Clinical characteristics and mortality rates for suprachoroidal hemorrhage: seven-year experience at a tertiary eye center.

PURPOSE: To investigate comorbidities and medications associated with acute (ASCH) and delayed (DSCH) suprachoroidal hemorrhage (SCH), and to explore visual outcomes and mortality following SCH. METHODS: Retrospective review of SCH cases diagnosed at a tertiary center between 2013 and 2019. Demographics, history, surgery type, visual acuity, intraocular pressure (IOP), and mortality data were reviewed. RESULTS: Fifty eyes of 50 patients experienced SCH related to surgery: 15 (30%) ASCH and 35 (70%) DSCH. Glaucoma surgery was the most common preceding surgery, and SCH was more likely to be delayed in glaucoma surgery relative to other surgeries (p = 0.001). The proportions of patients on anticoagulant, antiplatelet, or NSAID medications were 30% (n = 15), 52% (n = 26), and 12% (n = 6), respectively. The mean preoperative IOP was 25.0 ± 10.2 mmHg. The mean final best corrected visual acuity did not significantly differ between DSCH and ASCH (logMAR 1.92 vs. 2.36; p = 0.39). After controlling for pre-drainage visual acuity, final visual acuity was not statistically significantly different between eyes that were drained versus those that were not drained (p = 0.06). Of all 50 patients, the mortality rate was 12% with a mean time to mortality after SCH of 754 ± 564 days for those who died. CONCLUSION: DSCH was more common than ASCH, with glaucoma surgery being the most common procedure to result in SCH. Visual outcomes and mortality rate were comparable between ASCH and DSCH. Further research is needed regarding the role of surgical drainage on improving visual outcomes in eyes with SCH.

Eight-Year Incidence of Open-Angle Glaucoma in the Tema Eye Survey.

PURPOSE: To determine the incidence of open-angle glaucoma (OAG) and its risk factors in the Tema Eye Survey in Ghana, West Africa. DESIGN: Longitudinal, observational population-based study. PARTICIPANTS: One thousand two hundred five of 1500 participants 40 years of age or older selected randomly from 5603 participants originally drawn from the population and who had undergone a baseline examination. METHODS: All participants underwent baseline and follow-up ophthalmologic examinations 8 years apart. Glaucoma diagnosis was determined based on the International Society for Geographical and Epidemiologic Ophthalmology criteria. MAIN OUTCOME MEASURES: Incidence and odds ratio (OR). RESULTS: The response rate was 80.3%. Of 1101 nonglaucomatous participants at baseline who had complete follow-up data, 4.6% (95% confidence interval [CI], 3.7%-5.2%) demonstrated OAG over the 8-year period, or 0.58% (95% CI, 0.4%-0.8%) per year. The 8-year incidence increased with age from 3.1% in those 40 to 49 years old to 7.0% in those 60 to 69 years old. Baseline risk factors for incident OAG were male gender (OR, 2.1; 95% CI, 1.1-4.0; P = 0.025), older age relative to those 40 to 49 years old (those 50-50 years old: OR, 2.6; 95% CI, 1.2-5.7; those 60-69 years old: OR, 4.3; 95% CI, 2.0-8.8; and for those 70 years of age and older: OR, 6.3; 95% CI, 2.6-15.4; all P < 0.001), higher intraocular pressure (IOP; OR, 1.4; 95% CI, 1.1-1.8; P < 0.001), larger vertical cup-to-disc ratio (OR, 5.8; 95% CI, 5.2-6.6; P < 0.001), and thinner central cornea (OR, 1.2; 95% CI, 1.03-1.5; P = 0.013). A separate analysis performed with central corneal thickness-based IOP correction did not change the outcome of the associative model of incident glaucoma. CONCLUSIONS: The incidence of OAG is higher in this population than reported in nonblack populations outside Africa. This is important not only in Ghana and probably other West African countries but also wherever people of the West African diaspora reside. These data enhance our understanding of the epidemiologic factors of OAG in this setting and may serve as reference for public health policy and planning.

Association of Genetic Variants With Primary Open-Angle Glaucoma Among Individuals With African Ancestry.

