Intraocular pressure spikes after gonioscopy-assisted transluminal trabeculotomy (GATT).

PURPOSE: Intraocular pressure (IOP) spikes (IOP > 30 mmHg or > 10 mmHg above baseline IOP) are a common and worrisome complication of gonioscopy-assisted transluminal trabeculotomy (GATT). The purpose of this study is to identify risk factors for IOP spikes and to describe their characteristics, management, and clinical course in a large cohort of patients. METHODS: A retrospective, single-center study which included 217 consecutive eyes of patients that underwent GATT between December 2019 and April 2022 with follow-up of at least 90 days. RESULTS: IOP spikes occurred in 52 of 217 (24%) eyes. Spikes occurred in 15.5% of patients in whom pre-operative IOP-lowering medications were continued after surgery (90 eyes), and in 29.9% in whom IOP-lowering medications were stopped after surgery (127 eyes). Spikes were diagnosed at a mean of 7.7 ± 6.5 days after surgery. All IOP spikes occurred within the first month of surgery. The mean duration of a spike was 4.9 ± 5.4 days. Management of IOP spikes included adding a mean of 3.13 ± 1.7 groups of glaucoma medications. Thirty-seven (72.5%) eyes were treated with oral carbonic anhydrase inhibitor, 11 (21.6%) were treated with IV mannitol, and anterior chamber paracentesis was performed in 16 (31.4%). Six (11.8%) eyes underwent additional glaucoma surgery to control IOP. Patients that continued their pre-operative IOP-lowering medications after surgery were 2.3 times less likely to develop a spike as compared to patients who discontinued their medications (P = 0.016). Spikes were found to be a risk factor for failure of GATT. CONCLUSIONS: IOP spikes are a common occurrence after GATT. They most commonly appear during the first two post-operative weeks and usually resolve with topical and systemic IOP-lowering treatment. The continuation of IOP-lowering medications after GATT is recommended to lower the risk of IOP spikes.

THE EFFECT OF INTERNAL LIMITING MEMBRANE PEELING ON THE INNER RETINAL LAYERS IN PATIENTS WITHOUT MACULAR PATHOLOGIC CONDITION.

BACKGROUND: To examine the effect of internal limiting membrane peeling on the inner retinal layers in patients without macular pathological condition. METHODS: A prospective nonrandomized trial of patients undergoing pars plana vitrectomy with internal limiting membrane peeling for pathologic condition outside the macula was performed. Optical coherence tomography including macular ganglion cell layer, inner plexiform layer, and peripapillary retinal nerve fiber layer imaging was performed before surgery, 1, 3, and 6 months postoperatively, and at the end of follow-up (ranges between 4 and 17 months). Patients with any macular pathological condition on optical coherence tomography before surgery were excluded. The main outcome measure was change in thickness of the ganglion cell layer and inner plexiform layer. RESULTS: Ten patients who underwent pars plana vitrectomy with internal limiting membrane peeling for macula-on retinal detachment were included in the analysis. The mean age was 55 years, and the mean follow up was 10.8 months. All patients completed at least two postoperative follow-up visits that included an optical coherence tomography as per the protocol (range 2-6 months). There was an immediate reduction in the global (G), inferotemporal, superotemporal, and superior (S) ganglion cell layer thickness at the first follow up as compared with the preoperative state ( P = 0.028, P = 0.027, P = 0.026, and P = 0.027 respectively). From the first follow-up visit onward until the final follow-up, the thinning persisted, although there was no further statistically significant thinning. CONCLUSION: Peeling of the internal limiting membrane causes significant ganglion cell layer thinning in maculae without pathologic condition before surgery. At up to 17 months of follow-up, this effect seems to be immediate and nonprogressive.

[INTERVENTIONAL GLAUCOMA - A SHIFT IN THE TREATMENT PARADIGM].

