Factors associated with vision loss in Black or Hispanic patients 1 year after standalone or combined Ahmed glaucoma valve surgery.

PURPOSE: To determine factors associated with vision loss 1 year after Ahmed glaucoma valve (AGV) surgery in Black or Hispanic patients, who bear disproportionate glaucoma burdens yet have been underrepresented in pivotal trials. METHODS: This retrospective study included Black or Hispanic patients who received AGVs standalone or combined with phacoemulsification and/or cyclodestructive lasers. Univariate and multivariate generalized estimating equations evaluated the effects of baseline, surgical, and postoperative factors on vision loss of two Snellen lines or more at the 1-year follow-up visit. The primary term was the hypertensive phase (HP), which signified an intraocular pressure (IOP) reading > 21 mmHg within the first 3 postoperative months after reduction below 22 in the first week, without other tube malfunction. RESULTS: Of 241 eyes from 186 patients, vision loss of ≥ 2 lines at the 1-year follow-up visit occurred in 21.6% (N = 52). Vision loss of ≥ 2 lines occurred in 52.5% of eyes at week 1, 36.9% of eyes at month 1, and 27.0% of eyes at month 3. Between 6 months and 1 year, vision loss frequencies stabilized. In the multivariate model, HP (OR = 4.71 (2.14, 10.38)), total quadrants with split fixation (1.47 (1.20, 1.81)), follow-up non-glaucomatous eye pathology (2.89 (1.44, 5.80)), and concurrent cataract surgery (0.42 (0.22, 0.82)) each met significance (p < 0.05). CONCLUSION: Post-AGV vision loss in the early follow-up period among Black or Hispanic patients was often transient. Hypertensive phase and split fixation each increased the odds of vision loss at 1 year, while concurrent cataract surgery decreased the odds.

The association between corneal hysteresis and surgical outcomes from trabecular meshwork microinvasive glaucoma surgery.

PURPOSE: To assess whether an association exists between pretreatment corneal hysteresis (CH) and the magnitude of intraocular pressure (IOP) and medication burden reduction following microinvasive glaucoma surgery (MIGS). METHODS: Retrospective chart review of 84 eyes from 57 patients with CH measurements who underwent trabecular meshwork MIGS in a glaucoma practice in New York City with follow-up visits at 3-6 and 9-12 months. MIGS included canaloplasty, goniotomy, microbypass stents, or a combination thereof. RESULTS: The lowest and middle CH tertiles experienced significantly reduced mean IOP at 3-6-month follow-ups (p = .007, < .001), whereas the highest tertile did not (p = .06). At 9-12-month follow-ups, a significant mean IOP reduction only persisted in the middle tertile (p = .001). For medication burden reduction, only the highest CH tertile experienced significant mean reductions at both 3-6- and 9-12-month follow-ups (p = .015, .028). Notably, 7 patients in the lowest CH tertile failed MIGS and required an additional surgical or laser procedure within 24 months of MIGS, whereas only 3 patients failed in the other tertiles (likelihood ratio < .05). Multivariate analysis excluding MIGS failures demonstrated an inverse association between CH and the magnitude of post-operative IOP reduction at both 3-6- and 9-12-month follow-ups when controlling for baseline IOP and medication changes (p = .002, .026). CONCLUSION: There was an inverse association between pretreatment CH and the magnitude of IOP reduction following surgery. There is also evidence of an increased need for repeat surgery or other intervention in patients with lower CH who undergo MIGS.

Corneal hysteresis and its relevance to glaucoma.

PURPOSE OF REVIEW: Glaucoma is a leading cause of irreversible blindness worldwide. It is estimated that roughly 60.5 million people had glaucoma in 2010 and that this number is increasing. Many patients continue to lose vision despite apparent disease control according to traditional risk factors. The purpose of this review is to discuss the recent findings with regard to corneal hysteresis, a variable that is thought to be associated with the risk and progression of glaucoma. RECENT FINDINGS: Low corneal hysteresis is associated with optic nerve and visual field damage in glaucoma and the risk of structural and functional glaucoma progression. In addition, hysteresis may enhance intraocular pressure (IOP) interpretation: low corneal hysteresis is associated with a larger magnitude of IOP reduction following various glaucoma therapies. Corneal hysteresis is dynamic and may increase in eyes after IOP-lowering interventions are implemented. SUMMARY: It is widely accepted that central corneal thickness is a predictive factor for the risk of glaucoma progression. Recent evidence shows that corneal hysteresis also provides valuable information for several aspects of glaucoma management. In fact, corneal hysteresis may be more strongly associated with glaucoma presence, risk of progression, and effectiveness of glaucoma treatments than central corneal thickness.

