 months, the success rate was 71.8% for the phaco-KDB group and 68.8% for the KDB-alone group. In the phaco-KDB group at 12 months (n = 124), mean IOP was significantly reduced from 16.7 (standard error [SE] 0.4) mmHg on 1.9 (SE 0.1) medications to 13.8 (SE 0.4) mmHg on 1.5 (SE 0.1) medications. In the KDB-alone group at 12 months (n = 16), mean IOP was significantly reduced from 20.4 (SE 1.3) mmHg on 3.1 (SE 0.2) medications to 14.1 (SE 0.9) mmHg on 2.3 (SE 0.4) medications. The most common complications were transient hyphema (17.3% at day 1) and IOP spike >10 mmHg from baseline at 1 week (10.2%). LogMAR visual acuity at 12 months was unchanged from baseline in the KDB-alone group (0.218 [SE 0.07] and 0.306 [SE 0.09], respectively, P = 0.244) and significantly improved in the phaco-KDB group (0.184 [SE 0.02] and 0.340 [SE 0.03], P < 0.001). CONCLUSIONS: Goniotomy with the KDB has a favorable safety profile and is an effective procedure at reducing IOP and medication burden as a standalone procedure or combined with phacoemulsification.

An optimized lactate dehydrogenase release assay for screening of drug candidates in neuroscience.

INTRODUCTION: Quantification of lactate dehydrogenase (LDH) release is a widely accepted assay for the quantitative determination of cell viability and late-stage apoptosis. Major disadvantages of commercially available LDH assay kits include proprietary formulations, limited options for optimization and high cost, all resulting in limited reproducibility in research applications. Here, we describe a novel, custom LDH assay suitable in the context of plate reader-based screening of drug candidates for glioprotection, but with wide applicability to other cell types and experimental paradigms. METHODS: We developed a novel and highly reproducible LDH release assay that is more cost-effective than commercially available assays with comparable performance. The assay was validated by assessing 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid antioxidant protection against tert-butylhydroperoxide-induced oxidative stress in C6 astroglioma cells. Assay performance was validated by direct comparison and compatible with other methods of measuring cellular viability, namely 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and 6-carboxy-2', 7' dichlorodihydrofluorescein diacetate assays. RESULTS: There was no statistically significant difference between results obtained with the novel custom assay and a commercially available assay CytoTox96® (Promega, Madison, WI). DISCUSSION: The novel custom LDH release assay allows the reproducible quantification of cell viability and is highly cost-effective when compared to commercially available assays (approximately 25 times cheaper). In addition and in contrast to commercially available assays, the identification and detailed description of all assay components and procedures provide greater control over experimental conditions and design. We provide a detailed standard operating procedure permitting our novel assay to be readily adapted depending on experimental requirements.