INTRODUCTION: Glaucoma is a progressive optic neuropathy and is the leading cause of preventable irreversible blindness worldwide. Glaucoma causes progressive visual field loss and can have significant implications on the patient's quality of life. Lowering intraocular pressure (IOP) is the only treatment proven to prevent vision loss from glaucoma. It is achieved using medication, laser treatment and surgery. The treatment paradigm of glaucoma has been one whereby surgical intervention has been left for advanced cases due to a variety of reasons, mainly concerning safety and long term success. The past two decades have seen a paradigm shift towards earlier IOP lowering interventions using a wide array of different technologies in the laser and surgical spaces. This review aims to understand the background to this paradigm shift, its necessity, and its potential impact on the vision and life of glaucoma patients.

Application of Nd:YAG laser to the anterior vitreous in malignant glaucoma - a systemic review and meta-analysis.

PURPOSE: The study aims to review the efficacy, safety, and technique of Nd:YAG laser vitreolysis for the management of malignant glaucoma (MG). METHODS: We performed a search of electronic databases for all published studies which included technical specifications of Nd:YAG laser application for MG. Individual patient data was extracted and evaluated in a weighted pooled analysis. RESULTS: Thirty eyes were reported on from seven studies worldwide. Age of affected patients ranged between 37 and 82 years. Nd:YAG vitreolysis was performed either through an iritodomy (66.7%, 18/27 eyes), transpupillary (18.5%, 5/27 eyes), or through both simultaneously (14.8%, 4/27 eyes). Treatment intensity ranged between 1.0 and 11.00 mJ with 75.9% (22/29 eyes) of treatments being 3.0 mJ or lower. Between 1 and 41 pulses per session were applied. Rates of both anatomical and intraocular pressure resolution were examined. Overall, in a pooled analysis, 77% of eyes demonstrated MG resolution with no further treatment required after Nd:YAG vitreolysis (95% CI: 58.1 to 91.4%). A trend for lower need of additional interventions was seen with transpupillary application (11.1% versus 42.1%). No complications were reported. CONCLUSIONS: Nd:YAG laser vitreolysis is a safe procedure, associated with MG resolution in the majority of reported cases, regardless of treatment intensity. Transpupillary treatment may be associated with lower risk of re-intervention.

Trans-optic suture fixation of malpositioned intraocular lenses.

PURPOSE: To report a technique for fixating posterior chamber intraocular lenses (PCIOLs) to the sclera by passing sutures through the lens material. METHODS: Cases in which PCIOLs were fixated to the sclera using trans-optic sutures were included in this series. Intra and post-operative complications were recorded, and lens position was assessed using slit-lamp examination. RESULTS: Fourteen cases were included in this series. In nine cases, the procedure was performed using 9-0 polypropylene in pseudophakic eyes to correct subluxation, centration, tilt or to replace a broken haptic. In five cases, this technique was used for primary PCIOL fixation using a flanged 6-0 polypropylene suture in aphakic eyes. In all cases, the lenses remained centered and stable at the end of follow-up, and no post-operative complications occurred. CONCLUSION: Trans-optic suturing is a safe and effective alternative method for fixation of IOLs in a variety of pseudophakic and aphakic clinical scenarios.

Ophthalmic emergency-room visits during the Covid-19 pandemic - a comparative study.

BACKGROUND: The goal of this study is to compare ophthalmic emergency room (OER) visits during the Coronavirus disease-19 (Covid-19) pandemic to those during a control period. METHODS: We compared all visits to the OER to Meir Medical Center in Israel, from March 15th to April 15th, 2020, during the Covid-19 pandemic and government mandated quarantine, to the same period in 2019. Factors analyzed were patient demographics, chief complaints, referral patterns, exam findings, treatments given, hospitalizations and surgical interventions. RESULTS: We included in this study 1311 visits of 1158 patients, 477 during the 2020 Covid-19 pandemic and 834 during the same period in 2019. The demographic distribution (age, gender, and ethnicity) was similar between the two periods. LogMAR visual acuity at presentation was worse during the Covid-19 pandemic (0.42 ± 0.6 and 0.34 ± 0.5 in 2020 and 2019 respectively; p = 0.025) and the number of emergent surgeries was higher (3.7% in 2020 vs 1.8% in 2019, p = 0.026). In 2019 there was a higher likelihood of involvement of both segments of the eye (4.82% versus 1.2%, p < 0.01) and more diagnoses were given to each patient (1 ± 0.5 versus 0.93 ± 0.35, p = 0.001; During the Covid - 19 pandemic medications (both topical and systemic) were prescribed more often (1.22 ± 0.95 in 2020 and 0.84 ± 0.67 in 2019, p < 0.001). CONCLUSIONS: OER visits were less frequent during the Covid - 19 pandemic as compared to 2019, though the demographics of the patients remained unchanged. Visits during the pandemic tended to be for more severe ocular conditions, with worse visual acuity at presentation and required more medical and surgical treatment which imply higher necessity of ocular evaluation. This analysis can aid healthcare resource management in similar scenarios in the future.

