Outcomes of trabeculectomy in microspherophakia.

PURPOSE: To report the outcomes of trabeculectomy in eyes with glaucoma in microspherophakia. MATERIALS AND METHODS: In a retrospective non-comparative case series, we analyzed 29 eyes of 18 patients with glaucoma in microspherophakia, who underwent primary trabeculectomy between 1998 and 2012. Success was defined as complete if the intraocular pressure (IOP) was ≤ 21 and > 5 mm Hg without any antiglaucoma medication and qualified if IOP ≤ 21 and >5 mm Hg with or without antiglaucoma medications. Eyes not falling into qualified success criteria were labeled as failure. RESULTS: The median age at the time of trabeculectomy was 23 years (inter quartile range: 12, 28). The mean IOP reduced from 31.1 ± 8.6 mm Hg to 14.6 ± 4.4 mm Hg after trabeculectomy over a median follow up of 77 months (P < 0.001). The probability of complete success was 96% (95% CI: 77-99%) at one year, 88% (95% CI: 67-96%) at 2 years, which was maintained till 7 years and decreased to 79% (95% CI: 50-92%) at 8 years. The probability of qualified success was 100% till 7 years and decreased to 90% (95% CI: 47-98%) at 8 years. The median number of postoperative medications reduced from 2 to 0 postoperatively (P < 0.001) . Five eyes (21%) developed post-operative shallow anterior chamber (AC) requiring anterior chamber reformation, with 2 of these eyes needing lensectomy for resolution of this complication. CONCLUSION: Primary trabeculectomy had good success rate in glaucoma associated with microspherophakia. Post-operative shallow AC was a frequent complication needing additional intervention.

Comparison of outcomes of trabeculectomy with mitomycin C vs. ologen implant in primary glaucoma.

PURPOSE: To compare the safety and efficacy of trabeculectomy with Ologen implant vs. trabeculectomy with Mitomycin C (MMC). MATERIALS AND METHODS: In a prospective, randomized, pilot study, 39 eyes of 33 subjects with medically uncontrolled primary glaucoma, aged 18 years or above underwent trabeculectomy either with MMC (20 eyes) or with Ologen implant (19 eyes). The primary outcome measure was cumulative success probability, defined as complete if the intraocular pressure (IOP) was > 5 and ≤ 21 mm Hg without anti-glaucoma medications or additional surgery and qualified if an IOP was > 5 and ≤ 21 mm Hg with or without anti-glaucoma medications. RESULTS: Mean (± standard deviation) follow-up in Ologen group was 19.1 ± 8.1 months, and in MMC group was 18.0 ± 8.4 months. Mean IOP reduction at 6 months was significantly lower (P = 0.01) in the MMC group (11.9 ± 2.9 mm Hg) as compared to Ologen group (14.6 ± 2.7 mm Hg). However, at 12 months (P = 0.81) and 24 months (P = 0.32), the mean IOP was similar between the 2 groups. Complete success probability at the end of 6 months in Ologen group was 100% (95% confidence interval: 59.1 - 99.0) was similar (P = 0.53) to that in MMC group (93.8%, 95% CI: 63.2 - 99.1). The incidences of early post-operative complications were similar in the 2 groups, except hyphema, which was significantly more in Ologen group (P = 0.02). CONCLUSION: In this pilot study, the success of trabeculectomy and complications were similar in both Ologen and MMC groups at the end of 6 months.

Outcomes of laser peripheral iridotomy in angle closure disease.

PURPOSE: To evaluate the long-term outcomes of laser peripheral iridotomy (LPI) in primary angle closure disease. METHODS: We retrospectively reviewed the medical records of all Indian subjects of primary angle closure (PAC) and primary angle closure glaucoma (PACG) who underwent LPI between 2003 and 2004. Subjects requiring additional treatment in the form of antiglaucoma medications or trabeculectomy during the follow-up were identified. Baseline factors predicting the need for additional treatment following LPI in primary angle closure disease (PAC+PACG) were analyzed. RESULTS: 84 eyes (PAC:PACG = 16:68) of 47 subjects had undergone LPI during the study period. Over a mean follow-up of 50 ± 22.7 months, 68 eyes (PAC:PACG = 9:59) required additional treatment, of which 26 eyes (PAC:PACG=2:24) subsequently underwent trabeculectomy. Over the initial 20 months of follow-up after LPI, the cumulative probability of requiring no additional treatment was similar between PAC [63.6% (95% CI: 29.7-84.5)] and PACG eyes [64.0% (95% CI: 44.5-78.3)]. Subsequently, the cumulative probability of requiring no additional treatment in PACG eyes dropped to 24.8% (9.7-43.5) at 4 years and 9.9% (1.8-26.7) at 7 years. Presenting IOP (p = 0.01) and highest recorded IOP before LPI (p = 0.03) were the most significant predictors of the need for additional treatment after LPI. Extent of synechial angle closure (p = 0.04) and the cup to disc ratio (p = 0.05) significantly predicted the need for trabeculectomy subsequently in PACG eyes. CONCLUSIONS: The majority of angle closure eyes required additional treatment after LPI. Eyes with a higher presenting IOP were more likely to require additional treatment and those with a greater amount of synechial angle closure and larger cup disc ratio at presentation were more likely to require surgery over the follow-up.