Importance: Primary open-angle glaucoma presents with increased prevalence and a higher degree of clinical severity in populations of African ancestry compared with European or Asian ancestry. Despite this, individuals of African ancestry remain understudied in genomic research for blinding disorders. Objectives: To perform a genome-wide association study (GWAS) of African ancestry populations and evaluate potential mechanisms of pathogenesis for loci associated with primary open-angle glaucoma. Design, Settings, and Participants: A 2-stage GWAS with a discovery data set of 2320 individuals with primary open-angle glaucoma and 2121 control individuals without primary open-angle glaucoma. The validation stage included an additional 6937 affected individuals and 14 917 unaffected individuals using multicenter clinic- and population-based participant recruitment approaches. Study participants were recruited from Ghana, Nigeria, South Africa, the United States, Tanzania, Britain, Cameroon, Saudi Arabia, Brazil, the Democratic Republic of the Congo, Morocco, Peru, and Mali from 2003 to 2018. Individuals with primary open-angle glaucoma had open iridocorneal angles and displayed glaucomatous optic neuropathy with visual field defects. Elevated intraocular pressure was not included in the case definition. Control individuals had no elevated intraocular pressure and no signs of glaucoma. Exposures: Genetic variants associated with primary open-angle glaucoma. Main Outcomes and Measures: Presence of primary open-angle glaucoma. Genome-wide significance was defined as P < 5 × 10-8 in the discovery stage and in the meta-analysis of combined discovery and validation data. Results: A total of 2320 individuals with primary open-angle glaucoma (mean [interquartile range] age, 64.6 [56-74] years; 1055 [45.5%] women) and 2121 individuals without primary open-angle glaucoma (mean [interquartile range] age, 63.4 [55-71] years; 1025 [48.3%] women) were included in the discovery GWAS. The GWAS discovery meta-analysis demonstrated association of variants at amyloid-ß A4 precursor protein-binding family B member 2 (APBB2; chromosome 4, rs59892895T>C) with primary open-angle glaucoma (odds ratio [OR], 1.32 [95% CI, 1.20-1.46]; P = 2 × 10-8). The association was validated in an analysis of an additional 6937 affected individuals and 14 917 unaffected individuals (OR, 1.15 [95% CI, 1.09-1.21]; P < .001). Each copy of the rs59892895*C risk allele was associated with increased risk of primary open-angle glaucoma when all data were included in a meta-analysis (OR, 1.19 [95% CI, 1.14-1.25]; P = 4 × 10-13). The rs59892895*C risk allele was present at appreciable frequency only in African ancestry populations. In contrast, the rs59892895*C risk allele had a frequency of less than 0.1% in individuals of European or Asian ancestry. Conclusions and Relevance: In this genome-wide association study, variants at the APBB2 locus demonstrated differential association with primary open-angle glaucoma by ancestry. If validated in additional populations this finding may have implications for risk assessment and therapeutic strategies.

Primary Open-Angle Glaucoma Preferred Practice Pattern(®) Guidelines.

UNLABELLED: PRIMARY OPEN-ANGLE GLAUCOMA PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Primary Open-Angle Glaucoma Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary open-angle glaucoma with an algorithm for patient management and detailed recommendations for evaluation and treatment options.

Primary Angle Closure Preferred Practice Pattern(®) Guidelines.

UNLABELLED: PRIMARY ANGLE CLOSURE PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Primary Angle Closure Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary angle closure with detailed recommendations for evaluation and treatment options.

Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern(®) Guidelines.

UNLABELLED: PRIMARY OPEN-ANGLE GLAUCOMA SUSPECT PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Primary Open-Angle Suspect Glaucoma Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary open-angle glaucoma suspect with detailed recommendations for evaluation and treatment options.

Osteogenesis imperfecta and primary open angle glaucoma: genotypic analysis of a new phenotypic association.