Endophthalmitis after intravitreal injections versus cataract surgery: a 15-year cohort.

PURPOSE: To compare the clinical features, visual outcomes and causative organisms between endophthalmitis secondary to cataract surgery or to intravitreal injections (IVI). SETTING: Meir Medical Center, Kfar Saba, Israel. DESIGN: Retrospective, non-randomized comparative chart review. METHODS: Medical records of patients with proven or suspected endophthalmitis admitted to the Ophthalmology Department at Meir Medical Center 2/2002-2/2017 were reviewed. Clinical characteristics including presenting and final visual acuity (VA) outcomes, causative organisms and time to admission were assessed. RESULTS: Among 84 patients in our study, 35 had preceding cataract surgery and 12 had preceding IVI. The post-cataract group showed a significant improvement in VA following treatment with a presenting and final VA (logMar ± SD) of (1.80 ± 0.54 and 1.39 ± 0.65, P < 0.01) as opposed to the post-IVI group (1.72 ± 0.26 and 1.81 ± 0.32, P = 0.692), while most patients in the cataract group exhibited some degree of VA recovery (70.96%). Patients undergoing cataract surgery were divided into two separate groups; those who underwent cataract surgery in a private center and those operated at a public center. Patients undergoing surgery at a private medical center showed improvement in VA outcomes following treatment (1.80 ± 0.57 and 1.13 ± 0.66, P < 0.01) as opposed to those operated on at our public medical center. CONCLUSIONS: Overall, patients with endophthalmitis following cataract surgery had better visual outcomes and were more likely to show a VA improvement following treatment when compared with endophthalmitis following IVI. Final VA outcomes of patients with endophthalmitis after cataract surgery performed in a private center were better than those operated on and treated in a public medical center.

Sensory Changes in Periocular Skin After Upper Eyelid Surgery.

The aim of this interventional, prospective study is to estimate the change in periocular cutaneous sensation after upper eyelid surgery. The trial included 48 eyes of 24 patients undergoing upper eyelid blepharoplasty or upper eyelid blepharoplasty and blepharoptosis repair. Eyelid sensation was measured using a Cochet-Bonnet filament-type esthesiometer at 4 predetermined anatomical locations in the upper eyelid. The mean esthesiometry reading was calculated at the preoperative visit (4.06 cm), at 2-week postoperative visit (4.38 cm), and at final postoperative visit (4.52 cm). Paired t test showed no significant difference in sensation measurement at second visit compared with baseline (P = 0.205) or at final visit compared with baseline (P = 0.092). Paired t test showed no correlation between type of surgery and change in sensation. Sex and age did not influence change in sensation. In 40 of 42 eyelids, (95.24%), patients reported no reduction in subjective eyelid sensation. The authors conclude that eyelid sensation was not compromised objectively or subjectively by upper eyelid skin incision surgery. Surgeons can reassure patients contemplating surgery that it is very unlikely that cutaneous sensation will be damaged.

A Novel Technique for Measuring Eyelid Force.

