Long-term course with iris changes after trabeculectomy for uveitic glaucoma associated with iris mammillation: a case report.

BACKGROUND: Iris mammillation is a rare disease characterized by the distribution of multiple nodules on the iris surface. The course of uveitic glaucoma with iris mammillation has never been reported. CASE PRESENTATION: A 56-year-old woman, who presented with unilateral decreased vision, visited our hospital for treatment of uveitic glaucoma in the right eye. Multiple nodules were scattered over the iris surface in that eye. This case was diagnosed as iris mammillation on clinical findings. After excluding malignant tumors such as melanoma, trabeculectomy was performed. The resected iris had no pathologically malignant findings. The iris nodules evolved to a sand-like appearance, and the intraocular pressure remained stable without recurrent inflammation 7 years after trabeculectomy. CONCLUSIONS: In a case of unilateral uveitic glaucoma with iris mammillation, filtration surgery was performed after excluding the presence of a malignancy, and the long-term postoperative course has been stable.

[Optical coherence tomography and optical coherence tomography angiography for detecting glaucoma progression. Part 1. Study methods, measurement variability and the role of age-related changes]. / Opticheskaya kogerentnaya tomografiya i opticheskaya kogerentnaya tomografiya-angiografiya v opredelenii progressirovaniya glaukomy. Chast' 1. Metody issledovaniya, variabel'nost' pokazatelei i rol' vozrastnykh izmenenii.

This paper reviews the literature on the role of optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) in the diagnosis of glaucoma and considers the significance of evaluating retinal nerve fiber layer and ganglion cell complex in assessment of glaucoma progression, variability and reproducibility of the method, as well as the influence of age-related retinal changes on the results, analyzes the role of OCTA in glaucoma monitoring. Optical coherence tomography is a modern standard for glaucoma diagnosis and monitoring, and OCTA shows high potential as an auxiliary diagnostic tool.

[Application of the organ-on-a-chip technology in experimental ophthalmology]. / Primenenie tekhnologii «organ-na-chipe¼ v eksperimental'noi oftal'mologii.

Organ-on-chip is a microfluidic device that can reproduce in vitro the minimal functional unit of an organ or system of organs and model various physiological processes and body structures with high accuracy. This review covers the main approaches to the use of the organ-on-chip technology in modern experimental ophthalmology. The analysis of literature sources revealed the following main applications of the organ-on-chip technology in ophthalmology; the technology allows modeling the anterior eye surface and its diseases, such as dry eye syndrome, as well as disorders of the posterior segment of the eye such as age-related macular degeneration, diabetic macular edema, diabetic retinopathy, glaucoma. Culturing of eye tissues in microfluidic systems helps identify the toxic effects and pharmacological activity of new compounds, and provides an opportunity for deeper understanding of the normal physiology of the eye and the pathogenesis of ocular diseases. In addition, the technology can reduce the cost and duration of experiments. Thus, the organ-on-a-chip technology has a great potential in the field of experimental ophthalmology and preclinical trials of new ophthalmic drugs.

Mumbai metropolitan region eye care facility survey: Mumbai Eye Disease Study (MEDiS) report #1.

Purpose: To examine the eye care practice in the Mumbai Metropolitan Region (MMR). Methods: This study consisted of primary and secondary research conducted in five zones of MMR. The primary research included interviews with the patients, eye care providers, and key opinion leaders. The secondary research included analyzing data from the professional ophthalmology societies, public health domain, and health insurance providers. We divided people into three economic classes by annual income - low (1.8 m). We analyzed the collected data to estimate the eye care demand-supply, quality of eye care, health-seeking behavior, gap in eye care delivery, and eye care expenditure. Results: We examined 473 key eye care facilities and interviewed 513 people. The ophthalmologist density in MMR was 80/million, and it was the highest in North MMR. Most ophthalmologists visited several facilities. Cataract surgery and glaucoma care coverage were better than other specialties; it was poor for oncology and oculoplastic services. Annual eye examination practice was poor in the low- and middle-income groups than in the high-income group (48%-50% vs. 85%). Most people preferred visiting eye care facilities within 5 km of their residence. Out-of-pocket spending was between 60% and 83%. Lower-income group people preferred public facilities. Conclusion: MMR eye care needs further improvement in affordable and accessible eye care, health literacy, public health surveillance, research into the application of newer technologies to provide less-expensive home care for the elderly and minimize their hospital visits, and collection and analysis of big data to address city-specific eye health issues.

