Short-term outcomes of Mitomycin-C augmented phaco-trabeculectomy using subconjunctival injections versus soaked sponges: a randomized controlled trial.

OBJECTIVES: To determine whether subconjunctival Mitomycin-C (MMC) injections are as safe and effective as sponge-soaked MMC in phaco-trabeculectomy. METHODS: This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and an uncontrolled primary open-angle glaucoma. One hundred thirty-nine patients were recruited but 15 were ineligible for analysis. The patients were randomized into a sponge/injection group. All participants received a twin-site phaco-trabeculectomy. They were followed up on days 1, 15, 30, 3 months and 6 months post-operatively. A p-value < 0.05 was considered significant. INTERVENTIONS: Participants in the sponge group received an augmentation of their phaco-trabeculectomy with sponges soaked in a mixture of 0.04% MMC and 2% preservative-free Lignocaine in a 1:1 ratio, placed in the subconjunctival space for four minutes. Participants in the injection group received the same mixture as a subconjunctival injection, after surgical draping. RESULTS: There were 62 patients in each group. The groups had no significant differences in their baseline characteristics. The mean IOP at 6 months was significantly lower in the injection group (14.8 ± 3.7 mm Hg) than in the sponge group (17.1 ± 6.4 mm Hg) (p = 0.02). There was no notable difference in the complications or the final post-operative visual outcome but a significantly greater number of patients in the sponge arm required removal of the releasable suture (p = 0.001) and additional anti-glaucoma medications (p = 0.04) at six months post-operatively. CONCLUSIONS: Subconjunctival MMC achieves a lower IOP with fewer anti-glaucoma medications than sponge-soaked MMC at six months for twin-site phaco-trabeculectomy in primary open-angle glaucoma with no additional risks.

Long-term outcomes of Mitomycin-C augmented trabeculectomy using subconjunctival injections versus soaked sponges: a randomised controlled trial.

PURPOSE: To compare the safety and efficacy of subconjunctival injection of Mitomycin C(MMC) with sponge-applied MMC during trabeculectomy. METHODS: This prospective, randomised, interventional study was conducted on consecutive patients with uncontrolled glaucoma. 137 patients were randomised into an Injection group (Group 1, n = 66) and a sponge group (Group 2, n = 71). Trabeculectomy was performed in all patients who were followed up on days 1, 15, 30, 3 months, 6 months, 1 year, 2 years & 3 years postoperatively. Baseline & follow-up visits were compared to find out difference in the number of antiglaucoma medications (AGM), Intraocular pressure (IOP), and Best Corrected Visual Acuity (BCVA). In Group 1, the surgeon used MMC 0.2 mg/ml as subconjunctival injection and two separate semicircular surgical sponges soaked with MMC solution of 0.2 mg/mL were inserted subconjunctivally in Group 2. RESULTS: Mean preop IOP was 34.21 ± 13.3 mmHg & 34.17 ± 10.6 mmHg in group 1 & 2 respectively, which reduced to 11.34 ± 3.7& 12.57 ± 4.7 mmHg(6 months),11.97 ± 4.2 & 13.60 ± 5.3 mmHg(1 year),12.42 ± 4.4 & 11.77 ± 2.8 mmHg (2 years) &11.25 ± 3.2 & 11.81 ± 3.2 mmHg at final visit(P < 0.001 in both groups)with no significant difference between the groups. The mean number of preoperative AGM was 2.32 ± 0.7 & 2.32 ± 0.8 in group1 & 2 respectively which reduced to 0.78 ± 0.9 (P < 0.001) & 1.13 ± 1.1(P = 0.930) at 3 years. Overall success rates were 75.3% in group 1 and 70.7% in group 2 at 3 years(p = 0.512). Postoperative complications and the final post-operative visual outcomes were similar between the groups. CONCLUSION: Subconjunctival Injection of MMC is as safe and effective as sponge application with comparable surgical outcomes and complications in the long term.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma.

PURPOSE: To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma. METHODS: This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity. RESULTS: There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout. CONCLUSION: Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

"Long-term safety and efficacy of injection mitomycin C(MMC) versus sponge application in trabeculectomies".