PURPOSE: Osteogenesis imperfecta (OI) is a group of inherited disorders characterized by bone fragility. Ocular findings include blue sclera, low ocular rigidity, and thin corneal thickness. However, there are no documented cases linking OI and primary open angle glaucoma (POAG). In this report, we describe three individuals, one isolated case and two from a multiplex family, with OI type I and POAG. METHODS: Available family members with OI and POAG had a complete eye examination, including visual acuity, intraocular pressure (IOP), pachymetry, slit-lamp exam, dilated fundus exam, and visual fields. DNA from blood samples was sequenced and screened for mutations in COL1A1/2 and myocilin (MYOC). RESULTS: All subjects had OI type I. Findings of POAG included elevated IOP, normal gonioscopy, and glaucomatous optic disc cupping and visual field loss. POAG cosegregated with OI in the multiplex family. The multiplex family had a single nucleotide insertion (c.540_541insC) in COL1A1 resulting in a frameshift mutation and a premature termination codon. The sporadic case had a COL1A1 splice acceptor site mutation (c.2452-2A>T or IVS36-2A>T) predicted to result in a premature termination codon due to intron inclusion or a cryptic splice site. None of the glaucoma cases had mutations or sequence changes in MYOC. CONCLUSIONS: We identified two novel mutations in COL1A1 in individuals with OI type I and POAG. Thus, some mutations in COL1A1 may be causative for OI and POAG. Alternatively, susceptibility genes may interact with mutations in COL1A1 to cause POAG.

The Effect of Bimatoprost Implant on Glaucoma Patients: An Observational Study.

PRCIS: In this retrospective study of glaucoma patients receiving the bimatoprost implant at Duke Eye Center, the number of topical intraocular pressure-lowering medications was significantly reduced through 12 months after the implant. PURPOSE: To study the effects of the bimatoprost implant on intraocular pressure (IOP) and the need for topical IOP-lowering medications in glaucoma patients in the clinical practice setting. PATIENTS AND METHODS: Patients who received the bimatoprost implant at Duke Eye Center from November 2020 to October 2021 were identified. Exclusion criteria included addition of other IOP-lowering medications concurrent with the implant and <1 month of follow-up. The change in IOP and number of topical IOP-lowering medications from baseline to months 1, 3, 6, 9, and 12 after the implant was calculated. Subgroup analysis was performed for different glaucoma severities. RESULTS: A total of 63 patients and 92 eyes were included (mean age 77.8 ± 10.1 years). Glaucoma severity ranged from mild (11%), moderate (30%), to severe (54%). There was a nonsignificant decrease in IOP at all timepoints. The mean number of topical IOP-lowering medications significantly decreased by 0.81, 0.75, 0.63, 0.70, and 0.67 at month 1, 3, 6, 9, and 12, respectively (all P < 0.001). There was no significant change in the total number of medications, including the bimatoprost implant. When divided by glaucoma severity, the reduction in the number of topical medications was significant at 1, 3, and 6 months for mild/moderate disease and at 1 month for severe disease. During the follow-up period, 19 eyes underwent additional laser or surgical procedures, 68% of which had a history of prior incisional glaucoma surgery. CONCLUSIONS: The bimatoprost implant may reduce the need for topical IOP-lowering agents over a 1-year period, especially in mild to moderate-stage glaucoma. The efficacy of the implant may be more limited in severe glaucoma, and further work is needed to characterize its long-term effects.

Surgical Outcomes, Ocular Safety and Tolerability of Bio-Interventional Cyclodialysis with Allograft Scleral Reinforcement: Clinical Experience of More than 240 Cases.

Background: To report the surgical safety of reinforced bio-interventional cyclodialysis with scleral allograft reinforcement. Methods: This was a consecutive case series of 243 eyes with open-angle glaucoma who underwent a bio-scaffolded cyclodialysis (BSC) procedure for uveoscleral outflow enhancement using allogeneic bio-spacers to maintain patency of the internal filtration conduit. Results: 79% of the eyes underwent concomitant phacoemulsification cataract surgery prior to BSC intervention, while the remaining eyes underwent stand-alone BSC surgery. All patients had a postoperative surgical safety period of at least 30 days. There were no sight-threatening or serious ocular adverse events. There was one case of prolonged iritis beyond 30 days, which resolved with topical treatment. Two cases (0.8%) of intraoperative and five (2%) of postoperative non-sight-threatening hyphema were without clinical sequelae, which resolved with conservative management. There were 11 cases of IOP elevation and one case of numeric hypotony without maculopathy, which resolved within the study period. The rate of secondary surgical intervention for IOP control was low, and overall, IOP for the cohort improved in the postoperative period, with 78.6% of eyes achieving IOP ≤ 18 mmHg without an increase in medications. Conclusions: Allogeneic biotissue for cyclodialysis intervention demonstrates a biocompatible ocular profile as an implantable material for internal scleral reinforcement during uveoscleral outflow enhancement surgery.