Predictive factors and visual outcomes after immediate pars plana vitrectomy for posteriorly dislocated lens fragments during complicated phacoemulsification surgery.

Purpose: To investigate the prognostic factors for visual outcome in patients undergoing immediate pars plana vitrectomy (PPV) for posteriorly dislocated lens fragments during phacoemulsification surgery. Methods: This was a single-center, retrospective, cross-sectional study of 37 eyes of 37 patients undergoing immediate PPV for posteriorly dislocated lens fragments from 2015 to 2021. The primary outcome measure was changes in the best-corrected visual acuity (BCVA). Additionally, we analyzed the predictive factors for poor visual outcomes (BCVA <20/40) and perioperative complications. Results: The mean (±standard deviation [SD]) age of the patients was 66.57 (±10.86) years, with an almost identical gender profile (M: F = 18/19 [48.64%:51.36%]). The median (interquartile range [IQR]) log of minimum angle of resolution (logMAR) BCVA improved significantly from the baseline (1 [0.6-1.48], ~20/200) to the final visit (0.3 [0.2-0.6], ~20/40) (P < 0.0001) after a mean (±SD) follow-up of 6.35 (±6.32) months. The final BCVA was 20/40 or better in 59.5% of the eyes. Poor final BCVA (<20/40) was associated with small preoperative pupillary size (P = 0.02), presence of preoperative ocular pathology (P = 0.02) including uveitis, glaucoma, and clinically significant macular edema (CSME), intraoperative displacement of >50% of lens matter into the vitreous (P < 0.001), use of iris-claw lens (P < 0.001), and postoperative cystoid macular edema (CME; P = 0.007). The postoperative complications included CME (13.51%), retinal detachment (10.81%), chronic uveitis (8.11%), glaucoma (8.11%), iritis (2.7%), posterior chamber IOL (PCIOL) dislocation (2.7%), and vitreous hemorrhage (2.7%). Conclusion: For retained lens fragments in complicated phacoemulsification surgery, immediate PPV is a viable approach with the potential for a good visual outcome. The important predictors for poor visual outcomes include a small preoperative pupil size, preexisting ocular pathology, displacement of significant volume of lens matter (>50%), use of an iris-claw lens, and CME.

Cataract versus combined surgery in pseudoexfoliation glaucoma.

Purpose: Pseudoexfoliation glaucoma (XFG) is often associated with a higher rate of intraoperative complications and failure. This study aims to compare the long-term clinical and surgical outcomes of cataract surgery alone versus combined surgery in XFG. This was a retrospective: comparative case series. Methods: All patients with XFG who underwent either cataract surgery alone [group 1: either phacoemulsification, PHACO/small-incision cataract surgery (SICS), n = 35] or combined surgery (group 2: phacotrabeculectomy, PHACOT or SICS + trabeculectomy, n = 46) from 2013 to 2018 by a single trained surgeon were screened and recalled for a detailed clinical examination, including Humphrey visual field analysis at 3-monthly intervals for a minimum of 3 years. Surgical success (intraocular pressure, IOP, <21 mm Hg and >6 mm Hg with (qualified success) or without medicines, complete success, survival rates, visual field changes, and need for additional procedures/medicines for IOP control were compared between groups. Results: A total of 81 eyes of 68 patients with XFG were included in this study (groups 1-35 eyes and groups 2-46 eyes each). Both groups achieved 27-40% IOP reduction from preoperative IOP levels, P < 0.001. Surgical success rates were similar in both groups (complete success 66% vs 55%, P = 0.4), qualified success 17% vs 24%, P = 0.8, in groups 1 and 2). Kaplan-Meier analysis showed a marginally better survival rate for group 1, 75% (55-87%), than group 2, 66% (50-78%), at 3 and 5 years which was not significantly different. The number of eyes that progressed at 5 years after surgery (5-6%) was similar in both groups. Conclusion: Cataract surgery can be as effective as combined surgery in XFG eyes with regards to final visual acuity, long-term IOP profile, and visual field progression, and complications/survival rates are comparable between the two procedures.

Changes in emergency glaucoma care during the COVID-19 pandemic in South India.