AIMS: To compare the long-term safety and efficacy of subconjunctival injection mitomycin C(MMC) with conventional sponge applied MMC during trabeculectomy. METHODS AND MATERIAL: Retrospective analysis of 98 eyes of 90 patients who underwent trabeculectomy with Mitomycin C were divided into two groups, group 1- sponge (n = 52) and group 2- Injection(n = 46). Follow-up data were collected on day one, day 15, one month, three months, six months, one year, two years and three years. Data from baseline and follow-up visits were analyzed and compared to study the significant difference in intraocular pressure (IOP), number of antiglaucoma medications (AGM) and best corrected visual acuity (BCVA) . P-value of <0.05 was considered statistically significant. RESULTS: Mean preop IOP was 34.61 ± 13.3 mmHg in group one and 33.07 ± 9.6 mmHg in group two, which reduced to 11.43 ± 3.2 and 11.59 ± 3.2 mmHg at three years (p < 0.001 in both groups) with no significant difference between the groups. Mean number of preoperative AGM was 2.28 ± 0.8 and 2.42 ± 0.7 in group one and two respectively which reduced to 1.19 ± 1.1(p = 0.405) and 0.88 ± 0.9(p = 0.001) at three years. Complete and overall success rates (complete + qualified) were 59.3% and 78.9% in group one and 60.9% and 80.4% in group two at three years. No statistically significant difference was found in complication rates, post-operative interventions, and final visual outcome in both groups. CONCLUSIONS: Subconjunctival Injection MMC was a safe and effective alternative to sponge application with comparable long term surgical outcomes.

Myocilin Mutation N480K Leads to Early Onset Juvenile and Adult-onset Primary Open Angle Glaucoma in a Six Generation Family.

PRCIS: A pathogenic autosomal dominant MYOC mutation N480K detected in 6 generations of an Indian family is primarily responsible for juvenile open angle glaucoma (JOAG) and adult-onset primary open angle glaucoma (POAG), emphasizing the importance of screening this mutation at a younger age. PURPOSE: To screen myocilin mutations in a large South Indian family with early-onset JOAG and adult-onset POAG. METHODS: In a large South Indian family with 20 members, 8 members diagnosed as JOAG, 7 members as POAG, 4 members as JOAG suspect, and 1 member as POAG suspect were screened for myocilin ( MYOC) mutations using Sanger sequencing. Whole exome sequencing was performed on clinically suspected JOAG/POAG individuals. RESULTS: Myocilin gene mutation N480K (c.1440C>G) was detected in 20 family members, including proband, of whom 8 were JOAG and 7 were POAG patients, 3 were JOAG suspects, and 2 were unaffected. Among the unaffected carriers, 1 was less than 5 years old, and another was 25 years old. The earliest to develop the disease was a 10-year-old child. The penetrance of the mutation was 95% over 10 years of age. This family had JOAG/POAG suspects with no N480K MYOC mutation, and they were further screened for other mutations using whole-exome sequencing. Polymorphisms CYP1B1 L432V and MYOC R76K were detected in 3 JOAG/POAG suspects, and among these 3, one had another CYP1B1 polymorphic variant R368H. The presence of the CYP1B1 polymorphism along with an MYOC polymorphic variant among the JOAG/POAG suspects needs additional studies to explore their combined role in the onset of glaucoma. CONCLUSIONS: This study reveals that MYOC mutation is primarily responsible for JOAG and adult-onset POAG in a family, emphasizing the importance of screening for this mutation at a younger age for early treatment.

Early outcomes of 5-0 Prolene gonioscopy-assisted transluminal trabeculotomy combined with phacoemulsification in eyes of Indian glaucoma patients.