PURPOSE: We present a novel technique to directly measure the eyelid upward force generation. This technique can be used during routine clinical examination using an inexpensive, portable force gauge. METHODS: This prospective case series was conducted January to June 2015 in an ophthalmology clinic affiliated with a tertiary care medical center. A convenience sample of 42 patients (40-90 years of age) without known eyelid pathology participated. The eyelid upward net force generated was measured directly using a handheld dynamometer noninvasively attached to the upper eyelid. Comparison of the eyelid-brow upward force generated with eyelid upward net force generated allowed us to assess the contribution of levator and frontalis muscles to the force generated during upgaze. Data were evaluated with relation to gender and age. RESULTS: Upper eyelid force generated was 53.3 g OD and 53.9 g OS; the generated force during frontalis muscle fixation was 38.4 g OD and 41.1 g OS. The levator and frontalis muscles showed a 3:1 ratio respectively in their contribution to the force generated during upgaze. Although no statistically significant differences were seen between eyes, gender, or within age groups, younger patients showed increased generating force which is attributed to the levator muscle. Interclass correlation coefficient showed virtually no correlation between clinical eyelid assessments and direct muscle force measurement. Reliability for repeated direct force measurements by the same physician was strong, with interclass correlation coefficient 0.951 to 0.969. No adverse events occurred. CONCLUSIONS: We describe a simple, reliable, inexpensive, new method for assessing upper eyelid upward force generation. Because the levator muscle serves as the primary contributor to eyelid elevation, this directly measurable eyelid assessment may help to increase understanding of its functional contribution and assessment when assessing eyelid pathologies.

Wound temperature profiles of coaxial mini-incision versus sleeveless microincision phacoemulsification.

BACKGROUND: Temperature profiles at the corneal wound of coaxial mini-incision (2.4 mm) cataract surgery and sleeveless microincision (1.1 mm) cataract surgery were compared. DESIGN: Prospective, controlled, paired-eye clinical trial conducted in a tertiary care hospital. PARTICIPANTS: Twenty patients with mild-to-moderate bilateral nuclear sclerotic cataract. METHODS: Twenty patients underwent bilateral cataract surgery within a 1-month period. One eye was operated on by conventional coaxial mini-incision (2.4 mm) phacoemulsification. The second eye underwent microincision surgery by using a naked phacoemulsification tip and a specialized 19-gauge anterior chamber maintainer as the sole fluid source (three-port microincision cataract surgery technique). Patients had moderate bilateral cataracts with no other anterior segment pathology. Temperature at the corneal wound was constantly recorded by using infrared thermal imaging. MAIN OUTCOME MEASURES: Temperatures at the corneal wound. RESULTS: Mean temperatures at the corneal surgical wound were not significantly different between the coaxial and sleeveless groups (31.1 °C ± 2.3 vs. 31.0 °C ± 2. 0; P = 0.89). There was also no difference in maximum temperatures reached during phaco-emulsification. Temperatures did not rise above 40 °C during any surgery, and there were no corneal burns. Final visual acuity and intraoperative and postoperative complication rates were similar between the two groups. CONCLUSIONS: The temperature profile at the surgical wound using a microincisional sleeveless phacoemulsification technique is comparable with that of the conventional coaxial mini-incision method.

Profile of Patients Presenting for Cataract Surgery in a Public Hospital: A 15 Year Perspective.

BACKGROUND: In recent decades cataract surgery has shifted slowly from public hospitals to ambulatory surgery centers, demonstrating changes in the profile of patients presenting to public hospitals for cataract surgery. These changes may potentially affect the complexity of surgeries, their volume, resident training, and perhaps also visual outcomes and patient satisfaction. OBJECTIVES: To assess the changes in the medical and demographic characteristics of patients undergoing cataract surgery in a public hospital over a period of 15 years. METHODS: We retrospectively reviewed the records of patients undergoing preoperative assessment before cataract surgery. Records for the period October 2000 to January 2001 (100 patients), October 2006 to January 2007 (100 patients), and October 2013 to January 2014 (150 patients) were assessed for demographic, systemic and ocular related parameters. RESULTS: There was a significant increase in the average age of patients (70.4, 72.4, 73.9 years, P = 0.026), with a significant increase in the percentage of patients of Arab ethnicity (17%, 11%, 28.7%, P = 0.002), and concomitant systemic co-morbidities (38%, 46%, 64.7%, P < 0.0001). There was an increase in the percentage of patients with narrow palpebral fissures (0%, 2%, 8%, P = 0.003), deep-set eyes (2%, 4%, 18%, P < 0.0001), dense nuclear sclerotic cataract (38%, 34.4%, 56.9%, P = 0.001), and a significant increase in the percentage of patients taking alpha-blocking medications (0%, 8%, 10.7 %, P = 0.004). CONCLUSIONS: Patients presenting for cataract surgery in 2013 compared to those in earlier periods are older, sicker and have more ocular conditions potentially affecting cataract surgery outcomes, patient satisfaction and residents' training.