Purpose: To assess the differences in the pattern of presentation of glaucoma emergency conditions during the various phases of pandemic-related travel restrictions: first wave-related lockdown, unlock period, and the second wave-related lockdown. Methods: The number of new emergency glaucoma conditions, the various diagnoses, and the total number of all new glaucoma patients presenting to the glaucoma services at five tertiary eye care centers in south India from 24th March 2020 to 30th June 2021 were collected from the electronic medical records and were analyzed. The data were compared with the corresponding time period in the year 2019. Results: In total, 620 patients presented with an emergency glaucoma diagnosis during the first wave-related lockdown as against 1337 during the same period in 2019 (P < 0.0001). During the unlock period, 2659 such patients visited the hospital compared with 2122 in 2019 (P = 0.0145). During the second wave-related lockdown, there were 351 emergency patients compared with 526 patients in 2019 (P < 0.0001). Lens-induced glaucomas (50.4%) and neovascular glaucoma (20.6%) were the most common diagnoses during the first wave-related lockdown. During the unlock period, there was a greater proportion of neovascular glaucoma (P = 0.0123). The second wave-related lockdown had a greater proportion of phacolytic glaucomas (P = 0.005) and acute primary angle closure (P = 0.0397) patients. Conclusion: The study demonstrates that emergency glaucoma care was grossly underutilized by the people during the lockdowns. Trivial conditions like cataracts or retinal vascular diseases if not treated appropriately may progress to become emergencies in the future.

Comparison of conjunctiva-related complications between scleral and corneal patch grafts in Ahmed glaucoma valve implantation.

Purpose: Comparison of the conjunctiva related complication rates and success rates among eyes with Ahmed glaucoma valve (AGV) implantation in which eye bank derived scleral and corneal patch grafts had been used to cover the tube. Methods: Retrospective comparative study. Patients who underwent AGV implantation between January 2000 to December 2016 were included. Demographic, clinical data, intra and post operative data was obtained from electronic medical records. Conjunctiva related complications were divided into two groups: with and without implant exposure. Conjunctiva related complication rates, success rate, risk factors among eyes with corneal and scleral patch graft were compared. Results: Three hundred and twenty three eyes of 316 patients underwent AGV implantation. Scleral patch graft was used in 214 eyes of 210 patients (65.9%) and corneal patch graft was used in 109 eyes of 107 patients (34%). Median follow up was 14 months. There was no significant difference in the conjunctiva related complication rate (7.3 % in corneal patch graft versus 7.0% in scleral patch graft;p=0.5) and conjunctival dehiscence rate (3.7% versus 4.6%, P = 0.7) among the two groups. Success rate was significantly higher in the corneal patch graft group versus the scleral patch graft group (98% versus 72%; p=0.001). Eyes with corneal patch graft had a higher survival rate (P = 0.01). Conclusion: There was no significant difference in the rate of conjunctiva related complications following corneal and scleral patch grafts used to cover the AGV tube. Eyes with corneal patch graft had a higher success rate and survival rate.

Consensual eye intra-ocular pressure rise following unilateral glaucoma surgery.

Purpose: Consensual eye intra-ocular pressure (IOP) increase has been reported following ipsilateral glaucoma surgery. The study evaluated the need for increase in anti-glaucoma medications (AGM) ± glaucoma surgery to control the IOP in consensual eye following unilateral glaucoma surgery. Methods: Data of 187 consecutive patients who underwent either trabeculectomy or AGV implant were collected. Index (IE) and fellow eye (FE) IOP (baseline, follow-up day 1, week 1, months 1 and 3), acetazolamide and AGM use, FE surgery, glaucoma status, and relevant ophthalmological data were collected. Results: A significant increase from a baseline IOP of 14.4 mmHg was noted at week 1 (15.8 mmHg, p-0.005) and month 1 (15.62 mmHg, p-0.007) in FE (n-187). Among the 61 patients (33%, n-187) who needed additional intervention to reduce FE IOP, 27 (14.4%) underwent FE trabeculectomy. In the IE trabeculectomy group (n-164), significant increase in FE IOP was noted in week 1 (15.87 mmHg, p-0.014) and month 1 (15.61 mmHg, p-0.02), and in the IE AGV group (n-23) at day 1 (15.91 mmHg, p-0.06). Pre-operative acetazolamide resulted in significant increase in FE IOP at week 1 and month 1. Maximum increase in FE IOP of nearly 3.5 mm Hg was noted when IE IOP was persistently <5 mmHg at one month following surgery. Mean FE IOP remained elevated at all visits. Conclusion: An increase in fellow eye IOP needing any additional intervention in a third and surgical intervention in nearly a sixth meant that FE IOP be strictly monitored and addressed following unilateral glaucoma surgery.