Retinal blood vessel positional shifts and glaucoma progression.

PURPOSE: To determine the characteristics and significance of retinal blood vessel (RBV) positional shifts over time in a cohort of patients with progressive glaucoma. DESIGN: Retrospective cohort study. PARTICIPANTS: Baseline and serial stereophotographs from 1 eye of 125 patients with open-angle glaucoma with ≥8 reliable Swedish interactive threshold algorithm standard visual fields (VFs) were included. On the basis of global rates of threshold sensitivity change, patients with glaucoma were divided into groups of minimal (<-0.02 decibels [dB]/year), moderate (-0.02 to -0.65 dB/year), or fast (≥-0.65 dB/year) progression. To determine whether graders' assessments of RBV positional shifts were false-positives, a control group consisting of 33 patients with glaucoma with 2 sets of photographs taken on the same day was included. METHODS: Masked graders reviewed serial photographs aligned with automated alternation flicker (EyeIC, Narbeth, PA) and assessed them for the presence of any discrete RBV positional shifts (2 graders) and for traditional measures of structural progression (2 graders), including neuroretinal rim loss, parapapillary atrophy progression, and disc hemorrhage (DH). MAIN OUTCOME MEASURES: Presence or absence of RBV positional shifts, rates of VF progression, and presence or absence of traditional measures of structural progression. RESULTS: A total of 158 image sets (125 longitudinal and 33 same-day controls) from patients with glaucoma were included. Retinal blood vessel shifts were noted in 33 of 125 (26.4%) longitudinally followed glaucomatous eyes and 2 of 33 (6%) same-day control patients (P = 0.01). Agreement between graders I and II was 90.4% (kappa=0.77; P< 0.001). Eyes with RBV positional change progressed more rapidly than those without (-0.55 vs. -0.29 dB/year; 95% confidence interval [CI], 0.03-0.48); P = 0.03). Retinal blood vessel shift was present in 12.1% of minimal progressors versus 31.5% of moderate and fast progressors (P = 0.04). Rate of VF progression was statistically associated with RBV shift (odds ratio [OR], 2.2; 95% CI, 1.1-4.5; P = 0.03). Other variables significantly associated with RBV shift included neuroretinal rim loss (OR, 21.9; 95% CI, 5.7-83.6; P< 0.001) and DH (OR, 4.6; 95% CI, 1.5-15.5; P< 0.01). A multivariable model revealed that rim loss and DH, but not rate of functional change, were significantly associated with RBV shift. CONCLUSIONS: Retinal blood vessel positional shifts occurred in eyes with functionally progressive glaucoma, neuroretinal rim loss, and DH. This is a novel clinical finding that could help identify glaucoma progression or individuals at higher risk for future progression.

Isolated foveal hypoplasia without nystagmus.

We report the case of a 23-year-old healthy Caucasian male with isolated foveal hypoplasia without nystagmus. Clinical examination and spectral-domain optical coherence tomography demonstrated the bilateral absence of a foveal depression and the patient was diagnosed with isolated foveal hypoplasia. This is a rare condition which is probably under-diagnosed since it can exist without nystagmus and low vision.

The 0.19-mg Fluocinolone Acetonide Intravitreal Implant for Diabetic Macular Edema: Intraocular Pressure-Related Effects over 36 Months.