The effects of traditional Muslim prayer positions on intraocular pressure in subjects with and without glaucoma.

PURPOSE: To compare the magnitude and duration of intraocular pressure (IOP) increase during the two principal Islamic prayer positions, Ruku (standing while bowing forward at a 90-degree angle), and Sujud (kneeling with the forehead touching the ground) in healthy subjects and patients with primary open-angle glaucoma (POAG). METHODS: Prospective, observational case series. Ninety-five eyes of 47 patients (27 with POAG and 68 without POAG) were included. Eligible candidates underwent IOP measurements in the sitting position and in two prayer positions using the Goldmann applanation tonometer and the Icare-Pro tonometer. IOP was measured at set intervals until it returned to baseline. RESULTS: Mean IOP increased from a sitting baseline value of 16.1 ± 2.9 mmHg (8.6-26) to 19.3 ± 4.2 mmHg (10.2-32.3) following 30 s of Ruku (p ≤ 0.0001) and from 16.1 ± 0.4 mmHg to 22.2 ± 3.1 mmHg (14.9-37) following Sujud (p ≤ 0.0001). IOP increased similarly in the POAG and non-POAG groups in both positions. Twenty-six eyes (27%) failed to normalize within 2mmHg of baseline, but all returned to baseline after another five minutes. CONCLUSIONS: Performing traditional Muslim prayer positions increases IOP significantly. The increase did not resolve immediately in approximately a quarter of individuals. These findings may have a considerable impact on Muslim patients with glaucoma.

Uveitic Flare-Ups After Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Patients with Uveitic Glaucoma.

PURPOSE: To assess the risk of gonioscopy-assisted transluminal trabeculotomy (GATT) inducing an uveitic flare-up in patients with uveitic glaucoma (UG). METHODS: This retrospective study included consecutive UG patients who underwent GATT at a single medical center between June 2020 and September 2022. The main outcome measure was the occurrence of a surgery-related uveitic complication defined as either an uveitic flare-up defined by the Standardization of Uveitis Nomenclature (SUN) criteria, or the appearance of cystoid macular edema (CME) from 2 weeks to 3 months after surgery. RESULTS: A total of 25 eyes of 22 patients were included in the study. Age ranged from 10-78 and 64% were women. The most common uveitic etiologies were juvenile idiopathic arthritis (JIA, 24%) and herpetic infection (24%). A total of 48%of the patients were on systemic immunosuppressants prior and unrelated to surgery. Eight eyes (32%) had severe glaucomatous damage prior to surgery, and 20% of the patients had undergone previous glaucoma surgery. Two cases (8%) demonstrated uveitic flare-up in the early postoperative period: a case of mild anterior chamber reaction and a case of CME with persistent edema prior to surgery. Average intraocular pressure (IOP) was reduced from 26.7 mm Hg on four medications to 12.2 on 1.1 after 1 year. One patient required reoperation for IOP control. CONCLUSIONS: With careful pre and postoperative care, GATT seems to be a low-risk procedure for uveitic flare-ups in patients with UG.

Reproducibility of Manifest Refraction in Patients With Keratoconus Compared With Healthy Subjects: A Prospective Cohort Study.