Relationship between severity of visual field loss at presentation and rate of visual field progression in glaucoma.

PURPOSE: To evaluate the relationship between severity of visual field (VF) loss at presentation and rate of VF progression in glaucoma. DESIGN: Clinic-based, retrospective study. PARTICIPANTS: We included 512 eyes of 310 primary glaucoma patients. METHODS: We analyzed the VFs of all subjects of primary glaucoma who had >5 VFs between 1989 and 2008. Based on the mean deviation (MD), we classified the VF loss as mild (MD > -6 dB), moderate (MD ≤ -6 to ≥ -12 dB) or severe (MD < -12 dB). Guided Progression Analysis software which gives the rate of progression (ROP) of Visual Field Index per year was used to assess the ROP. MAIN OUTCOME MEASURES: Relationship between severity of VF loss at presentation and ROP. RESULTS: The median duration of follow-up was 6.8 years. The ROP increased (worsened) by 0.02% per year for every dB worsening of MD (P = 0.02) and for every year of increasing age (P = 0.001). Association between MD and ROP showed a significant positive relationship in mild (ß = 0.18; P = 0.001) and a significant negative relationship in severe (ß = -0.16; P<0.001) VF loss category. Association between MD and ROP was not significant in the moderate VF loss category (ß = -0.05; P = 0.61). CONCLUSIONS: In early stages of glaucoma, the ROP worsened as the severity increased, but, in later stages of the disease, ROP became smaller as the severity increased. There is a need for better methods to detect progression in eyes with severe glaucomatous damage.

Predictors of normal optic nerve head, retinal nerve fiber layer, and macular parameters measured by spectral domain optical coherence tomography.

PURPOSE: To evaluate the effects of signal strength, age, sex, optic disc size, and axial length on the normal optic nerve head (ONH), retinal nerve fiber layer (RNFL), and macular measurements with spectral domain optical coherence tomography (SD-OCT). METHODS: In an observational, cross-sectional study, 119 eyes of 60 normal subjects of Indian origin underwent ONH, RNFL, and macular imaging with SD-OCT during the same visit. Linear mixed-modeling methods were used to evaluate the effects of signal strength, age, sex, optic disc area, and axial length on ONH, RNFL, and macular measurements. RESULTS: ONH rim measurements increased and cup measurements decreased with increasing signal strengths. For a 10-unit increase in signal strength, total rim area increased by a mean of 0.1 mm(2). ONH measurements also increased with increasing optic disc size. Rim measurements decreased and cup measurements increased with increasing axial length. None of the predictors influenced RNFL measurements. Macular inner retinal thickness decreased by a mean of 1.7 µm and macular full retinal thickness decreased by an average of 3.4 µm for every decade's increase in age. Sex did not influence any of the measurements. CONCLUSIONS: Signal strength, optic disc size, and axial length had a significant effect on ONH measurements, whereas age had a significant effect on macular measurements. None of the predictors evaluated influenced the RNFL measurements. These predictors should be considered when evaluating change in the structural measurements in glaucoma over time.

Agreement among 3 methods of optic disc diameter measurement.

PURPOSE: To assess the agreement among clinical, Heidelberg Retina Tomograph (HRT), and optic disc photography in the optic disc diameter measurement. METHODS: Prospective, observational study of 55 eyes of 55 subjects who underwent horizontal and vertical optic disc diameter measurements with +90 diopter lens on slit-lamp biomicroscopy (clinical) and on HRT and optic disc photography. Measurements were compared and agreement among the methods was assessed using intraclass correlation coefficients and Bland and Altman plots. RESULTS: Mean vertical diameter measured by clinical (1.93±0.28 mm) and on disc photography (1.9±0.22 mm) were comparable (P=0.812) and both were significantly greater (P<0.0001) than that measured on HRT (1.69±0.20 mm). Mean horizontal diameter by clinical (1.82±0.19 mm) and on disc photography (1.79±0.22 mm) were comparable (P=0.789) and both were significantly greater (P<0.01) than that measured on HRT (1.66±0.16 mm). The 95% limits of agreement on Bland and Altman plots ranged from 0.54 mm (clinical and disc photography) to 0.93 mm (clinical and HRT) for vertical diameter measurements and from 0.51 mm (HRT and disc photography) to 0.63 mm (clinical and HRT) for horizontal diameter measurements. Proportional bias was detected in the agreement between clinical and HRT as well as clinical and disc photography in vertical disc diameter measurement. CONCLUSIONS: Agreement between clinical and disc photography for optic disc diameter is better than that between either of these 2 methods and HRT. With the increasing disc size, there is an increasing disagreement in the vertical disc diameter measurements between the clinical and HRT as well as clinical and disc photography.