Aqueous misdirection syndrome: clinical outcomes and risk factors for treatment failure.

PURPOSE: To evaluate the outcomes of postoperative aqueous misdirection and factors predicting failure of interventions. METHODS: This retrospective study included 49 eyes from 47 patients with aqueous misdirection following glaucoma or cataract surgery. Resolution of aqueous misdirection (AM) was deepening of the central anterior chamber (AC) and intraocular pressure (IOP) ≤ 21 mmHg. The Cox proportional hazards regression model was used to evaluate risk factors for failure of various treatments. RESULTS: 10/49 eyes (20%) resolved with conservative management, and 39/49 eyes (80%) needed multiple intervention, of which 95% (37/39) eyes achieved resolution of aqueous misdirection. Pseudophakia predicted the need for multiple interventions with a hazard ratio of 2.391 (1.158-4.935), p = 0.02). Among the risk factors assessed for resolution of AM, longer axial length (HR: 0.61 (0.414-0.891), p < 0.01) and eyes with prior glaucoma surgery predicted resolution (HR: 0.142 (0.027-0.741), p < 0.01) and delayed presentation predicted failure (HR: 1.002 (1.0002-1.0031), p < 0.02). CONCLUSION: Pseudophakic eyes were more refractory and predicted the need for multiple interventions. Eyes with prior glaucoma surgery and those with longer axial length had achieved resolution faster, and delayed presentation was a risk factor for failure to resolve.

Development and evaluation of Order of Magnitude (OM): a virtual reality-based visual field analyzer for glaucoma detection.

PURPOSE: This study introduces the Order of Magnitude (OM), a cost-effective, indigenous, virtual reality-based visual field analyzer designed for detecting glaucomatous visual field loss. METHODS: The OM test employs a two-step supra-thresholding algorithm utilizing stimuli of 0.43°diameter (equivalent to Goldmann size III) at low and high thresholds. A comparative analysis was conducted against the Humphrey visual field (HVF) test, considered the gold standard in clinical practice. Participants, including those with glaucoma and normal individuals, underwent comprehensive eye examinations alongside the OM and HVF tests between April and October 2019. Diagnostic sensitivity and specificity of the OM test were assessed against clinical diagnoses made by specialists. RESULTS: We studied 157 eyes (74 glaucomatous, 83 control) of 152 participants. Results demonstrated a high level of reliability for both OM and HVF tests, with no significant difference observed (P = 0.19, Chi-square test). The sensitivity and specificity of the OM test were found to be 93% (95% CI 86-100%) and 83% (95% CI 72.4-93%), respectively, while the HVF test showed sensitivity and specificity of 98% (95% CI 93.9-100%) and 83% (95% CI 73.9-92.8%), respectively. CONCLUSION: These findings suggest that the OM test is non-inferior to the reference standard HVF test in identifying glaucomatous visual field loss.

Intraoperative challenges and outcomes of pediatric cataract surgery following glaucoma filtering surgery.

PURPOSE: To analyze the intraoperative challenges of cataract surgery in children, following glaucoma filtering surgery. METHODS: This was a retrospective study to analyze intra-op challenges and outcomes of pediatric cataract surgery in post-glaucoma filtration surgery eyes, between January 2007 and December 2019. RESULTS: We included 20 eyes of 16 children. The most common glaucoma surgery performed was trabeculectomy and trabeculotomy (14 eyes). The median age at the time of cataract surgery was 74.5 months. The most common cataract surgery performed was lens aspiration with posterior chamber intraocular lens implantation (LA + PCIOL) (9/20). The most common intraoperative challenge faced was difficulty in capsulorrhexis (ten eyes), followed by extension of primary posterior capsulotomy (six eyes). At the final follow up eight eyes had improvement in visual acuity, five eyes had stable visual acuity and five eyes had a drop in visual acuity. In 12/20 eyes IOL was implanted, nine eyes in-the-bag and three eyes had in ciliary sulcus. None of the IOLs in the bag had decentration of IOL. The median postoperative IOP (p = 0.12) and median number of postoperative AGM (p = 0.13) at 2 years remained stable compared to the preoperative values. The IOP remained well controlled in 4 eyes without anti-glaucoma medications and in 14 eyes with anti-glaucoma medications and none needed additional surgery for IOP control. Two eyes developed retinal detachment postoperatively. CONCLUSION: Cataract surgery in pediatric eyes with prior glaucoma surgeries, have challenges with capsulorrhexis and IOL stability. The visual outcomes were reasonably good so was the IOP control.