PURPOSE: To evaluate effects of the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN) on intraocular pressure (IOP) in patients with diabetic macular edema (DME). DESIGN: Secondary analysis of a 36-month, phase IV, nonrandomized, open-label, observational study. PARTICIPANTS: The study included 202 eyes from 159 patients who received the 0.19-mg FAc implant after a successful prior steroid challenge per the United States label indication. METHODS: Study eyes were assessed for IOP values, incidence of IOP elevations, and best-corrected visual acuity (BCVA) for up to 36 months post-FAc implant. RESULTS: Mean IOP was stable over 36 months post-FAc; IOP change from baseline peaked at 2.12 mmHg at 9 months, then declined to baseline levels. At 36 months, eyes had a 32.5% cumulative probability of an IOP event > 25 mmHg and a 15.6% probability of an IOP event > 30 mmHg (Kaplan-Meier). The probability of requiring IOP-lowering medication at any time by month 36 was 38.3%. A total of 78% of eyes did not have IOP elevations > 25 mmHg if similar values were seen with the previous steroid challenge. Although 7.4% of eyes had an IOP > 30 mmHg during a scheduled study visit, most exceeded this threshold only once (60%). Regardless of IOP status, mean BCVA remained stable. CONCLUSIONS: Over 36 months, the 0.19-mg FAc implant was associated with relatively stable IOPs in patients with DME, and there was no significant impact of IOP elevations identified regarding their effects on long-term visual outcomes. The probability that a prior corticosteroid challenge will not predict an IOP elevation > 25 mmHg over 36 months post-FAc is 22%; therefore, routine IOP monitoring should be scheduled. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ocular, Visual, and Anatomical Outcomes in Eyes Requiring Incisional Intraocular Pressure-Lowering Surgery Following the 0.19-mg Fluocinolone Acetonide Intravitreal Implant.

BACKGROUND AND OBJECTIVE: To assess ocular, visual, and anatomical outcomes following the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN®) and incisional intraocular pressure (IOP)-lowering surgery in diabetic macular edema. PATIENTS AND METHODS: From a 36-month, phase 4, open-label, observational study (N = 202 eyes, 159 patients), 8 eyes (7 patients) required IOP-lowering surgery post-FAc; eyes were segregated by FAc-induced (n = 5, 2.47%) versus neovascular glaucoma (NVG)-related (n = 3, 1.49%) IOP elevations and assessed for IOP, best corrected visual acuity (BCVA), central subfield thickness (CST), and cup-to-disc ratio (c/d). RESULTS: Changes at 36 months were +5.4 letters BCVA (P > 0.05) and +0.09 c/d (P = 0.0217); IOP and CST were unchanged. FAc-induced-group eyes required fewer IOP-lowering medications than NVG-group eyes (2.0 versus 4.0; P < 0.01) but for longer duration (15.2 versus 2.6 months; P < 0.001). CONCLUSIONS: Post-FAc IOP-lowering surgery, regardless of cause, largely did not affect the outcomes measured; these procedures, then, may not meaningfully threaten positive outcomes. [Ophthalmic Surg Lasers Imaging Retina 2024;55:22-29.].

Relationship between corneal hysteresis and optic nerve parameters measured with spectral domain optical coherence tomography.

BACKGROUND: Corneal hysteresis (CH) has been associated with visual field damage in glaucoma and is related to the velocity of perimetric glaucoma progression. We undertook this investigation to determine whether CH is associated with structural markers of glaucoma damage on spectral domain optical coherence tomography (SD-OCT). METHODS: In this retrospective study, 131 patients under glaucoma evaluation were evaluated with SD-OCT (Cirrus; Carl Zeiss Meditec, Dublin, CA) and had CH measurements with the ocular response analyzer (Reichert, Inc., Buffalo, NY). Pearson and partial correlation adjusting for age were preformed to examine the association between CH and variables of interest. Generalized estimating equations were used to construct simple and multiple linear models. RESULTS: While Pearson correlations were modest overall, CH best correlated with mean deviation (MD; r = 0.19) followed by average retinal nerve fiber layer (RNFL) thickness (r = 0.18) and vertical cup to disc ratio (r = -0.11) in the open angle glaucoma group. In univariable models, CH varied as a function of MD (ß = 0.1, 95 % CI 0.03, 0.1; p < 0.001) and of average RNFL thickness (ß = 0.2, 95 % CI 0.1, 0.4; p = 0.001). In a multivariable analysis including MD, age, average RNFL thickness, and glaucoma status, MD (p = 0.001) and age (p < 0.001) retained significant associations with CH. CONCLUSIONS: In patients under evaluation and treatment for glaucoma, CH was more closely related to visual field MD than to structural markers of glaucoma damage as measured by SD-OCT.