PURPOSE: To measure and compare the inter-examiner reproducibility of manifest refraction in patients with keratoconus. DESIGN: Prospective, inter-examiner reliability analysis comparing cases and controls. METHODS: Patients with keratoconus (KC) and healthy subjects had undergone manifest refraction by the same 2 skilled optometrists; each was masked to the refraction of the other, on the same day. The KC group comprised patients with KC, who were recruited from the cornea clinic. The control group consisted of healthy individuals who wore spectacles and did not have KC. Participants for the control group were recruited from the clinic's staff, including doctors, technicians, nurses, and medical students. The study took place in 1 tertiary medical center in Israel from April 2021 to May 2022. The results of the manifest refraction and achieved corrected distance visual acuity (CDVA) were compared between groups. RESULTS: A total of 120 eyes of 60 patients were enrolled in the study, 30 in the keratoconus group and 30 in the control group. A difference of 0.67 ± 0.83 diopters (D) and 0.19 ± 0.21 D in the absolute manifest cylinder was observed between the optometrists in the keratoconus (95% LoA, -0.96, 2.30) and control group (95% LoA, -0.22, 0.61), respectively (P < .001). Multivariate analysis revealed a 22-fold higher likelihood of an error exceeding 0.75 D in cylinder measurements (odds ratio = 22.24; 95% CI = 2.39-206.95) and a 10-fold likelihood of a difference of at least 1 row on the Snellen chart for corrected distance visual acuity (odds ratio = 10.32; 95% CI = 2.39-44.44) in the KC group. CONCLUSIONS: When compared to healthy subjects, patients with KC exhibited greater variability in manifest refraction. This discrepancy has the potential to influence the decision-making process when managing patients with KC.

Gonioscopy-assisted transluminal trabeculotomy (GATT) with scleral or iris fixation for subluxated intraocular lenses and glaucoma.

INTRODUCTION: This retrospective chart review aims to report a combined surgical approach of intraocular lens (IOL) fixation and gonioscopy-assisted transluminal trabeculotomy (GATT) for the treatment of subluxated IOLs and glaucoma or ocular hypertension. METHODS: Charts of patients who underwent IOL fixation combined with GATT between November 2019 and July 2023 were reviewed. The main outcome measure was surgical success, defined as a well-centered IOL and an IOP of 18 mmHg or lower and either a 30% IOP reduction or a reduction in medications as compared to baseline. Complications and the need for reoperation were recorded. RESULTS: Eleven patients who underwent GATT with IOL fixation were included. The mean age was 80.45 years (range: 73-90). IOL subluxation was associated with pseudoexfoliation in all cases. Seven patients underwent scleral fixation, and four underwent iris fixation. The mean follow-up was 15.36 (range: 2.7-26.6) months. The success rate was 72.73%. The mean baseline IOP was 20.63 ± 6.56 mmHg on 2.81 ± 1.53 medications. Four patients were on oral carbonic-anhydrase inhibitor (CAI) before surgery. The mean IOP at the end of the follow-up was 13.86 ± 3.5 mmHg on 1.36 ± 1.57 medications, and none were on oral CAIs. No intraoperative complications occurred, and transient hyphema and vitreous hemorrhage were the most common postoperative complications. All patients had a well-centered IOL. No patients needed additional surgery for IOL position or IOP control. The mean corrected distance visual acuity was 0.634 ± 0.62 logMAR at baseline and 0.36 ± 0.38 at the end of follow-up. CONCLUSIONS: GATT can be combined with IOL fixation to the sclera or iris to effectively reduce IOP and medication usage.

Anterior Chamber Intraocular Lens Implantation Versus Four-Flanged Scleral Fixation Technique for Patients With Loss of Capsular Support During Routine Cataract Surgery.

PURPOSE: To compare the outcomes of anterior chamber intraocular lens (AC-IOL) implantation versus the four-flanged scleral fixation technique in eyes with loss of capsular support during routine cataract surgery. METHODS: This was a retrospective cohort study of all patients in whom an IOL was implanted either during or after short-term aphakia due to loss of capsular and sulcus support in a routine cataract surgery with at least 6 months of follow-up time between 2015 and 2023 in a tertiary medical center in Israel. Two different IOL implantation techniques were compared: the implantation of an angle-supported ACIOL and four-flanged scleral fixation. Main outcome measures included postoperative complications such as pseudophakic bullous keratopathy, loss of intraocular pressure control and glaucoma, IOL subluxation, and retinal detachment. RESULTS: Sixty-five eyes of 65 patients were included in the study, 33 eyes in the AC-IOL group and 32 eyes in the flange group. Follow-up time was 29.92 ± 20.02 months in the AC-IOL group and 20.17 ± 15.56 months in the flange group (P = .087). Pseudophakic bullous keratopathy was observed in 10 (30.3%) patients in the AC-IOL group and in 1 (3.1%) patient in the flange group (P = .04). This association remained significant using survival analysis (P = .006). In 4 (12.1%) patients in the AC-IOL group, a glaucoma filtering procedure was performed to control the intraocular pressure compared with none in the flange group (P = .042). CONCLUSIONS: In the setting of loss of capsular support during routine cataract surgery, four-flanged scleral fixation showed an overall lower rate of complications and significantly reduced rate of subsequent surgical interventions. [J Refract Surg. 2024;40(8):e520-e526.].