Outcomes of Ahmed glaucoma valve implantation and risk factors for graft failure in eyes with Descemet's stripping endothelial keratoplasty.

PURPOSE: The aim of this study was to assess the efficacy of Ahmed glaucoma valve (AGV) in eyes with Descemet's stripping endothelial keratoplasty (DSEK) and glaucoma and evaluate the risk factors for failure. METHODS: Retrospective interventional study included 27 eyes (27 subjects) that underwent AGV implantation following DSEK. The main outcome measure was AGV success, defined as IOP between 6 and 21 mmHg with or without topical antiglaucoma medications (AGMs). Secondary outcome measure was graft survival. Graft failure was defined as corneal edema for ≥ 1 month or irreversible graft opacity requiring intervention. RESULTS: Eighteen eyes (66.7%) had anterior chamber tube and 9 eyes (33.3%) had sulcus tube placement. Median follow-up was 1.2 years (interquartile range, IQR, 0.5-2.5 years). Following AGV implantation, the median IOP decreased significantly (p < 0.0001), median number of AGMs reduced significantly (p < 0.001) and median visual acuity was maintained (p = 0.76). Cumulative success probability of AGV was 75.8 ± 10.6% at 1 year, and 75.8 ± 10.6% at 2 years. For 24 clear grafts before AGV, estimates of success post-AGV were 100% at 1 year, 77.8 ± 10% at 2 years and 51.9 ± 16.4% at 3 years. Postoperative tube intervention was a borderline significant risk factor for graft failure (p = 0.05) with hazards ratio of 7.2; however, tube location was not associated with failure. CONCLUSIONS: AGV can be considered an effective surgical option for IOP control in eyes with DSEK and glaucoma. However, high risk of long-term graft failure in these eyes needs to be considered specially those eyes needing tube intervention.

Phacoemulsification versus Phacotrabeculectomy in Medically Controlled Primary Angle Closure Glaucoma with Cataract in an Indian Cohort: A randomized controlled trial.

PURPOSE: To compare the outcomes of phacoemulsification with phacotrabeculectomy in primary angle closure glaucoma (PACG) eyes with medically controlled intraocular pressure (IOP). METHODS: Prospective, randomized control trial including 33 eyes of 33 patients who underwent phacoemulsification (Phaco) and 37 eyes (37 patients) who underwent phacotrabeculectomy (PT). The primary outcome measure was survival defined as IOP control (IOP ≥ 6 and ≤ 21 mmHg without antiglaucoma medications (AGM) at different time points. Secondary outcome measures were the rate of visual recovery and complications. RESULTS: The mean age in years (PT: 58.5 ± 9.8, Phaco:61.6 ± 8.9; p = 0.16), preoperative mean deviation in decibel (PT: -18.7 ± 9.3; Phaco: -16.6 ± 7.9; p = 0.32) and the mean follow up in years (PT: 2.5 ± 1.8; Phaco: 2.8 ± 2.0; p = 0.63) were similar in the two groups. The mean preoperative AGMs were more in the PT group (PT: 2.13 ± 0.97, Phaco: 1.60 ± 0.78; p = 0.01). In both the groups the survival was similar at all-time points (PT: 78% at 1-year and 52% at 5-years, Phaco: 80% at 1 year and 59% at 5 years (P = 0.82). The postoperative visual acuity in LogMAR was significantly better in the Phaco group at 1 month (PT: 0.22 ± 0.38, Phaco:0.06 ± 0.07; p = 0.02). Postoperative AGM (p = 0.68) and rate of visual field progression PT: -0.46 ± 0.41 dB/year; Phaco: -0.38 ± 0.73 dB/year; p = 0.67) were similar in both groups. One eye in PT group developed malignant glaucoma which resolved with laser hyaloidotomy and cycloplegic therapy. CONCLUSIONS: More rapid visual recovery with similar IOP control and similar visual field stability favor phacoemulsification to phacotrabeculectomy in medically controlled PACG eyes with cataract.

Clinical characteristics of comorbid retinal dystrophies and primary angle closure disease.