Glaucoma Surgery SOS: Emergency Department Utilization Greater Among Younger and First-Time Surgical Glaucoma Patients.

PURPOSE: To describe the frequency, findings, and interventions of patients' emergency department visits after all types of glaucoma surgery DESIGN: Retrospective cohort study SUBJECTS: All surgical glaucoma patients between 2013 and 2021 METHODS: This single institution study collected demographics, surgery type, and surgical parameters for each patient. Subsequently, for those visiting the emergency department within 50 days of surgery, data was collected on reason for visit, findings, and ophthalmic intervention. Logistic regression models were used to determine the odds of ED visits based on multiple risk factors. MAIN OUTCOME: Postoperative presentation to ED RESULTS: Among 9155 surgeries in 5505 patients, 5.7% had ED visits within 50 days, with 46.3% having ocular complaints. Patients with ocular diagnoses presented earlier than those without (p < 0.001). Patients who presented to the ED with an ocular diagnosis were found to be significantly younger than those who did not present (62.2 ± 18.6 vs 65.4 ± 18.0 years old, p < 0.028). Furthermore, white patients were more likely than black patients to present with an ocular diagnosis compared to a non-ocular diagnosis (OR 2.64, 95% CI 1.67-4.18, p<0.001). Patients undergoing their first glaucoma surgery had a much higher chance of presenting to the ED compared to patients who had undergone more than one surgery (OR: 3.75, 95%CI 2.74 - 5.14, p < 0.001). Those who underwent traditional surgeries were more likely than patients with trabecular meshwork bypass stent (TMBS) to present to the ED with an ocular diagnosis (OR: 3.02, 95% CI 1.29 - 7.08, p = 0.011). Filtering surgeries and glaucoma drainage device (GDD) revisions exhibited more vision-threatening conditions than glaucoma drainage devices (p = 0.037 and p = 0.010 respectively). Ophthalmology consultation was sought for 88.0% of ocular diagnoses. Most received medical therapy (71.0%), primarily IOP-lowering drops. CONCLUSION: ED visits after glaucoma surgery are infrequent, yet more often seen in younger patients or those undergoing their first glaucoma surgery. TMBS, but not trabecular meshwork excision and/or Schlemm's canal dilation (TME/SCD), were less likely to present to the ED than traditional surgeries. Filtering surgeries and tube revisions presented more often with visual threatening conditions.

Primary Practice Patterns for the Initial Management of Open Angle Glaucoma.

PRCIS: About one-fourth of survey respondents from an ASCRS database initiate treatment for primary open angle glaucoma (POAG) with laser trabeculoplasty. Factors impacting physicians' choice of laser versus topical treatment for POAG were explored. PURPOSE: To characterize primary treatment preferences (topical medication versus laser trabeculoplasty or intracameral sustained release implants) in primary open angle glaucoma (POAG) patients and determine factors related to primary intervention selection. METHODS: A 33-question survey was distributed to an American Society of Cataract and Refractive Surgery database on treatment choices made by ophthalmologists for POAG. Data collected included country of practice, years of practice, completion of glaucoma fellowship training, type of practice, and preference for the first line of treatment for POAG. Multiple logit regression was used to compare the effect of covariates on physicians' choice of either topical medication or laser trabeculoplasty for POAG. RESULTS: A total of 252 of 19,246 (1.3%) surveys were returned. Almost three-quarters of respondents used topical medication as the first line of treatment for POAG (73.6%), whereas 26.4% preferred to start with laser treatment. Significant variables associated with the selection of laser (vs. drops) are practicing in the United States (odds ratio [OR] 2.85; 95% CI, 1.33-6.10), the more recent completion of ophthalmology residency (OR 1.95; 95% CI, 1.00-3.77), the greater volume of minimally invasive glaucoma surgeries (MIGS) (OR 1.68; 95% CI, 1.18-2.40), and a glaucoma patient base greater than 25% (OR 2.21; 95% CI, 1.09-4.48). CONCLUSIONS: For the first-line treatment of POAG, laser trabeculoplasty is more likely to be preferred, over topical drops, by U.S. physicians who are relatively new in practice, who have a larger glaucoma patient base, and who perform more MIGS.