Challenging the "Topical Medications-First" Approach to Glaucoma: A Treatment Paradigm in Evolution.

Topical glaucoma medications are effective and safe, but they have numerous well-documented limitations that diminish their long-term utility and sustainability. These limitations can include high rates of nonadherence (with associated glaucoma progression), concerning side effects, inconsistent circadian intraocular pressure (IOP) control, complex dosing regimens, difficulty with self-administration, costs, and decreased quality of life. Despite these limitations, topical medications traditionally have been first-line in the glaucoma treatment algorithm, as no other minimally invasive treatment alternatives existed. In recent years, however, novel interventional therapies-including sustained-release drug-delivery platforms, selective laser trabeculoplasty, and micro-invasive glaucoma surgery procedures-have made it possible to intervene earlier without relying on topical medications. As a result, the topical medication-first treatment approach is being reevaluated in an overall shift toward earlier more proactive interventions.

Optic disc cupping after circumpapillary Pd-103 slotted plaque radiation therapy.

OBJECTIVE: To investigate vascular and morphologic optic disc changes after slotted plaque radiation therapy for choroidal melanoma involving the optic disc. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Thirty-nine patients with choroidal melanoma involving the optic nerve. METHODS: Each melanoma was treated with palladium-103 slotted plaque brachytherapy (incorporating and/or surrounding the optic nerve sheath) between 2005 and 2019. Imaging of the optic nerve before and after radiation allowed for documentation and evaluation of optic nerve pallor and cup-to-disc ratio (CDR) changes. Optical coherence tomography (OCT) CDR measurements and intraocular pressure (IOP) were recorded pretreatment and at follow-up. Of these patients, 22 also had OCT angiography (OCT-A) images with sufficient quality for evaluation of blood vessel density and length. Differences in cup-to-disc measurements were correlated with changes in OCT-A-measured vessel density and length. RESULTS: Following slotted plaque radiation therapy, there was no significant increase in IOP or optic nerve pallor. OCT and colour photography revealed significant increases (both p < 0.001) in CDR from pretreatment to the last follow-up. Increased CDRs on OCT were significantly correlated to OCT-A-measured change in vessel length (p = 0.027). Similarly, increased CDR ratios on fundus photography were significantly correlated with OCT-A-measured change in vessel density (p = 0.043) and length (p = 0.019). CONCLUSION: Fundus photography and OCT measurements revealed increased optic disc cupping following slotted plaque radiation therapy. Cupping was associated with OCT-A evidence of synchronous progressive peripapillary vascular occlusion and attenuation. Therefore, slotted plaque radiation-induced peripapillary and papillary ischemia was associated with increased CDR ratios and optic disc cupping.

Surface epithelialization of the type I Boston keratoprosthesis front plate: immunohistochemical and high-definition optical coherence tomography characterization.

BACKGROUND: The aim of this work is to characterize a transparent tissue layer partially covering the anterior surface of the type I Boston permanent keratoprosthesis front plate in four patients. METHODS: The tissue over the front plate was easily scrolled back as a single transparent layer using a sponge. In two cases, histopathologic analysis was undertaken and immunofluorescent staining with a cytokeratin 3-specific antibody was performed. The relationship of the tissue to the keratoprosthesis device was further characterized using spectral domain high-definition optical coherence tomography (HD-OCT). RESULTS: Histopathologic analysis revealed the tissue to be non-keratinized squamous epithelium. No goblet cells were seen, suggesting the cells were of corneal, and not conjunctival, epithelial origin. Immunofluorescent staining of all cells was positive for cytokeratin 3, a protein strongly associated with corneal epithelium. The tissue was easily discerned by HD-OCT and was of substantial thickness near the external junction between the keratoprosthesis device and the carrier corneal tissue. In three cases, visual acuity was unaffected by the presence or absence of this tissue. In one case, a prominent tissue margin temporarily obscured the visual axis and reduced visual acuity; this resolved with mechanical central debridement and has not recurred. CONCLUSIONS: The transparent tissue layer covering the anterior surface of the type I Boston keratoprosthesis front plate was found to represent non-keratinized squamous epithelium, most likely of corneal epithelial origin. This potentially represents a further step in bio-integration of the keratoprosthesis device. In particular, epithelial coverage of the critical junction between the device and the carrier corneal tissue might serve an important barrier function and further reduce the incidence of infection and extrusion of the type I Boston permanent keratoprosthesis.