PURPOSE: To assess the clinical characteristics of comorbid retinal dystrophies and primary angle closure disease. DESIGN: Retrospective study from January 1992 to June 2020. METHODS: This descriptive study included 92 eyes of 46 patients with comorbid retinal dystrophies and primary angle closure disease (PACD) that included eyes with primary angle closure suspect, primary angle closure and primary angle closure glaucoma. Demographic profile, clinical characteristics of PACD and its association with retinal dystrophies are described. RESULTS: The study included 46 patients (92 eyes). Males were majority, 63%. Mean (± standard deviation) age when retinal dystrophy was diagnosed was 29.6 ± 9.4 years and PACD was diagnosed at 32.23 ± 7.92 years. Mean BCVA at presentation was 1.07 ± 0.87 log MAR [95% confidence interval (CI) 0.87, 1.26]. Mean Intraocular pressure at diagnosis of glaucoma was 27 ± 16 mmHg (95% CI 23.5, 31.5 mmHg). The most common retinal dystrophy associated with PACD was retinitis pigmentosa (RP) followed by RP with retinoschisis. The hospital-based prevalence of PACD among all patients with RP and retinoschisis was 0.19% and 0.15% respectively. Laser peripheral iridotomy was performed in 74 eyes (80.5%). Glaucoma was managed medically in majority of the eyes (58 eyes, 63.04%) and minority required surgical management with trabeculectomy (11, 11.9%). CONCLUSION: Retinitis pigmentosa is the most common retinal dystrophy associated with PACD. Comorbid PACD in eyes with retinal dystrophies was observed in second to third decade of life. This calls for screening for angle closure in eyes with retinal dystrophies from second decade onwards to identify the comorbid PACD and treat or refer them appropriately.

Topiramate induced bilateral hypopyon uveitis and choroidal detachment: a report of two cases and review of literature.

BACKGROUND: Topiramate (TPM) is a drug commonly used by neurophysicians and psychiatrists for a plethora of indications. Topiramate has been reported to induce acute angle closure glaucoma as an adverse effect. However, there is limited literature on Topiramate causing hypopyon uveitis and intense ocular inflammation. It is imperative for ophthalmologists as well as physicians to be aware of the potential sight threatening ocular adverse effects of Topiramate. We report 2 rare consecutive cases of severe hypopyon uveitis and choroidal detachments after using Topiramate. CASE PRESENTATION: Two patients presented with sudden onset of angle closure, bilateral hypopyon uveitis and choroidal detachments. On reassessing a detailed treatment history, it was found that both patient were taking oral Topiramate which had been started 2 weeks before the onset of ocular symptoms. The bilateral hypopyon and angle closure were considered to be induced by Topiramate and the drug was discontinued. The patients were started on oral and topical steroids which led to resolution of hypopyon uveitis and choroidal detachments. The visual acuity improved and the intraocular pressure also got normalised in both the cases. CONCLUSIONS: Topiramate can lead to a bilateral hypopyon uveitis and severe ocular inflammation. An urgent cessation of topiramate along with topical and systemic steroids is required to prevent serious complications.

Outcomes of neovascular glaucoma in eyes presenting with moderate to good visual potential.

PURPOSE: To compare the disease characteristics and treatment outcomes of patients with neovascular glaucoma (NVG) presenting with visual acuity (VA) 6/60 or better in two different health systems. METHODS: Retrospective chart review of consecutive patients with NVG who presented between January 2016 to January 2018 in 5 tertiary-centres in India and one eye-specialist centre in London (UK) was performed. The baseline characteristics, treatment provisions, and visual outcomes in the India and UK cohorts were compared. RESULTS: At presentation, 18% (83 of 451) and 22% (59 of 270) of patients with NVG had VA 6/60 or better in India and the UK cohorts, respectively. The aetiologies of NVG were similar with proliferative diabetic retinopathy being the most common cause (60.9%, India; 64.4%, UK; p = 0.38). Previous panretinal photocoagulation was more prevalent in the UK cohort compared to the India cohort (94.9% versus 66.3%, respectively; p < 0.001). The mean number of intravitreal anti-VEGF injections per eye was higher in the Indian cohort (1.65 ± 0.97 versus 1.14 ± 1.02 injections; p < 0.001). The number of eyes with closed angles (36.9% India versus 30.5% UK; p = 0.45) and the number of eyes needing glaucoma interventions (52.1% India; 62.7% UK; p = 0.82) were similar in two cohorts. Among glaucoma surgeries, trabeculectomies were more commonly performed in the Indian cohort (23 vs 4; p < 0.001),while glaucoma drainage device surgeries were more prevalent in the UK cohort (18 vs 4 p < 0.001). After a median follow-up of 21 months (IQR 8.4-34.8 India; 24-36 months UK), favourable visual outcomes (vision stable or improved) were similar in both health systems (52.5% in the Indian cohort vs 43.4% in the UK cohort; p = 0.28). On multivariate regression analysis, the need for trans-scleral cyclophotocoagulation was associated with worse visual outcomes in both cohorts. CONCLUSIONS: The causes and clinical profile of neovascular glaucoma with presenting visual acuity 6/60 or better in India and the UK were similar. Only up to 50% of eyes achieved favourable visual outcomes with current management protocols in both health systems.