Younger Age and Longer Case Times Associated With Emergency Department Visits After Cataract Surgery.

PURPOSE: To characterize the frequency, reasons, hospital costs, and risk factors for emergency department (ED) visits within 30 days of cataract surgery. DESIGN: Retrospective cohort study. METHODS: A retrospective review of all cataract surgeries at Duke Health between 2013 and 2021 was conducted. Demographics, case characteristics (length, complexity by billing codes, anesthesia type), ED visit findings, and hospital costs were collected. Logistic regression models were used to determine the odds of ED visits based on several risk factors. RESULTS: Of 34 246 patients (57 656 eyes) undergoing cataract surgery at Duke Health from 2013 to 2021, a total of 607 patients (1.77%) had 680 ED visits within 30 days of surgery. The most common ED diagnosis was cardiovascular (24.4%), whereas ocular complaints constituted 15.4% of visits. The most common ocular diagnoses were high intraocular pressure, rebound iritis, and posterior vitreous detachment. Hospital costs were lowest for ocular diagnoses (mean $467.72) and highest for trauma diagnoses (mean $4660.55). Risk factors for ED visits included case lengths greater than 30 minutes (OR 2.1, 95% CI 1.56-2.83, P < .001), the combination of Monitored Anesthesia Care (MAC) and retrobulbar anesthesia or general anesthesia (OR 2.98, 95% CI 1.73-5.12, P < .001), and age less than 70 years (OR 1.39, 95% CI 1.16-1.65, P < .001). CONCLUSIONS: ED visits within 30 days of cataract surgery are uncommon. Longer case lengths, anesthesia other than MAC alone, and younger age are associated with higher odds of ED visits.

Low prevalence of myocilin mutations in an African American population with primary open-angle glaucoma.

PURPOSE: Mutations in the myocilin gene (MYOC) are associated with primary open-angle glaucoma (POAG) in many different populations. This study represents the first large survey of MYOC mutations in an African American population. METHODS: We recruited 529 African American subjects with POAG and 270 African American control subjects in this study. A complete eye examination and blood collection was performed in all study subjects. Genomic DNA was extracted. The entire coding sequence of MYOC was amplified and sequenced using the Sanger method. Identified MYOC variants were compared with previously reported MYOC mutations. RESULTS: We identified a total of 29 MYOC variants including six potential MYOC mutations. Two mutations (Thr209Asn and Leu215Gln) are novel and are found only in cases and no controls. We also identified four previously reported MYOC mutations in cases and no controls (Tyr453MetfsX11, Gln368X, Thr377Met, and Ser393Arg). The overall frequency of glaucoma-causing MYOC mutations in our African American population with POAG was 1.4%. CONCLUSIONS: We identified two novel probable glaucoma-causing MYOC mutations (Thr209Asn and Leu215Gln). This study indicates that, despite the high prevalence of POAG, MYOC mutations are rare in the African American population.

Blindness and visual impairment in an urban West African population: the Tema Eye Survey.