Goldmann applanation tonometry compared with corneal-compensated intraocular pressure in the evaluation of primary open-angle Glaucoma.

BACKGROUND: To better understand the role of corneal properties and intraocular pressure (IOP) in the evaluation of primary open-angle glaucoma (POAG); and to determine the feasibility of identifying glaucomatous optic neuropathy (GON) using IOP corrected and uncorrected for corneal biomechanics. METHODS: Records from 1,875 eyes of consecutively evaluated new patients were reviewed. Eyes were excluded if central corneal thickness (CCT) or Ocular Response Analyzer (ORA) measurements were unavailable. Presence or absence of GON was determined based on morphology of the optic disc, rim and retinal nerve fiber layer at the time of clinical examination, fundus photography and Heidelberg Retinal Tomography. Goldmann-applanation tonometry (GAT) in the untreated state was recorded and Goldmann-correlated (IOPg) and corneal-compensated IOP (IOPcc) were obtained using the ORA. Glaucomatous eyes were classified as normal or high-tension (NTG, HTG) using the conventional cutoff of 21 mm Hg. One eligible eye was randomly selected from each patient for inclusion. RESULTS: A total of 357 normal, 155 HTG and 102 NTG eyes were included. Among NTG eyes, IOPcc was greater than GAT (19.8 and 14.4 mm Hg; p < 0.001) and the difference between IOPcc and GAT was greatest for this subgroup of patients with NTG (p ≤ 0.01). The maximum combined sensitivity and specificity for detection of GON occurred at 20.9 mm Hg for GAT (59%, 90%) and 18.4 mm Hg for IOPcc (85%, 85%) and the area under the curve was greater for IOPcc (0.93 vs. 0.78; p < 0.001). CONCLUSIONS: IOPcc may account for measurement error induced by corneal biomechanics. Compared to GAT, IOPcc may be a superior test in the evaluation of glaucoma but is unlikely to represent an effective diagnostic test.

A Review of Excisional Goniotomy Performed with the Kahook Dual Blade for Glaucoma Management.

Aim: To review the published literature describing clinical outcomes of excisional goniotomy using the Kahook Dual Blade (KDB) for the management of glaucoma. Background: A family of less invasive glaucoma procedures-including excisional goniotomy with the KDB-has been developed to provide moderate reductions in intraocular pressure and/or medication burden in eyes with therapeutic needs that may not warrant the risks associated with more traditional procedures such as trabeculectomy and tube-shunt implantation. This review's goal is to synthesize the existing literature into a compendium of excisional goniotomy's indications, technique, efficacy and safety outcomes, and optimal place in glaucoma management. Review results: Excisional goniotomy with the KDB effectively lowers IOP and reduces the medication burden in eyes with POAG and other forms of glaucoma across the spectrum of both baseline IOP and disease severity. The procedure exhibits a safety profile that is on par with other angle-based surgical interventions and enhanced safety compared to filtration procedures. It can be performed by comprehensive ophthalmologists as well as glaucoma specialists. This procedure as a standalone operation delivers IOP reductions consistent with filtration surgery, and in combination with cataract surgery delivers both IOP and medication reductions at least as great as other minimally invasive procedures. Conclusion: Given the broad base of evidence supporting its use in a wide variety of clinical scenarios, excisional goniotomy with the KDB can play a meaningful role in the achievement of patient-specific glaucoma therapy goals. Clinical significance: These aggregate findings support the efficacy and safety of excisional goniotomy with the KDB and clarify the patient profiles best suited for this procedure. How to cite this article: Dorairaj S, Radcliffe NM, Grover DS, et al. A Review of Excisional Goniotomy Performed with the Kahook Dual Blade for Glaucoma Management. J Curr Glaucoma Pract 2022;16(1):59-64.

Outcomes of Sutureless Ahmed Glaucoma Valve Surgery: A Retrospective Study.