Gonioscopy-assisted transluminal trabeculotomy in patients with advanced glaucoma.

Purpose: To evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with advanced glaucoma. Methods: Records of 46 patients with advanced glaucoma were reviewed retrospectively in this single-center chart review. The main outcome measure was surgical success; intra-ocular pressure (IOP) and IOP lowering medication use were secondary outcome measures. Success was defined as an IOP of 18 mmHg or lower (criterion A) or 14 mmHg or lower (criterion B) and one of the following: IOP reduction >30% from baseline on the same or fewer medications or IOP ≤ of baseline on fewer medications as compared to baseline. Results: Forty-seven eyes were included in the analysis. The average mean deviation was -17.5 ± 7.2 dB (range -8.0 to -33.0). The average follow-up was 6.8 months (range 3.2-22.3). Success at 6 months was 91% for criterion A and 75% for criterion B (n = 33). Mean IOP was reduced from 19.3 ± 6 mmHg (12-40) on 3.7 ± 1.4 medications to 13.2 ± 5.8 mmHg on 1.6 ± 1.4 medications at the 6th post-operative month (P < 0.001 for both IOP and medications). At the last follow-up visit, 37 patients (78%) had an IOP of 14 mmHg or lower, and ten of these patients were unmedicated. Transient hyphema and IOP spikes were the most prevalent adverse events following surgery. Three eyes required further surgery for IOP control. None of the patients lost vision because of surgery. Conclusions: GATT is a viable surgical option in cases of advanced glaucoma. Careful patient selection and attentive post-operative management are imperative.

Segmental Suture Gonioscopy-Assisted Transluminal Trabeculotomy: Comparison of Superior Versus Inferior Hemisphere Outcomes.

PRCIS: Analysis of efficacy, safety, and risk factors for failure of superior versus inferior 180-degree segmental gonioscopy-assisted transluminal trabeculectomy showed no significant difference between approaches, with novel risk factors for failure identified. PURPOSE: Compare the efficacy, safety, and risk factors for failure of superior versus inferior 180-degree segmental suture gonioscopy-assisted transluminal trabeculotomy (GATT). DESIGN: Multicenter, retrospective interventional cohort study of 297 eyes of 243 glaucomatous patients, which underwent superior or inferior 180-degree suture hemi-GATT surgery combined with phacoemulsification at one of 3 Canadian ophthalmological surgical centres in Calgary, Alberta or Toronto, Ontario. MAIN OUTCOME MEASURES: The primary outcome measure was the hazard ratio (HR) of failure for the "primary success" criteria. "Primary success" was defined as an intraocular pressure (IOP) <18 mm Hg and either 1) IOP reduced by ≥20% from baseline on the same number of IOP-lowering medications or 2) IOP ≤ baseline on fewer medications. Secondary outcome measures included HRs of failure for alternative criteria ("complete success", "qualified success" and "20% IOP reduction"), cross-sectional analysis, and Cox proportional hazard analysis for risk factors associated with increased failure for the complete cohort. RESULTS: Baseline characteristics were similar between groups. The crude and adjusted HR of failure for the "primary success" criteria for superior surgeries relative to inferior surgeries were 1.27 (95% CI = 0.86-1.88) and 1.50 (95% CI = 0.91-2.46), with no statistically significant difference between approaches. Of the secondary criteria, there was statistical significance in favor of inferior surgeries only for crude analysis of the "20% reduction" criteria (1.40/1.27 (95% CI = 1.01-1.92). Increased risk of failure by the "primary success" measure for either intervention was seen with primary open angle glaucoma, advanced disease, and age below 70 years. There were no significant differences in the frequency of postoperative complications between cohorts, which were present in 72 superior (44.4%) and 67 inferior (49.6%; P value = 0.41) eyes; mostly early postoperative hyphema, iritis, and corneal edema. CONCLUSIONS: This retrospective study showed no difference in inferior versus superior 180 degrees of hemi-GATT/phacoemulsification cataract surgeries through the majority of analyses. Nonmodifiable factors including glaucoma type, advanced disease, and younger age were associated with a significantly higher risk of failure in this cohort. Further study is warranted.