OBJECTIVE: To determine the prevalence, causes, and risk factors of blindness and visual impairment among persons aged 40 years or older residing in an urban West African location. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 5603 participants residing in Tema, Ghana. METHODS: Proportionate random cluster sampling was used to select participants aged 40 years or older living in the city of Tema. Presenting distance visual acuity (VA) was measured at 4 and 1 m using a reduced logarithm of the minimum angle of resolution tumbling E chart and then with trial frame based on autorefraction. A screening examination was performed in the field on all participants. Complete clinical examination by an ophthalmologist was performed on participants with best-corrected visual acuity (BCVA) <20/40 or failure of any screening test. MAIN OUTCOME MEASURES: Age- and gender-specific prevalence, causes, and risk factors for blindness (VA of <20/400 in the better eye, World Health Organization definition) and visual impairment (VA of <20/40 in the better eye). RESULTS: A total of 6806 eligible participants were identified, of whom 5603 (82.3%) participated in the study. The mean age (± standard deviation) of participants was 52.7 ± 1 0.9 years. The prevalence of visual impairment and blindness was 17.1% and 1.2%, respectively. After refraction and spectacle correction, the prevalence of visual impairment and blindness decreased to 6.7% and 0.75%, respectively, suggesting that refractive error is the major correctable cause of visual impairment and blindness in this population. Of 65 subjects with a VA <20/400, 22 (34%) were correctable with refraction, 21 to the level of visual impairment and 1 to normal. The remaining 43 patients (66%) had underlying pathology (cataract in 19, glaucoma in 9, nonglaucomatous optic neuropathy in 3, corneal opacities in 3, retinal disease in 3, and undetermined in 5) that prevented refractive correction. Increased age was a significant risk factor for blindness and visual impairment. CONCLUSIONS: There is a high prevalence of blindness and visual impairment among those aged ≥ 40 years in Tema, Ghana, West Africa. Refractive error is a major cause of blindness and visual impairment in this population, followed by cataract, glaucoma, and corneal disease.

Glaucoma Progression Analysis software compared with expert consensus opinion in the detection of visual field progression in glaucoma.

PURPOSE: To compare the results of Glaucoma Progression Analysis (GPA, Carl Zeiss Meditec, Dublin, CA) to subjective expert consensus in the detection of glaucomatous visual field progression. DESIGN: Retrospective, observational case series. PARTICIPANTS: We included 100 eyes of 83 glaucoma patients. METHODS: Five serial Humphrey visual fields from 100 eyes of 83 glaucoma patients were evaluated by 5 masked glaucoma subspecialists for determination of progression. Four months later, with a randomly reordered patient sequence, the same visual field series were reevaluated by the same graders, at which time they had access to the Glaucoma Progression Analysis (GPA) printout. MAIN OUTCOME MEASURES: The level of agreement between majority expert consensus and GPA, both before and after access to GPA data, was assessed using kappa statistics. RESULTS: On initial review and on reevaluation with access to the GPA printout, the level of agreement between majority expert consensus and GPA was fair (kappa = 0.52, 95% confidence interval [CI], 0.35-0.69 and kappa = 0.62; 95% CI, 0.46-0.78, respectively). Expert consensus was more likely to classify a series of fields as showing progression than was GPA (P ≤ 0.002). There was good agreement between expert consensus on initial review and reevaluation 4 months later (kappa = 0.77; 95% CI, 0.65-0.90). CONCLUSIONS: The level of agreement between majority expert consensus of subjective determination of visual field progression and GPA is fair. In cases of disagreement with GPA, the expert consensus classification was usually progression. Access to the results of GPA did not significantly change the level of agreement between expert consensus and the GPA result; however, expert consensus did change in 11 of 100 cases.

Hydrogel Sealant for Closure of Clear Corneal Incisions in Combined Glaucoma Procedures.

Purpose: The purpose of this study is to determine whether ReSure hydrogel sealant is superior to standard suture for closure of clear corneal incisions in the setting of combined glaucoma procedures. Setting: Glaucoma Department, Duke University Eye Center. Design: This is a retrospective case series. Subjects studied were patients in a 6-year period undergoing combined phacoemulsification and glaucoma surgery. All cases were performed by the same surgeon. Wound closure methods correlated with discrete timeframes, as ReSure replaced suture midway through the study period, thereby establishing sutured closure as an analogous control group. Methods: All cases included a phacoemulsification procedure requiring a 2.4 mm clear corneal incision. Upon completion of the phacoemulsification portion of the case, the wound was closed with either ReSure hydrogel or standard 10-0 suture closure. The researchers assessed the rate of Seidel-positive corneal wound leak on postoperative day one. Results: In all cases employing ReSure, no wound leak was observed at postoperative day one. Within the suture group, 3 cases showed Seidel positivity of the corneal incision. This equates to a statistically significant difference in wound leak frequency of 2.04% (P = 0.012); confidence interval, 0.21 to 5.82. Conclusion: ReSure was able to maintain closure 100% of the time over hundreds of combined cases. Suture, though the standard of practice, did not perform to this level, presenting with 3 cases of spontaneous wound leak. We conclude that ReSure is highly effective and superior to suture in closure of clear corneal incisions in combined glaucoma procedures.