INTRODUCTION: This study compared the safety and efficacy of sutureless Ahmed glaucoma valve surgery (AGV standalone) to sutureless AGV plus cataract surgery (AGV-CEIOL) in Black or Hispanic patients. METHODS: Records from Black or non-white Hispanic patients who received either AGV standalone or AGV-CEIOL from 2014 to 2019 at a Bronx, New York practice were reviewed. All surgeries were performed using a sutureless technique with Tisseel fibrin glue. Primary outcomes included failure (defined as intraocular pressure (IOP) > 21 mmHg, ≤ 5 mmHg, or reduced by < 20% after the first 3 months; loss of light perception; or reoperation for glaucoma), hypertensive phase, IOP changes, and medication changes. Secondary outcomes included postoperative complications and interventions. RESULTS: A total of 203 eyes that received AGV standalone (n = 78) or AGV-CEIOL (n = 125) were analyzed. Mean follow-up duration was 42.2 ± 17.5 months, with similar cohort-specific intervals (P = 0.68). Failure among AGV-CEIOLs (44.8%, n = 56) and AGV standalones (47.4%, n = 37) occurred at similar frequencies; log-rank testing indicated comparable 5-year survival (P = 0.56). Mean IOP among AGV-CEIOLs (15.8 ± 12.1 mmHg) was greater than standalones (8.6 ± 5.1 mmHg) at post-op day 1 (P < 0.001). The AGV-CEIOL group had a 60% lower odds of experiencing a hypertensive phase after adjustment for baseline group differences (P = 0.01). Five-year IOP reduction was similar between groups in the multivariable model (P = 0.45). There were no significant differences in medications (P > 0.05 at all time points) or in total complications (P = 0.28). More standalones required reoperation (39.7%, n = 31) compared to AGV-CEIOLs (21.6%, n = 24; P = 0.007). CONCLUSIONS: Sutureless AGV-CEIOL was noninferior to sutureless AGV standalone when performed in Black or non-white Hispanic patients. The combined group experienced the hypertensive phase less frequently despite higher day 1 IOP.

Impact of Heads-Up Display Use on Ophthalmologist Productivity, Wellness, and Musculoskeletal Symptoms: A Survey Study.

Purpose: To explore how ophthalmologist productivity, wellness, and musculoskeletal (MSK) symptoms are affected by heads-up display (HUD) use. Methods: A digital survey was emailed to the United States ophthalmologists. Questions covered topics including MSK health, surgical output, work hours, wellness hours, and factors related to HUD use. Results: One hundred and forty-four ophthalmologists responded, and 99 completed all eligible questions. HUDs were utilized by 33 respondents, 29 of whom submitted complete surveys. HUD users worked 353 more hours annually (P = 0.01) and performed 673 more cases (P = 0.07) than nonusers. MSK symptom presence (P = 0.79), severity (P = 0.80), and frequency (P = 0.86) were independent of use. Over half (n = 16/29) of users identified symptomatic improvement attributable to the device, mostly in the cervical and lumbar regions. Mean job stress was moderate-severe for both users and nonusers (P = 0.10), and there was no significant difference in wellness hours (P = 0.44). Retina specialists (P = 0.02) and males (P = 0.03) were more likely to have operated with the technology. Nearly half of heads-up surgeons (n = 12/29) had obtained new equipment to target MSK symptoms, versus 1.4% of nonusers (n = 1/70; P = 0.0009). Most of those who operated with HUDs would recommend them to others (69.0%, n = 20/29), but 44.8% (n = 13/29) indicated ergonomic challenges. Primary concerns included awkward viewing angles, setup difficulties, and a lack of access. Conclusions: HUD surgeons reported greater work output versus nonusers without significant compromises in wellness or MSK health. User feedback suggests that the technology may lessen neck and low back pains, but barriers including cost and system inconveniences may impede adoption.

Peripapillary choroidal thickness in glaucoma measured with optical coherence tomography.