PURPOSE: To study the early postoperative efficacy and safety of 5-0 Prolene gonioscopy-assisted transluminal trabeculotomy (GATT) combined with phacoemulsification in Indian eyes. METHODS: This was a prospective, interventional study. Patients with primary and secondary glaucoma who underwent GATT combined with phacoemulsification (Phaco-GATT) or standalone GATT were included. All patients were evaluated on postoperative days 1, 15, and 30, as well as 3 months and 6 months postoperatively. Baseline and follow-up visits were compared to determine the significant difference in the number of intraocular pressure (IOP), antiglaucoma medications (AGM), and best corrected visual acuity (BCVA). Other outcome measures included surgical success, complications, and interventions. A P value of < 0.05 was considered statistically significant. RESULTS: One hundred and five eyes (95 patients) were included. Seventy-five eyes underwent GATT along with phacoemulsification and 30 eyes underwent GATT. In the Phaco-GATT group, the mean IOP reduced significantly from 17.71 ± 6.85 to 12.29 ± 4.44, 12.33 ± 4.44, and 12.18 ± 3.49 mmHg and in the GATT group, it reduced from 21.67 ± 11.42 mmHg to 16.38 ± 8.42, 16.47 ± 10.26, and 13.10 ± 3.25 mmHg at 1, 3, and 6 months, respectively (P < 0.001). The number of AGM also significantly reduced from 1.67 ± 1.22 to 0.41 ± 0.87 and 0.34 ± 0.82 in the phaco-GATT group and from 2.63 ± 1.19 to 0.67 ± 1.09 and 0.60 ± 1.25 in the GATT group at 3 and 6 months, respectively (P < 0.001). Complete success (IOP > 6-≤21 mmHg/20% reduction without AGM) was 96.7% in the Phaco-GATT group and 91.2% in the GATT group. BCVA improved from log of minimum angle of resolution 0.30 to 0.00 (P < 0.001) in phaco-GATT group. Hyphema was the most common complication. Macrohyphema (>1 mm) was seen in six patients, out of which two patients required anterior chamber wash. IOP spikes (>30 mmHg) were seen in three patients. CONCLUSION: In Indian eyes, GATT combined with phacoemulsification and standalone GATT are efficacious and safe with good surgical outcomes.

Glaucoma awareness, anxiety and its impact on patients undergoing visual field testing and optical coherence tomography.

PURPOSE: To assess the effect of Glaucoma awareness, knowledge, and anxiety on patients under visual field analysis by Humphrey's visual field analyzer (HFA) and optical coherence tomography(OCT). METHODS: This prospective comparative cohort study included glaucoma patients undergoing HFA (Group A)(n = 150) and OCT(Group B) (n = 150). Each group consisted of 75 newly diagnosed patients and 75 patients who were on follow-up. Participants completed State trait anxiety inventory form Y2(STAI) before and after the test to assess pre-test and intra-test anxiety. Another validated and structured questionnaire was used to assess patient awareness and knowledge of glaucoma. Anxiety scores were used to make correlations and comparisons between the two groups and also against visual field reliability indices. The impact of awareness on anxiety scores and its correlation with reliability indices were also determined. RESULTS: Overall pretest and intratest anxiety scores in patients undergoing HFA were 52.39(9.5) and 52.45(8.6)and OCT 53.04(8.0) and 53.83(8.2) respectively.Pretest anxiety was less in follow-up patients of both groups(Group A-51.04,Group B-52.72).There was no statistically significant difference between the groups(pretest p = 0.52,Intratest p = 0.15). Anxiety score was found to be significantly high in female participants(54.07,p = 0.01)and those without awareness(p < 0.001). Patients with education of graduation and above in group B had significantly lower anxiety scores(p = 0.007). CONCLUSION: Anxiety levels induced by both diagnostic modalities HFA and OCT appear to be similar and it does not affect the reliability indices.Anxiety score was higher in female participants and participants lacking disease awareness.

Ophthalmological examination and imaging features that better predict risk of Angle Closure in siblings.