Glaucoma as the presenting sign of intraocular tumors: beware of the masquerading sign.

PURPOSE: To discuss the clinical presentation and management of intraocular tumors masquerading as primary glaucoma or non-tumor-related secondary glaucoma. METHODS: Retrospective chart review. RESULTS: Ten patients with unsuspected intraocular tumor were referred to glaucoma clinic with a diagnosis of primary glaucoma or non-tumor-related secondary glaucoma. The mean age at referral was 25 years (median, 22 years; range, 1 day to 58 years). Referral diagnosis included neovascular glaucoma (n = 6), congenital glaucoma (n = 3), and angle-closure glaucoma (n = 1). The significant clinical signs included corneal edema (n = 3), megalocornea (n = 3), iris neovascularization (n = 4), hyphema (n = 2), and pseudohypopyon (n = 2). The mean interval between the onset of symptoms and the establishment of accurate diagnosis was 4 months (median, 3 months; range, 0.5-13 months). Two patients underwent inadvertent trabeculectomy, and one patient underwent evisceration prior to definitive diagnosis. The final diagnosis included uveal melanocytoma (n = 2), ciliary body medulloepithelioma (n = 2), choroidal melanoma (n = 2), retinoblastoma (n = 1), retinal capillary hemangioblastoma (n = 1), choroidal schwannoma (n = 1), and uveal metastasis (n = 1). The treatment modalities included plaque radiotherapy (n = 1), enucleation (n = 6), palliative systemic chemotherapy (n = 1), a combination of enucleation, systemic chemotherapy, and external beam radiotherapy (n = 1), and one patient was lost to follow-up. There was no evidence of death over a mean follow-up period of 13 months (median, 5 months; range, 2 weeks to 7 years). CONCLUSION: Unilateral raised intraocular pressure, iris neovascularization, or both may be the presenting features of intraocular tumors. High degree of suspicion and a thorough examination reveals the definitive diagnosis.

Comparison of Scleral Tono-Pen Intraocular Pressure Measurements with Goldmann Applanation Tonometry.

SIGNIFICANCE: Measuring the intraocular pressure (IOP) on the sclera can be an alternative to conventional corneal measurement in eyes with scarred corneas. However, these measurements have to be evaluated prior in normal eyes. Our study aimed to evaluate scleral IOP using Tono-Pen and compared it with corneal Goldmann applanation measurements. PURPOSE: The aim of this study was to evaluate the ability of limbal and scleral Tono-Pen IOP readings to predict central corneal Goldmann applanation tonometry (GAT) readings in eyes with normal corneas. METHODS: In a cross-sectional study, 115 eyes of 115 patients attending a tertiary eye care center underwent GAT on the central cornea followed by Tono-Pen readings at the central cornea, at the limbus, and at the sclera. Bland-Altman plots were used to determine the agreement between different methods of IOP measurement. RESULTS: The median IOP (interquartile range) by GAT performed on the central cornea was 18 (16, 24) mmHg, and the IOP ranged from 10 to 54 mmHg. The median IOPs (interquartile range) by Tono-Pen obtained at central cornea, limbus, and sclera were 16 (13, 23), 23 (17, 28), and 33 (27, 44) mmHg, respectively. The Pearson correlation coefficient and the 95% limits of agreement between GAT readings and Tono-Pen readings at the central cornea were 0.9 (P < .001) and -4.9 to 8.74 mmHg, respectively. The correlation coefficient between GAT readings and Tono-Pen readings at the limbus and GAT readings and Tono-Pen readings at the sclera was 0.46 (P < .001) and 0.23 (P = .01), respectively. The 95% limits of agreement between these pairs of readings were -20.55 to 13.66 and -44.02 to 13.37 mmHg, respectively. CONCLUSIONS: This study showed limited ability of Tono-Pen readings obtained at the limbus and sclera to predict the central corneal GAT IOP readings in eyes with normal corneas at various IOP ranges.