As choroidal changes have been suggested in glaucoma, we examined peripapillary choroidal thickness (CT) in patients with and without primary open-angle glaucoma (POAG) using spectral-domain optical coherence tomography (SD-OCT). We collected measurements retrospectively on 70 eyes of 70 patients consecutively undergoing SD-OCT. POAG (n = 31) and suspect eyes (n = 39) had two reliable and repeatable Humphrey 24-2 visual fields with glaucoma hemifield test outside or within normal limits, respectively. A 360-degree peripapillary scan was performed using the standard protocol for retinal nerve fiber layer (RNFL) assessment. Using provided software, two independent masked investigators manually segmented CT as the area of visible choroidal vasculature. Agreement between investigators was determined using Lin's concordance correlation coefficient (CCC). A single masked observer determined clock hours of parapapillary atrophy (PPA) and the presence of ßPPA for each optic nerve quadrant. Correlation between RNFL and CT was assessed; two-sample t-tests were used to determine differences in RNFL and CT between POAG and suspect eyes; and linear regression was used to model changes in RNFL and CT. We found that independent measurements of CT by two observers were highly correlated (Lin's CCC for global CT; ρ(c) = 0.93, p < 0.001). RNFL and CT measurements were not significantly correlated for any peripapillary location (|r| ≤ 0.15, p ≥ 0.22). Global CT (ß = -1.94, 95% confidence interval [CI] -2.76, -1.13) but not RNFL thickness (ß = -0.18, 95% CI -0.58, 0.22) decreased significantly with age. Compared to suspect eyes, eyes with POAG had significantly thinner RNFL measurements at all locations (p ≤ 0.005) but CT measurements did not differ between groups for any location (p ≥ 0.13). Adjusting for glaucoma status and age, total (ß = 3.15 95% CI -0.24, 6.53) and ß clock hours of PPA (ß = 1.33, 95% CI -1.72, 4.38) were not significantly associated with global CT; the spatial distribution of PPA was not associated with underlying CT, though PPA was graded subjectively and may have been subject to spatial mismatch with a singular peripapillary eccentricity on SD-OCT. We conclude that eyes with POAG did not demonstrate reduced CT nor was there a correlation between RNFL and CT maps. This study does not support the use of CT assessment in glaucoma diagnosis or management.

Digital Survey Assessment of Factors Associated with Musculoskeletal Complaints Among US Ophthalmologists.

PURPOSE: To quantify features of musculoskeletal (MSK) complaints among US ophthalmologists and analyze factors related to symptom severity. METHODS: Cornea, glaucoma, retina, and comprehensive practitioners were invited to complete a web-based survey via email. Data on demographics, practice and procedural volumes, wellness activities, job stress, MSK health, the Total Disability Index (TDI), and ergonomics were collected. Significance testing was performed to evaluate factors related to TDI score. RESULTS: Of the 245 ophthalmologists contacted, 58.8% (n = 144) responded at least in part to the survey. Pain episodes were reported in 81.4% (n = 83) of 102 respondents, with 48.1% (n = 49) experiencing daily or weekly attacks. The neck, low back, and shoulders were commonly affected, yet only 57.1% (n=20) of those with shoulder pain reported a corresponding diagnosis. The mean TDI score was 6.2 ± 7.3%, indicating minimal disability related to the spine. Demographics, volume metrics, and wellness hours were each not significantly associated with TDI score (p > 0.05). Higher job stress ratings were reported by those who experienced more frequent pain attacks (p = 0.02) and those with higher TDI scores (p = 0.001). Greater difficulty with clinic, laser, and surgery job tasks was observed in respondents with higher TDI scores (p < 0.001, p = 0.005, and p < 0.001) and more bodily pain locations (p = 0.002, p = 0.002, and p = 0.001). Respondents who pursued practice modifications (p = 0.03) and treatments (p = 0.01) to reduce or prevent pain had higher mean TDI scores, and 94.2% of respondents (n = 97) were interested in learning more about ergonomics. CONCLUSION: Mild MSK complaints were highly prevalent among the surveyed ophthalmologists, and a similar trend could be expected for other US ophthalmologists. Greater frequency and severity of pain may contribute to physician burnout. There may be underdiagnosis of MSK pathology yet also high demand for ergonomic strategies and MSK treatments, suggesting a need for practical solutions.

Comparison of Safety and Efficacy Between Ab Interno and Ab Externo Approaches to XEN Gel Stent Placement.