OBJECTIVE: Characteristics of individuals with angle closure may be useful in targeted screening of family members. Here, we assess if findings gathered during examination and imaging of patients with a known angle closure diagnosis (probands) could better determine the risk of angle closure in the patients' siblings. DESIGN: Cross-sectional study of patients with known angle closure and their siblings. SUBJECTS: Participants, and Controls: South Indian patients (probands) 30 years and older with open angles, suspect primary angle closure (PACS), or primary angle closure/primary angle closure glaucoma (PAC/PACG), and a biological sibling age 30 years or older (n=292 proband/sibling pairs). METHODS: Demographic data, relevant ocular history, and a comprehensive ophthalmic examination with Anterior Segment Optical Coherence Tomography (ASOCT) were obtained. Three clinically relevant models were created to analyze the contribution of specific proband factors in predicting sibling angle closure diagnosis, using demographic (age, gender), ocular exam (gonioscopy, optic nerve exam, visual acuity, intraocular pressure [IOP]), and ASOCT features to improve prediction beyond proband diagnosis alone evaluated by log likelihood ratio testing and statistical comparison of receiver operating characteristics (ROC). MAIN OUTCOME MEASURES: Sibling angle closure diagnostic accuracy. RESULTS: Demographic and ocular exam metrics did not improve the prediction of sibling angle closure for all three outcomes (sibling diagnosis: (1) PACS/PAC/PACG vs OA, (2) PAC/PACG vs PACS/OA, and (3) PAC/PACG vs PACS), adding no model improvement when compared to diagnosis alone. Models adding ASOCT metrics to the prior model including proband diagnosis, demographics and ocular exam measures led to significantly improved prediction of 2 of the 3 angle closure outcomes. Specifically, improvement was noted via likelihood ratio testing for prediction of PAC/PACG vs PACS/OA (p=0.01), or PAC/PACG vs PACS (p=0.001). For all 3 angle closure outcomes, ROC comparisons demonstrated significant improvement in AUC between the three models predicting sibling outcomes, demonstrating an increase in AUC with each successive nested model across all 3 sibling angle closure outcomes. CONCLUSIONS: Structural features of eyes with angle closure may assist in stratifying the risk of angle closure in patients' siblings. Further studies should consider evaluating this approach to achieve more targeted screenings.

Comparative study of surgical outcomes of twin-site phacotrabeculectomy with mitomycin C in primary open-angle glaucoma versus primary angle-closure glaucoma.

Purpose: To compare the surgical outcomes of twin-site phacotrabeculectomy with Mitomycin C (MMC) in primary open-angle glaucoma (POAG) versus primary angle-closure glaucoma (PACG). Methods: Prospective, comparative, observational study. Patients with visually significant cataract and primary glaucoma were divided into two groups: POAG and PACG. They underwent twin-site phacotrabeculectomy with MMC and followed up on days 1, 15, 1 month, 6 months, and 12 months. Baseline and follow-up visits were compared to find the differences in intraocular pressure (IOP), antiglaucoma medications (AGM), success rates, anterior chamber depth (ACD), and axial length (AXL). Results: There were 50 eyes each in POAG and PACG groups. Mean IOP reduction from baseline to 12 months (21.22 ± 6.0 to 11.40 ± 2.8-POAG group vs 24.16 ± 7.6 to 12.42 ± 3.2-PACG group) was statistically significant in both groups (P < 0.001), but no significant difference between groups (P = 0.095). There was a statistically significant decline in the number of AGM in POAG [1.66 (0.7) to 0.38 (0.7), P < 0.001] and PACG [2.10 (0.7) to 0.70 (0.8), P < 0.001]; the decline was more in POAG (P = 0.012) at last visit. Probability of overall (complete and qualified) success at 12 months postop was 72.0% [95% confidence interval (CI): 57.4-82.4] in PACG and 84.0% (95% CI: 70.5-91.7) in POAG group. There was a significant increase in ACD and a decrease in AXL in both groups (P < 0.001). More interventions were required in the PACG group (38, P = 0.012). Conclusion: Phacotrabeculectomy with MMC causes a significant reduction in IOP and improvement in biometric parameters in both POAG and PACG. Patients with PACG required more postoperative interventions, while a lesser number of antiglaucoma medications were needed in POAG patients.

Lowering of intraocular pressure after phacoemulsification in primary open-angle and angle-closure glaucoma: Correlation with lens thickness.