Intracanalicular Dexamethasone Insert or Topical Prednisolone Following iStent and Hydrus Surgery for Glaucoma.

PRCIS: Using an intracanalicular dexamethasone insert or topical prednisolone following iStent and Hydrus surgery provided similar short-term control of postoperative inflammation. PURPOSE: The purpose of this study was to compare postoperative inflammation in patients who received an intracanalicular dexamethasone insert or topical prednisolone after iStent or Hydrus insertion during cataract surgery. PATIENTS AND METHODS: Patients receiving a dexamethasone insert after iStent or Hydrus insertion were included and compared with age-matched controls who received topical prednisolone. Preoperative data were recorded. Postoperative inflammatory cell and the proportion of patients with zero anterior chamber cells was recorded at month 1. Postoperative intraocular pressure (IOP) and rate of cystoid macular edema were recorded at months 1 and 3. RESULTS: Forty eyes receiving topical prednisolone were compared with 35 eyes receiving a dexamethasone insert after iStent or Hydrus insertion. The mean postoperative inflammatory cell for the topical group at month 1 was 0.2±0.3, and the dexamethasone group, 0.3±0.5 ( P =0.816). Overall, 70% of patients in the topical group had zero anterior chamber cell at postoperative month 1 compared with 75.8% in the dexamethasone group ( P =0.583). The mean preoperative IOP for the topical group was 18.8±5.5 and the dexamethasone group was 17.1±4.1 ( P =0.064). Mean postoperative IOP for the topical group at months 1 and 3 was 17.6±6.4 and 15.1±3.1, respectively and the dexamethasone group, 17.5±4.8 and 15.0±3.4, respectively ( P =0.772 and 0.884). One patient developed cystoid macular edema in each group. CONCLUSION: There was no statistically significant difference in the proportion of patients who had zero anterior chamber cell at postoperative month 1 between groups receiving intracanalicular dexamethasone insert or topical prednisolone.

Risk Factors for Corneal Striae in Eyes After Glaucoma Surgery.

PRCIS: Eyes with corneal striae had steeper cornea, induced astigmatism, and higher corneal hysteresis (CH), which implies a relationship between striae, corneal shape, and the cornea's resistance to deformation at low intraocular pressures (IOPs). BACKGROUND: Anterior corneal striae (ACS) are associated with low IOP. However, the clinical significance of ACS is unclear. Here, we aim to evaluate differences in eyes with striae compared with eyes without striae. METHODS: Adults with ACS (cases) and without ACS (controls) ≥8 weeks after glaucoma surgery with an IOP ≤10 mm Hg were enrolled. Optical coherence tomography and optical biometry were performed. CH, defined as the difference in pressure between corneal indentation and reformation in response to an air jet, was obtained by the ocular response analyzer. Hypotony maculopathy (HM) was defined as optic disc swelling, vascular tortuosity attributed to hypotony, or clinical presence of chorioretinal folds confirmed on OCT. RESULTS: One hundred sixteen eyes (76 cases, 40 controls) were included. Cases had a lower IOP compared with controls (6.5±2.3 vs. 8.5±1, P<0.0001). A 1 mm Hg increase in CH increased ACS odds [odds ratio (OR)=1.51, P=0.01]. A 1 D increase in the flattest presurgical and postsurgical corneal power increased ACS odds by 1.83 (P=0.01) and 1.41 (P=0.02), respectively. Astigmatism increased in eyes with ACS by 1.11 D (P<0.001). ACS odds were increased with every 1 minute increase in mitomycin-C duration (OR=1.58, P=0.047) and decreased with the use of topical glaucoma medication (OR=0.62, P=0.03). Visual acuity decreased from logarithm of the minimal angle of resolution 0.22 (20/33 Snellen) presurgery to 0.28 (20/38) postsurgery (P=0.008), independent of ACS. HM occurred in 19% of cases (P=0.05). A higher postsurgical CH increased HM odds (OR=1.8, P=0.003). HM predicted a 0.41 mm decrease in axial length (P<0.0001), independent of IOP. CONCLUSION: ACS were associated with a steeper cornea, induced astigmatism, and higher CH, suggesting a relationship between striae, corneal shape, and the cornea's ability to resist deformations at lower IOP. CH, HM, and axial length shortening were associated independently of IOP.