PURPOSE: To compare the safety and efficacy of two different techniques for implantation of the XEN Gel Stent, a minimally invasive surgical device for the treatment of refractory glaucoma. METHODS: A retrospective chart review of eyes that received ab interno or ab externo XEN Gel Stent placement from February 2017 to October 2019 was conducted. A single surgeon (NMR) performed all operations. Eyes that received the XEN implant concomitant with a glaucoma drainage device insertion or that were lost to 6-month follow-up were excluded. Intraocular pressure (IOP) change, change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes compared between groups. RESULTS: Fifty eyes that underwent ab interno placement and 30 eyes that underwent ab externo placement were studied. The ab interno cohort demonstrated a mean IOP reduction of 8.4 ± 1.7 mmHg (28.6% decrease) by 12 months, compared to a mean reduction of 12.8 ± 3.0 mmHg (40.1% decrease) in the ab externo group (p = 0.208). Mean reduction in medication use was 1.81 ± 0.29 medications in the ab interno group and 1.86 ± 0.37 in the ab externo group (p = 0.913). By 12 months, 58% of ab interno eyes had required 5-fluorouracil injection compared to 36.7% of ab externos (p = 0.105). Bleb needling was applied to 42% and 26.7% of the eyes, respectively (p = 0.231). A second glaucoma surgery was necessary for 20% of the ab interno cohort and 10% of the ab externo cohort (p = 0.351). CONCLUSION: There were no differences in outcomes between ab interno and ab externo placement of the XEN Gel Stent. Both approaches are safe and effective for lowering IOP.

The Effects of Glaucoma and Glaucoma Therapies on Corneal Endothelial Cell Density.

A healthy corneal endothelium is required for corneal clarity. Both the glaucoma disease state and its various forms of treatment can have adverse effects on the corneal endothelium. Both the presence of glaucoma and the magnitude of intraocular pressure elevation are related to endothelial cell loss (ECL). Topical medical therapy, laser procedures, and both traditional surgeries-trabeculectomy and tube-shunts-and newer minimally invasive glaucoma surgeries have variable effects on ECL. This review will summarize the reported effects of glaucoma and its treatment on ECL. Concerns for corneal endothelial cell health should be part of the decision-making process when planning glaucoma therapy for lowering intraocular pressure, with added caution in case of planned device implantation in eyes with preexisting ECL and low endothelial cell density at high risk for corneal endothelial decompensation.

The effect of trabeculectomy on intraocular pressure of the untreated fellow eye in the collaborative initial glaucoma treatment study.

PURPOSE: To describe the intraocular pressure (IOP) of the untreated fellow eye after unilateral trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS). DESIGN: Data collected from a prospective, multicenter, randomized clinical trial. PARTICIPANTS: Three hundred patients with newly diagnosed open-angle glaucoma enrolled at 14 centers in the United States who were randomized to initial trabeculectomy. METHODS: After baseline evaluation and randomization to initial trabeculectomy in the study eye, patients were evaluated at 3 and 6 months and at 6-month intervals thereafter. The IOP was measured by Goldmann applanation tonometry. All eyes included in the analysis were untreated fellow eyes, and the data were censored for potential IOP-lowering events in the fellow eye, including trabeculectomy, argon laser trabeculoplasty, or cataract extraction. Predictive factors for IOP response in the fellow eye to initial trabeculectomy in the study eye were analyzed using a linear mixed model. MAIN OUTCOME MEASURES: Intraocular pressure in the untreated fellow eye during follow-up. RESULTS: Although the IOP in the fellow eye was lower than baseline at 3, 6, 12, 18, and 24 months after trabeculectomy in the study eye, this decrease was statistically significant only at month 12 (mean decrease from baseline, 0.73 ± 3.37 mmHg; P = 0.0134). Predictive associations with higher IOP in the fellow eye during follow-up included higher baseline IOP (P < 0.0001), lower level of education (P = 0.0129), time (P = 0.0005), and the presence of other vascular disease (P = 0.0069). Patients who ultimately required fellow eye trabeculectomy (P < 0.0001) or argon laser trabeculoplasty (P<0.0001), but not cataract extraction (P = 0.4597) in the fellow eye, had lower IOPs during follow-up after these procedures. CONCLUSIONS: There was no evidence of a substantial effect of trabeculectomy on the IOP of the untreated fellow eye during follow-up. Trabeculectomy does not seem to decrease the mean IOP of the fellow eye, as suggested by some previous studies. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.