PURPOSE: To assess anterior chamber configuration changes during phacoemulsification in primary angle-closure suspect (PACS/PAC) and primary open-angle glaucoma (POAG). METHODS: Prospective observational comparative study of anterior segment optical coherence tomography (AS-OCT) findings before and after phacoemulsification on three groups of patients (PACS/PAC, POAG, and controls). Data were collected over a period of 9 months. Main outcome measures included mean change in anterior chamber depth (ACD), angle opening distance (AOD), and trabecular iris space area (TISA). RESULTS: 153 patients (51 PACS/PAC, 51 POAG, and 51 controls) were included in the study. Change in all parameters (ACD, AOD at 500 um, and AOD at 750 um) between the groups demonstrated a greater change in PACS/PAC as compared to POAG and controls. AOD at 750 µm in the temporal quadrant, which has been considered to be having the highest correlation or best representation of the angle, increased in all groups after phacoemulsification (463.59 ± 10.99 vs. 656.27 ± 9.73 mm in PACS; 521.29 ± 16.36 vs. 674.37 ± 8.72 mm in POAG; 549.27 ± 12.40 vs. 702.82 ± 13.04 mm in controls, (P < 0.001). After phacoemulsification, intraocular pressure (IOP) decreased by 2.75 ± 1.17 mm Hg in PACS/PAC (P < 0.001), 2.14 ± 1.33 mm Hg in POAG and 1.90 ± 1.25 mm Hg in controls and it was statistically significant in the PACS group compared to control (P < 0.001). CONCLUSION: Phacoemulsification with intraocular lens implantation is associated with increase in the ACD and angle parameters and a corresponding decrease in IOP. Findings were more pronounced in PACS/PAC suggesting early phacoemulsification may be a treatment option in this group.

Surgically induced astigmatism following single site and twin site phacotrabeculectomy augmented with mitomycin C.

PURPOSE: To determine difference in surgically induced astigmatism (SIA), post-operative intraocular pressure (IOP) and axial length (AL) between single site and twin-site phacotrabeculectomy augmented with Mitomycin C (MMC). DESIGN: Prospective interventional randomised controlled study. METHODS: In a prospective interventional comparative study, eligible patients were scheduled for phacotrabeculectomy. They were randomised to either group A: single site or group B: twin-site phacotrabeculectomy with MMC 0.2 mg/mL. Axial length was measured by using Zeiss IOL master I, pre-operatively and at 1, 3, 6 and 12 months post-operatively. Corneal topography was performed using Bausch and Lomb Orbscan I pre-operatively and at 3, 6 and 12 months post-operatively to analyse surgically induced astigmatism. Vector analysis was used to analyse the surgically induced astigmatism. RESULTS: One hundred and eight eyes of which 55 patients in group A, and 53 patients in group B were enroled for vector analysis. The mean preoperative astigmatic vector power was +0.89 ± 0.4 D and +0.97 ± 0.5 D in group A and B respectively. The mean post-operative astigmatic vector power was +0.78 ± 0.4 D in group A and +0.96 ± 0.5 D in group B at the end of 12 months. Corneal topography showed post-operative superior flattening (51.8% at 3 months and 55.4% at 12 months) in group A (P = 0.072) compared to superior steepening (59.6% at 3 months and 61.5% at 12 months) in group B (P = 0.977). CONCLUSIONS: The two commonly used techniques of combined cataract and glaucoma surgery proved to be efficacious without significant difference in surgical induced astigmatism.

Agreement of findings of glaucoma screening between trained vision center technicians and glaucoma specialists at a tertiary hospital in South India.

Purpose: To study the agreement of findings of glaucoma screening between trained vision center (VC) technicians and glaucoma specialists in patients referred from VC to the glaucoma services of a tertiary eye care hospital in south India. Methods: This was a retrospective study comparing the findings of the VC technicians and the specialists of the glaucoma services in the base hospital, in patients referred from 13 VCs between January and June 2019. Medical records of 277 referred patients (out of 533 referrals) who attended the glaucoma clinic were analyzed. Results: Of the 277 patients, 111 (40%) were confirmed having glaucoma, 133 (48%) were suspects, 29 (10.4%) were normal, and four (1.4%) had other pathology. The mean age of the patients was 59.7 ± 13 years and 60.6% were females. There was no statistically significant difference between the mean intraocular pressure (IOP) measured (17 ± 7.2 mmHg at the VC and 18 ± 8.7 mmHg at the clinic, p = 0.16) and the cup-to-disc ratio (CDR) (0.7 ± 0.13 at the VC and 0.6 ± 0.18 at the clinic, p = 0.57). Bland-Altman plots with 95% limits of agreement supported that mean differences were close to zero, and the intraclass correlation coefficient at 95% CI showed good consistency between the measurement of IOP (0.78 [0.74 to 0.81]) and CDR (0.90 [0.88 to 0.92]) at the base hospital and vision center. Conclusion: There is good agreement between the findings of VC technicians and glaucoma specialists. VC technicians can help in detecting glaucoma in the community.