Angiopoietin receptor TEK interacts with CYP1B1 in primary congenital glaucoma.

Primary congenital glaucoma (PCG) is a severe autosomal recessive ocular disorder associated with considerable clinical and genetic heterogeneity. Recently, rare heterozygous alleles in the angiopoietin receptor-encoding gene TEK were implicated in PCG. We undertook this study to ascertain the second mutant allele in a large cohort (n = 337) of autosomal recessive PCG cases that carried heterozygous TEK mutations. Our investigations revealed 12 rare heterozygous missense mutations in TEK by targeted sequencing. Interestingly, four of these TEK mutations (p.E103D, p.I148T, p.Q214P, and p.G743A) co-occurred with three heterozygous mutations in another major PCG gene CYP1B1 (p.A115P, p.E229K, and p.R368H) in five families. The parents of these probands harbored either of the heterozygous TEK or CYP1B1 alleles and were asymptomatic, indicating a potential digenic mode of inheritance. Furthermore, we ascertained the interactions of TEK and CYP1B1 by co-transfection and pull-down assays in HEK293 cells. Ligand responsiveness of the wild-type and mutant TEK proteins was assessed in HUVECs using immunofluorescence analysis. We observed that recombinant TEK and CYP1B1 proteins interact with each other, while the disease-associated allelic combinations of TEK (p.E103D)::CYP1B1 (p.A115P), TEK (p.Q214P)::CYP1B1 (p.E229K), and TEK (p.I148T)::CYP1B1 (p.R368H) exhibit perturbed interaction. The mutations also diminished the ability of TEK to respond to ligand stimulation, indicating perturbed TEK signaling. Overall, our data suggest that interaction of TEK and CYP1B1 contributes to PCG pathogenesis and argue that TEK-CYP1B1 may perform overlapping as well as distinct functions in manifesting the disease etiology.

False Passage of 5-0 Polypropylene Suture into Episcleral Vein during Gonioscopy-Assisted Transluminal Trabeculotomy.

Gonioscopy-assisted transluminal trabeculotomy (GATT) is a promising cost-effective minimally invasive glaucoma surgery (MIGS). The main advantage is safety with regards to low risk for hypotony and its related complications. However, the Schlemm's canal (SC) based procedures have a different set of complications, the most common being hyphema and transient intraocular pressure spike. The other rare complications being, the false passage of the suture by traversing the external wall of the SC into the suprachoroidal space or posterior chamber or breaching the internal wall of the SC into the anterior chamber. Although these complications are rare, knowledge about them is important not only for early identification but for prevention and management if they occur. Through this case report, we describe a rare complication where the suture had traversed through a dilated episcleral vein during GATT. To our knowledge, there has been no prior report of such a complication.

Clinical profile, demographic distribution, and management of Posner-Schlossman syndrome: An electronic medical record-driven data analytics from an eye care network in India.