Incidence of Glaucoma Progression and Rate of Visual Field Deterioration in a Cohort of Urban Ghanaians.

PRCIS: The annual incidence of glaucoma progression (9.7%) and rates of visual field mean deviation (MD) change in progressors (-1.02±0.06 dB/y) are high in a small cohort of urban Ghanaians. PURPOSE: To report the incidence of glaucoma progression and the rate of visual field deterioration in a small cohort of Ghanaians. METHODS: One hundred ten subjects (204 eyes) diagnosed with glaucoma at a baseline population-based screening examination were re-examined a mean of 8.3±0.8 years later. Eyes were classified as having progressed if the optic disc alone, visual field alone or both showed significant glaucomatous changes on follow-up. Visual field MD was used to calculate the rate of visual field progression. RESULTS: Progression was observed in 89 (80.9%, 9.7%/year) subjects (130 eyes). Progression occurred in 32 (31.7%, 3.8%/year) subjects by optic disc alone (46 eyes), 38 (44.7%, 5.4%/year) subjects by visual field alone (58 eyes), and 19 (25.0%, 3.0%/year) subjects by both modalities (26 eyes). The average rate of change in MD differed significantly between progressors (-1.02±1.06 dB/y) and nonprogressors (+0.089±0.49 dB/y), P =0.001. The rate of visual field worsening was greater among those who were classified as having progressed by both structure and function (-1.29±0.68 dB/y) and by function alone (-1.21±1.20 dB/y) than by structure alone (-0.55±0.76 dB/y). Progression was significantly associated with older age [odds ratio (OR), 1.42; P <0.001] and higher baseline intraocular pressure (OR, 1.18; P =0.002). Factors associated with rate of MD change were baseline older age (OR, 1.66; P =0.003), higher intraocular pressure (OR, 2.81; P =0.007), better visual field MD (OR, 1.41; P =0.004), and systemic hypertension (OR, 1.15; P =0.029). CONCLUSION: The incidence and rate of visual field progression are high in this longitudinal study of Ghanaian subjects with glaucoma. The findings may have important clinical and public health policy ramifications.

Interobserver agreement and intraobserver reproducibility of the subjective determination of glaucomatous visual field progression.

PURPOSE: To determine the extent of interobserver agreement and intraobserver reproducibility of the subjective determination of visual field progression with achromatic automated static perimetry in eyes with glaucoma, and to determine the impact of access to Glaucoma Progression Analysis (GPA) data on interobserver agreement. DESIGN: Retrospective, observational case series. PARTICIPANTS: Five glaucoma subspecialists from 5 different academic medical centers. METHODS: Five visual field tests from each of 100 eyes of 83 patients being monitored for glaucoma were retrospectively identified and subjectively and independently evaluated by the 5 glaucoma subspecialists. Each set of visual fields was classified regarding progression as "none," "questionable," "probable," or "definite." More than 1 month later, the same expert observers reevaluated the same sets of visual field tests to allow determination of intraobserver reproducibility. A final subjective evaluation regarding progression was performed 3 months later, at which time the expert observers had access to the GPA printout. MAIN OUTCOME MEASURES: The level of interobserver agreement and intraobserver reproducibility was estimated using kappa statistics on the raw classification data and also on dichotomized data in which "none" and "questionable" progression were reclassified together as nonprogressed and " probable" and "definite" were reclassified as progressed. RESULTS: Intraobserver reproducibility was good to excellent (kappa = 0.62-0.78) for the raw data and moderate to good (kappa = 0.58-0.71) for the dichotomized data. Interobserver agreement was moderate (kappa = 0.45; 95% confidence interval [CI], 0.35-0.55) for the raw classification data and also for dichotomized data (kappa = 0.55; 95% CI, 0.46-0.64). Access to the GPA printout did not significantly change the level of interobserver agreement. CONCLUSIONS: Five glaucoma experts had good to excellent reproducibility of the determination of visual field progression compared with earlier evaluation of the same field sets. Agreement among the experts with each other was only moderate, and did not improve when each had access to GPA results. .