Clinical features of early-onset pediatric traumatic glaucoma and predictive factors for the need of early glaucoma surgery.

Purpose: To assess the clinical presentation of pediatric patients having early traumatic glaucoma and to analyze early predictors for the need of filtration surgery. Methods: Patients with early traumatic glaucoma after close globe injury (CGI) from January 2014 to December 2020 were retrospectively reviewed. Clinical features, treatment provided (medical and surgical), and visual outcomes were documented. Patients were divided into two groups based on the management required: group A- trabeculectomy and group B- medication + minor surgery. Results: A total of 85 patients were studied after applying the necessary inclusion and exclusion criteria. Out of these, 46 underwent trabeculectomy for the control of intraocular pressure (IOP) and the remaining 39 were managed with antiglaucoma medications. Significant male predominance of 9.6:1 was observed. Patients presented to the hospital after a mean duration of 8.5 days posttrauma. Wooden objects were most commonly responsible for trauma. Mean best corrected visual acuity at presentation was 1.91 log of minimum angle of resolution (logMAR). Mean IOP at presentation was 40 mmHg. The common anterior segment finding were severe anterior chamber (AC) reaction (63.5%), followed by angle recession (56.4%). Severe AC reaction (P = 0.0001) and corneal microcystic edema (P = 0.04) were significant predictive factors for early need of trabeculectomy. Conclusion: Need of trabeculectomy was higher in patients with severe AC reaction and corneal microcystic edema. The threshold to perform trabeculectomy should be lower, as glaucoma is often relentless, severe, and may result in irreversible vision loss.

Bilateral acute depigmentation of the iris determined in two cases after COVID-19 infection.

Bilateral acute depigmentation of the iris (BADI) is a rare disease characterized by iris atrophy. Although it can be self-limiting, it is sometimes progressive and can lead to glaucoma and severe vision loss. Two female patients were admitted to our clinic because of a change in iris color following coronavirus disease 2019 (COVID-19) infection. After the exclusion of other etiologies in the eye examination, BADI was diagnosed in both cases. Thus, it was shown that COVID-19 may also be involved in the etiology of BADI.

Development of a Novel Valve-Controlled Drug-Elutable Microstent for Microinvasive Glaucoma Surgery: In Vitro and Preclinical In Vivo Studies.

Purpose: Microinvasive glaucoma surgery (MIGS) has become an important treatment approach for primary open-angle glaucoma, although the safe and long-term effective lowering of intraocular pressure with currently available implants for MIGS is not yet achieved to a satisfactory extent. The study focusses on the development and in vitro and in vivo testing of a novel microstent for MIGS. Methods: A silicone elastomer-based microstent was developed. Implants were manufactured using dip coating, fs-laser cutting, and spray coating. Within the current study no antifibrotic drug was loaded into the device. Sterilized microstents were analyzed in vitro regarding pressure-flow characteristics and biocompatibility. Six New Zealand white rabbits were implanted with a microstent draining the aqueous humor from the anterior chamber into the subconjunctival space. Drainage efficacy was evaluated using oculopressure tonometry as a transient glaucoma model. Noninvasive imaging was performed. Results: Microstents were manufactured successfully and characterized in vitro. Implantation in vivo was successful for four animals with additional device fixation. Without additional fixation, dislocation of microstents was found in two animals. Safe and effective intraocular pressure reduction was observed for the four eyes with correctly implanted microstent during the 6-month trial period. Conclusions: The described microstent represents an innovative treatment approach for MIGS. The incorporation of a selectively antifibrotic drug into the microstent drug-elutable coating will be addressed in future investigations. Translational Relevance: The current preclinical study successfully provided proof of concept for our microstent for MIGS which is suitable for safe and effective intraocular pressure reduction and offers promising perspectives for the clinical management of glaucoma.