Gonioscopy-assisted transluminal trabeculotomy is an effective surgical treatment for uveitic glaucoma.

BACKGROUND: To assess the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in uveitic glaucoma (UG). METHODS: A retrospective interventional case series in which 33 eyes of 32 patients with UG underwent GATT with or without concomitant cataract extraction and intraocular lens implantation (CE/IOL) at three Canadian treatment centres from October 2015 to 2020. The main outcome measure was surgical success defined as an intraocular pressure (IOP) ≤18 mm Hg and at least one of the following: IOP within one mm Hg of baseline on fewer glaucoma medications as compared with baseline or a 30% IOP reduction from baseline on the same or fewer medications. Secondary outcome measures were IOP, medication usage and surgical complications. RESULTS: Mean patient age (mean±SD) was 49±16 years (range: 18-79) and 44% were female. GATT was performed as a standalone procedure in 52% of cases and the remainder were combined with CE/IOL. Surgical success was achieved in 71.8% (SE: 8.7%) of cases. Mean preoperative IOP (±SD) was 31.4±10.8 mm Hg on a median of 4 medications. 59% of patients were on oral carbonic anhydrase inhibitors (CAIs) prior to surgery. After 1 year, average IOP was 13.8 mm Hg on a median 1 medication, with 6% of patients being on oral CAIs. No sight threatening complications occurred during surgery or follow-up. CONCLUSION: GATT is an effective surgical strategy in the management of UG. This microinvasive conjunctival-sparing procedure should be considered early in these patients.

The effect of hypotensive drugs on intraocular lenses clarity.

OBJECTIVES: To assess the effect of hypotensive drugs on light absorbance, discoloration, opacification and precipitate formation of IOLs. METHODS: In this laboratory study, four types of IOLs (two hydrophilic-acrylic-L1 and L2, and two hydrophobic-acrylic-B1 and B2) were soaked in solutions containing Timolol-maleate 0.5%, Dorzolamide 2%, Brimonidine-tartrate 0.2%, Latanoprost 0.005%, Brimonidine-tartrate/Timolol-maleate 0.2%/0.5% and Dorzolamide/Timolol-maleate 2%/0.5%. Non-treated IOLs and IOLs soaked in balanced salt solution (BSS) served as controls. All Treated lenses were sealed in containers and placed in an oven at 82 degrees Celsius for 120 days. Each IOL was examined using four different techniques: light microscopy imaging, light absorbance measurements at 550 nanometers through the optic's center, assessment of by a scanning electron microscope (SEM), and energy dispersive Xray spectrometry (EDX). RESULTS: Ninety-eight IOLs were included. All BSS-soaked IOLs appeared clear with no significant discoloration or precipitate-formation. Light absorbance in these lenses was comparable to that of non-soaked, non-heated IOLs. No calcium or phosphate were detected in either of these groups. Light absorbance differed significantly between the four treated IOL types. The drops most affecting light absorbance differed between IOLs. Gross examination revealed brown and yellow discoloration of all IOLs soaked in Dorzolamide and Brimonidine-tartrate solutions, respectively. SEM demonstrated precipitates that differed in size, morphology and distribution, between different IOL-solution combinations. EDX's demonstrated the presence calcium and phosphor in the majority of precipitates and the presence of sulfur in brown discolored IOLs. CONCLUSIONS: In vitro, interactions between hypotensive drugs and IOLs induce changes in light absorbance, discoloration and precipitate formation.