PURPOSE: To describe the clinical profile, demographics, and management of Posner-Schlossman syndrome (PSS) in patients presenting to a multitier ophthalmology hospital network in India. METHODS: This cross-sectional hospital-based study included 3,082,727 new patients presenting between August 2010 and December 2021. Patients with a clinical diagnosis of PSS in at least one eye were included as cases. The data were collected using an electronic medical record system. RESULTS: Overall, 130 eyes of 126 (0.004%) patients were diagnosed with PSS. The majority of the patients were male (81.75%) and had unilateral (96.83%) affliction. The most common age group at presentation was during the fourth decade of life, with 46 (36.5%) patients. The overall prevalence was higher in patients from a higher socioeconomic status (0.005%) presenting from the metropolitan geography (0.008%) and in professionals (0.014%). A significant number of patients (108; 83.08%) had a raised intraocular pressure of >30 mm of Hg. The majority of the eyes had mild or no visual impairment (better than 20/70) in 99 (76.15%) eyes. Keratic precipitates were found in 59 (45.38%) eyes, anterior chamber cells in 43 (33.08%) eyes, and iris atrophy in seven (5.38%) eyes. The majority of eyes (127; 97.69%) had open angles on gonioscopy. The average duration of use of topical steroids was 1.70 ± 0.76 months, and the average duration of use of topical antiglaucoma medications (AGMs) was 1.66 ± 0.81 months, with 35 eyes (26.92%) requiring continued AGMs. Among the surgical interventions, trabeculectomy was performed in nine (6.92%) eyes and cataract surgery in five (3.85%) eyes. CONCLUSION: PSS more commonly affects males presenting during the fourth decade of life from higher socioeconomic status and is predominantly unilateral. The majority of the eyes have mild or no visual impairment, open angles, and require surgical intervention in a tenth of the eyes.

Intraocular pressure and gonioscopic findings in primary angle-closure disease in India-a big data study.

AIM: To describe the gonioscopic profile and intraocular pressure (IOP) in primary angle-closure (PAC) disease in patients presenting to a tertiary eye care network in India. METHODS: A cross-sectional hospital-based study that included 31 484 new patients presenting between 2011 and 2021. Patients with a clinical diagnosis of PAC/suspect/glaucoma were included. The data was collected from an electronic medical record system. RESULTS: PAC glaucoma (PACG) (47.55%) was the most common diagnosis followed by PAC (39.49%) and PAC suspect (PACS; 12.96%). Female preponderance (54.6%) was noted with higher mean age at presentation among males (P<0.0001). PACS and PAC showed the highest prevalence in 6th decade but PACG was higher at 7th decade. The probability of angle opening was 95.93%, 90.32% and 63.36% in PACS, PAC and PACG eyes respectively post peripheral iridotomy (PI). Plateau iris syndrome (PIS) was noted in 252 eyes and all showed post dilated rise of IOP. A post dilated IOP rise was also noted with 8.86%, 33.95% and 57.19% eyes with PACS, PAC and PACG respectively with IOP rise between 6-8 mm Hg across the disease spectrum. CONCLUSION: The superior quadrant is the narrowest angle and difficult to open with indentation and post PI. The probability of angle opening is less in PIS especially the complete variety along with post dilated IOP rise. The post dilated IOP rise in angle closure eyes warrants a careful dilatation, especially with PIS.

Congenital glaucoma in brittle cornea syndrome type 2 with a novel mutation in PRDM5.

Brittle cornea syndrome type 2 is associated with corneal thinning, joint hypermobility, dental and skeletal issues, osteal fragility, and deafness. We present a rare association of congenital glaucoma with brittle cornea syndrome type 2 and keratoglobus in a patient with a novel PRDM5 gene mutation. Our case underscores the importance of genetic testing for early clinical diagnosis and tailored surgical approaches.

Reverse pupillary block with pigment dispersion and elevated intraocular pressure following bilateral phakic intraocular lens implantation.

The authors describe a case of reverse pupillary block with pigment dispersion following sequential phakic intraocular lens (pIOL) implantation for high myopia, in a young female patient. The intraocular pressure (IOP) elevation began 3 weeks postoperatively, for which Nd-YAG laser peripheral iridotomies (PIs) were attempted elsewhere. Despite maximum medical therapy, the IOP was uncontrolled. She was referred to our institute for further management. Examination showed anteriorly displaced iris-pIOL diaphragm, iris pigment dispersion and raised IOP. The PIs were incomplete. Based on clinical evaluation and investigations, we concluded that the excess area of contact of the posterior iris over the pIOL caused a reverse pupillary block and pigment dispersion. The IOPs were controlled by repeating laser iridotomies and with medical therapy. Subsequently, the patient developed a low lens vault leading to bilateral cataract. Sequential explantation of the pIOL along with cataract extraction was performed and her vision was restored.

Glaucoma and refractive surgery: A comprehensive review.