Whole-exome sequencing identifies multiple pathogenic variants in a large South Indian family with primary open-angle glaucoma.

PURPOSE: To identify the pathogenic variants associated with primary open-angle glaucoma (POAG) using whole-exome sequencing (WES) data of a large South Indian family. METHODS: We recruited a large five-generation South Indian family (n = 84) with a positive family history of POAG (n = 19). All study participants had a comprehensive ocular evaluation. We performed WES for 16 samples (nine POAG and seven unaffected controls) since Sanger sequencing of the POAG candidate genes (MYOC, OPTN, and TBK1) showed no genetic variation. We used an in-house pipeline for prioritizing the pathogenic variants based on their segregation among the POAG individual. RESULTS: We identified one novel and five low-frequency pathogenic variants with consistent co-segregation in all affected individuals. The variant c.G3719A in RPGR-interacting domain of RPGRIP1 that segregated heterozygously with the six POAG cases is distinct from variants causing photoreceptor dystrophies, reported affecting the RPGR protein complex signaling in primary cilia. The cilia in trabecular meshwork (TM) cells has been reported to mediate the intraocular pressure (IOP) sensation. Furthermore, we identified a novel c.A1295G variant in Rho guanine nucleotide exchange factors Gene 40 (ARHGEF40) and a likely pathogenic variant in the RPGR gene, suggesting that they may alter the RhoA activity essential for IOP regulation. CONCLUSION: Our study supports that low-frequency pathogenic variants in multiple genes and pathways probably affect Primary Open Angle Glaucoma's pathogenesis in the large South Indian family. Furthermore, it requires larger case-controls to perform family-based association tests and to strengthen our analysis.

Aurolab aqueous drainage implant in the vitreous cavity: Our modifications over the conventional technique of glaucoma implant surgery.

Glaucoma drainage devices (GDDs) are used for managing refractory glaucoma due to failed trabeculectomy, neovascular glaucoma, traumatic glaucoma, and secondary glaucoma post keratoplasty. Aurolab aqueous drainage implant (AADI) is a nonvalved drainage implant conventionally implanted with the tube placed in the anterior chamber. Studies about the outcome of the various aqueous drainage devices implanted in the anterior chamber have reported complications such as tube extrusion, migration, blockage, erosion, and corneal decompensation. We propose modifying the conventional GDD implantation technique by placing the tube in the vitreous cavity, thereby negating the risk of anterior segment complications in patients with refractory glaucoma whose anterior segment is already compromised. Another novel approach implemented in this technique was making a scleral tunnel instead of using a scleral or corneal patch graft to cover the tube to prevent its migration. This article describes the surgical steps of this technique and its advantages, along with a surgical video.

The Heritability of Primary Angle Closure Anatomic Traits and Predictors of Angle Closure in South Indian Siblings.

PURPOSE: To estimate the heritability of ocular biometric and anterior chamber morphologic parameters and to determine predictors of angle closure concordance in South Indian probands with angle closure and their siblings DESIGN: Prospective observational cohort study METHODS: Subjects received a standardized ophthalmic examination, A-scan ultrasonography, pachymetry, and anterior segment optical coherence tomography (ASOCT) imaging. Heritability was calculated using residual correlation coefficients adjusted for age, sex, and home setting. Concordant sibling pairs were defined as both proband and sibling with angle closure. Predictors of angle closure concordance among siblings were calculated using multivariable logistic regression models. RESULTS: A total of 345 sibling pairs participated. All anterior chamber parameters were highly heritable (P < .001 for all). Similarly, all iris parameters, axial length, lens thickness (LT), central corneal thickness, anterior lens curvature, lens vault (LV), spherical equivalent, and intraocular pressure were moderately to highly heritable (P < .004 for all). LV and LT were more heritable among concordant siblings (P < .05 for both). In contrast, ASOCT angle parameters had statistically insignificant heritability estimates. In multivariable analyses, siblings older than their probands were more likely to be concordant for angle closure (OR 1.05, 95% CI 1.01, 1.09; P = .02) and siblings with deeper anterior chamber depths (ACDs) compared to their proband were less likely to be concordant for angle closure (OR 0.74, 95% CI 0.64, 0.86; P < .001). CONCLUSIONS: Iris, anterior chamber, and lens parameters may be heritable whereas angle parameters were not. LT and LV may play important roles in the pathogenesis of angle closure. Siblings who are older or have a shallower ACD may need more careful disease monitoring.