Usability and Clinician Acceptance of a Deep Learning-Based Clinical Decision Support Tool for Predicting Glaucomatous Visual Field Progression.

PRCIS: We updated a clinical decision support tool integrating predicted visual field (VF) metrics from an artificial intelligence model and assessed clinician perceptions of the predicted VF metric in this usability study. PURPOSE: To evaluate clinician perceptions of a prototyped clinical decision support (CDS) tool that integrates visual field (VF) metric predictions from artificial intelligence (AI) models. METHODS: Ten ophthalmologists and optometrists from the University of California San Diego participated in 6 cases from 6 patients, consisting of 11 eyes, uploaded to a CDS tool ("GLANCE", designed to help clinicians "at a glance"). For each case, clinicians answered questions about management recommendations and attitudes towards GLANCE, particularly regarding the utility and trustworthiness of the AI-predicted VF metrics and willingness to decrease VF testing frequency. MAIN OUTCOMES AND MEASURES: Mean counts of management recommendations and mean Likert scale scores were calculated to assess overall management trends and attitudes towards the CDS tool for each case. In addition, system usability scale scores were calculated. RESULTS: The mean Likert scores for trust in and utility of the predicted VF metric and clinician willingness to decrease VF testing frequency were 3.27, 3.42, and 2.64, respectively (1=strongly disagree, 5=strongly agree). When stratified by glaucoma severity, all mean Likert scores decreased as severity increased. The system usability scale score across all responders was 66.1±16.0 (43rd percentile). CONCLUSIONS: A CDS tool can be designed to present AI model outputs in a useful, trustworthy manner that clinicians are generally willing to integrate into their clinical decision-making. Future work is needed to understand how to best develop explainable and trustworthy CDS tools integrating AI before clinical deployment.

Gonioscopy-assisted transluminal trabeculotomy for open-angle glaucoma with failed incisional glaucoma surgery: two-year results.

BACKGROUND: To evaluate the safety and efficacy of gonioscopy-assisted transluminal trabeculotomy (GATT) in treating patients with open-angle glaucoma (OAG) who had failed prior incisional glaucoma surgery. METHODS: A consecutive case series of OAG patients aged ≥ 18 who underwent GATT with previous failed glaucoma incision surgery was retrospectively analyzed. Main outcome measures included intraocular pressure (IOP), the number of glaucoma medications, surgical success rate, and occurrence of complications. Success was defined as an IOP of ≤ 21 mmHg and a reduction of IOP by 20% or more from baseline with (qualified success) or without (complete success) glaucoma medications. For eyes with preoperative IOP of < 21 mmHg on 3 or 4 glaucoma medications, postoperative IOP of ≤ 18 mmHg without any glaucoma medications was also defined as complete success. RESULTS: Forty-four eyes of 35 patients (21 with juvenile-onset open-angle glaucoma and 14 with adult-onset primary open-angle glaucoma) with a median age of 38 years were included in this study. The proportion of eyes with 1 prior incisional glaucoma surgery was 79.5%, and the others had 2 prior surgeries. IOP decreased from 27.4 ± 8.8 mm Hg on 3.6 ± 0.7 medications preoperatively to 15.3 ± 2.7 mm Hg on 0.5 ± 0.9 medications at the 24-month visit (P < 0.001). The mean IOP and the number of glaucoma medications at each follow-up visit were lower than the baseline (all P < 0.001). At 24 months postoperatively, 82.1% of the eyes had IOP ≤ 18 mmHg (versus 15.9% preoperatively, P < 0.001), 56.4% reached IOP ≤ 15 mmHg (versus 4.6% preoperatively, P < 0.001), and 15.4% achieved IOP ≤ 12 mmHg (compared to none preoperatively, P = 0.009). While 95.5% of eyes took 3 or more medications preoperatively, 66.7% did not take glaucoma medication 24 months after GATT. Thirty-four (77.3%) eyes achieved IOP reduction greater than 20% on fewer medications. The complete and qualified success rates were 60.9% and 84.1%, respectively. No vision-threatening complications occurred. CONCLUSIONS: GATT was safe and effective in treating refractory OAG patients who failed prior incisional glaucoma surgery.

Automated 360-degree goniophotography with the NIDEK Gonioscope GS-1 for glaucoma.