The global surge in refractive surgeries, particularly among myopic individuals, has elicited concerns regarding potential inaccuracies in the measurement of intraocular pressure (IOP) post surgery, primarily associated with central corneal thinning. The incidence of elevated IOP after intraocular refractive surgeries is higher than expected and is multifactorial. Myopic eyes have a higher susceptibility to both primary and secondary glaucoma. Consequently, meticulous preoperative screening for glaucoma is imperative, coupled with systematic postoperative follow-up and evaluation. This comprehensive review analyses the etiology, mechanisms, and therapeutic strategies for managing elevated IOP following refractive surgery. We propose an algorithm to summarize the causative factors of elevated IOP and formulate effective interventions in these instances.

GAPO syndrome: a novel variant in ANTXR1 gene.

BACKGROUND: GAPO syndrome is a rare autosomal recessive disorder characterized by the acronym of growth retardation, alopecia, pseudo-anodontia and progressive optic atrophy. While the genetic alteration of the ANTXR1 gene has been known for its cause, the full range of its clinical and genetic manifestations is not well explored due to the syndrome's extreme rarity. MATERIALS/METHODS: We report two children born to a non-consanguineous parent in India with classical features of GAPO syndrome. The whole exome sequencing analysis (WES) was performed in both siblings, and the parent's genetic and clinical status was determined. The identified variation was characterized in silico using homology-based protein modelling. RESULTS: In WES analysis, a homozygous ANTXR1 gene indel variant c. 151_152 + 2delAAGT (p.Lys51fs) was identified in both siblings. The parents were identified as the carriers of the ANTXR1 variant. Additionally, they also displayed mild GAPO-related facial and glaucomatous features. In silico analysis and homology-based ANTXR1 protein structure illustrate a frameshift and the subsequent premature truncation of the protein. CONCLUSIONS: Our reports contribute to the comprehension of GAPO syndrome within the Indian context describing an ANTXR1 novel variant causing premature protein truncation. WES-based genetic testing can significantly aid in expertly diagnosing GAPO syndrome. In the present case scenario, a variable penetrance of ANTXR1 variation was acknowledged as the carrier parents also had a mild degree of GAPO-related features. Future reports that include parental clinical diagnosis can offer further insights in this context.

Profile of Newly Diagnosed Childhood Glaucoma in India: Indian Childhood Glaucoma Study (ICGS) Group 1.

OBJECTIVE: To report the profile of newly diagnosed childhood glaucoma using the Childhood Glaucoma Research Network (CGRN) classification, presenting over 1 year from across centers in India. DESIGN: Prospective observational multicentric study. SUBJECTS: Newly diagnosed children aged < 18 years diagnosed with childhood glaucoma according to CGRN criteria presenting between January and December 2019 to 13 centers across India. METHODS: All children underwent a comprehensive ocular examination, including examination under anesthesia for younger children, and were diagnosed with childhood glaucoma as per CGRN. Data were entered in a standard Excel chart. Refraction and visual acuity assessments were done when feasible. MAIN OUTCOME MEASURES: The profile of newly diagnosed childhood glaucoma in different parts of India and the severity of glaucoma at presentation. RESULTS: A total of 1743 eyes of 1155 children fulfilled the definition of glaucoma and were analyzed. Primary congenital glaucoma (PCG) comprised the single largest group (34.4%), most of which were infantile onset (19%). Neonatal-onset PCG comprised 6.2% of all glaucoma. Secondary glaucoma constituted 53.4% of all glaucoma, one-half of which were acquired conditions (28%), followed by isolated ocular anomalies (14.7%), glaucoma after cataract surgery (6.7%), and glaucoma with nonacquired systemic diseases (4.5%). Of the 1743 eyes with glaucoma, all 3 parameters for severity grading were available in 842 eyes, of which 501 (59.5%) eyes presented with mild, 320 (38%) with moderate, and 21 (2.5%) with severe glaucoma. Nearly one-third of the children (28.5%) were not brought back for follow-up after the initial treatment given. CONCLUSIONS: Our study has one of the largest numbers of consecutive children with glaucoma classified according to the CGRN classification. Despite a widely diverse population, the profile of childhood glaucoma was relatively uniform across India. Childhood glaucoma is a significant problem in India, primarily treated in tertiary care hospitals. The data presented may be the tip of the iceberg because we have only reported the children who reached the hospitals offering treatment for this challenging disease. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.