Predictors of Short-Term Intraocular Pressure Change after Laser Peripheral Iridotomy: A Prospective Randomized Study.

PURPOSE: To describe short-term intraocular pressure (IOP) changes after laser peripheral iridotomy (LPI) and identify factors predicting IOP lowering. DESIGN: Multicenter, prospective randomized study. PARTICIPANTS: Four hundred fifty-five South Indian eyes of 455 participants 30 years of age or older with a diagnosis of primary angle-closure suspect (PACS), primary angle closure (PAC), or PAC glaucoma (PACG). METHODS: Participants were randomized to superior or nasal/temporal LPI. Multivariate regression models were used to determine preoperative features and LPI parameters associated with change in IOP from baseline to the 2-week postoperative examination. MAIN OUTCOME MEASURES: Change in IOP at 2 weeks after LPI compared with baseline. RESULTS: Among all treated eyes, 11.0% of eyes demonstrated a 20% or more decrease in IOP after LPI, whereas 19.6% demonstrated at least a 20% increase in IOP. Intraocular pressure changes occurring after LPI did not differ by LPI location (P > 0.5 for all comparisons). Although the anterior chamber angle widened after LPI (P < 0.001) and was classified as open after laser in most eyes (64% in all 4 quadrants), there was no significant association between gonioscopic angle opening and LPI-induced IOP change (P = 0.7). Linear regression analysis demonstrated more IOP lowering with higher baseline IOP (3.2 mmHg more lowering per 10-mmHg higher baseline IOP; 95% confidence interval [CI], 2.3-4.1 mmHg) and PAC/PACG diagnosis (1.4 mmHg more IOP lowering vs. PACS diagnosis; 95% CI, 0.2-2.6 mmHg) predicted a lower IOP after LPI. After multivariate adjustment, only higher baseline IOP predicted lower IOP after LPI (P < 0.001). Features not associated with IOP lowering included demographic, visual, and A-scan measures; baseline gonioscopic angle width; total laser energy; LPI area; and LPI location (P > 0.08 for all). Eyes with PAC/PACG, as compared with PACS, demonstrated more IOP lowering after LPI (1.2±1.7 mmHg vs. -0.4±1.0 mmHg; P < 0.001) after adjusting for baseline IOP. CONCLUSIONS: Neither LPI location nor degree of gonioscopic angle opening was associated with statistically significant change in IOP after LPI. Although significant IOP lowering after LPI was uncommon in the overall cohort, higher baseline IOP and PAC/PACG diagnosis predicted lower postoperative IOP.

Clinical and genetic characterization of a large primary open angle glaucoma pedigree.

PURPOSE: To both characterize the clinical features of large primary open angle glaucoma (POAG) pedigree from a village in southern India and to investigate the genetic basis of their disease. MATERIALS AND METHODS: Eighty-four members of a large pedigree received complete eye examinations including slit lamp examination, tonometry, gonioscopy, and ophthalmoscopy. Some were further studied with perimetry. Those diagnosed with POAG were tested for disease-causing mutations in the myocilin and optineurin genes with Sanger sequencing. RESULTS: Fourteen of 84 family members were diagnosed with POAG, while eight were clinically judged to be POAG-suspects. The family structure and the pattern of glaucoma in the pedigree are complex. Features of glaucoma in this pedigree include relatively early age at diagnosis (mean 50 ± 14 years) and maximum intraocular pressures ranging from 14 to 36 mm Hg with a mean of 23 mm Hg ± 6.5 mm Hg. Patients had an average central corneal thickness (mean 529 ± 37.8 microns) and moderate cup-to-disc ratios (0.74 ± 0.14). No mutations were detected in myocilin, optineurin, or TANK binding kinase 1 (TBK1). CONCLUSIONS: We report a five-generation pedigree with a complex pattern of POAG inheritance that includes 22 POAG patients and glaucoma suspects. Although the familial clustering of POAG in this pedigree is consistent with dominant inheritance of a glaucoma-causing gene, mutations were not detected in genes previously associated with autosomal dominant glaucoma, suggesting the involvement of a novel disease-causing gene in this pedigree.