This study was registered with ClinicalTrials.gov (ID: NCT03715231). A total of 20 participants (37 eyes) who were 18 or older and had glaucoma or were glaucoma suspects were enrolled from the NYU Langone Eye Center and Bellevue Hospital. During their usual ophthalmology visit, they were consented for the study and underwent 360-degree goniophotography using the NIDEK Gonioscope GS-1. Afterwards, the three ophthalmologists separately examined the images obtained and determined the status of the iridocorneal angle in four quadrants using the Shaffer grading system. Physicians were masked to patient names and diagnoses. Inter-observer reproducibility was determined using Fleiss' kappa statistics. The interobserver reliability using Fleiss' statistics was shown to be significant between three glaucoma specialists with fair overall agreement (Fleiss' kappa: 0.266, p < .0001) in the interpretation of 360-degree goniophotos. Automated 360-degree goniophotography using the NIDEK Gonioscope GS-1 have quality such that they are interpreted similarly by independent expert observers. This indicates that angle investigation may be performed using this automated device and that interpretation by expert observers is likely to be similar. Images produced from automated 360-degree goniophotography using the NIDEK Gonioscope GS-1 are similarly interpreted amongst glaucoma specialists, thus supporting use of this technique to document and assess the anterior chamber angle in patients with, or suspected of, glaucoma and iridocorneal angle abnormalities.

Clinical identification of optic disk vascular alteration in glaucoma.

Background: Several characteristic vascular changes can be observed in the glaucomatous eyes, including changes in the vessel configuration and caliber, presence of collateral vessel on disk, and disk hemorrhage. Purpose: This video describes characteristic vascular changes in the optic nerve head, which can be observed on clinical examination in the glaucomatous eyes, and useful teaching points to identify the same. Synopsis: In glaucoma, as the optic cup enlarges, the normal pattern and course of retinal vessels on the optic disk are altered and show characteristic changes. Identification of these changes provides a clue to the presence of cupping. Highlights: In this video, the vascular changes and its identification in the glaucomatous disc are described, which would be useful to the residents. Video link: https://youtu.be/2eINumBx33E.

Physical Activity Is Associated With Macular Thickness: A Multi-Cohort Observational Study.

Purpose: To assess the association between physical activity and spectral-domain optical coherence tomography (SD-OCT)-measured rates of macular thinning in an adult population with primary open-angle glaucoma. Methods: The correlation between accelerometer-measured physical activity and rates of macular ganglion cell-inner plexiform layer (GCIPL) thinning was measured in 735 eyes from 388 participants of the Progression Risk of Glaucoma: RElevant SNPs with Significant Association (PROGRESSA) study. The association between accelerometer-measured physical activity and cross-sectional SD-OCT macular thickness was then assessed in 8862 eyes from 6152 participants available for analysis in the UK Biobank who had SD-OCT, ophthalmic, comorbidity, and demographic data. Results: Greater physical activity was associated with slower rates of macular GCIPL thinning in the PROGRESSA study (beta = 0.07 µm/y/SD; 95% confidence interval [CI], 0.03-0.13; P = 0.003) after adjustment for ophthalmic, demographic and systemic predictors of macular thinning. This association persisted in subanalyses of participants characterized as glaucoma suspects (beta = 0.09 µm/y/SD; 95% CI, 0.03-0.15; P = 0.005). Participants in the upper tertile (greater than 10,524 steps/d) exhibited a 0.22-µm/y slower rate of macular GCIPL thinning than participants in the lower tertile (fewer than 6925 steps/d): -0.40 ± 0.46 µm/y versus -0.62 ± 0.55 µm/y (P = 0.003). Both time spent doing moderate/vigorous activity and mean daily active calories were positively correlated with rate of macular GCIPL thinning (moderate/vigorous activity: beta = 0.06 µm/y/SD; 95% CI, 0.01-0.105; P = 0.018; active calories: beta = 0.06 µm/y/SD; 95% CI, 0.006-0.114; P = 0.032). Analysis among 8862 eyes from the UK Biobank revealed a positive association between physical activity and cross-sectional total macular thickness (beta = 0.8 µm/SD; 95% CI, 0.47-1.14; P < 0.001). Conclusions: These results highlight the potential neuroprotective benefits of exercise on the human retina.