Epigenetics in Glaucoma.

Primary open angle glaucoma (POAG) is defined as a "genetically complex trait", where modifying factors act on a genetic predisposing background. For the majority of glaucomatous conditions, DNA variants are not sufficient to explain pathogenesis. Some genes are clearly underlying the more "Mendelian" forms, while a growing number of related polymorphisms in other genes have been identified in recent years. Environmental, dietary, or biological factors are known to influence the development of the condition, but interactions between these factors and the genetic background are poorly understood. Several studies conducted in recent years have led to evidence that epigenetics, that is, changes in the pattern of gene expression without any changes in the DNA sequence, appear to be the missing link. Different epigenetic mechanisms have been proven to lead to glaucomatous changes in the eye, principally DNA methylation, post-translational histone modification, and RNA-associated gene regulation by non-coding RNAs. The aim of this work is to define the principal epigenetic actors in glaucoma pathogenesis. The identification of such mechanisms could potentially lead to new perspectives on therapeutic strategies.

Comparison of intraocular pressure profiles during the water drinking test and the modified diurnal tension curve.

OBJECTIVES: To compare intraocular pressure (IOP) during the water drinking test (WDT) and modified diurnal tension curve (mDTC) in open-angle glaucoma (OAG) patients, using multimodal, observer-masked tonometry. METHODS: Open-angle glaucoma subjects were prospectively enroled, excluding those who had undergone glaucoma filtration or laser surgery. Two-hourly mDTC Goldmann applanation (GAT) and rebound tonometry (RT) was performed between 8:00 and 16:00, and every 15 min for 45 min after ingestion of 800mls of water. Blood pressure, heart rate, pupillometry measurements, and optical coherence tomography (AS-OCT) were also recorded. RESULTS: Forty-two subjects' right eyes were included. 48% were using topical glaucoma medication. Mean baseline IOP was 14.9 ± 4.52 mmHg, with mean visual field mean deviation (±SD) -5.05 ± 5.45 dB. Strong association was found between maximum IOP during mDTC and WDT (r = 0.90, 95% CI 0.82-0.95 p < 0.0001) with agreement (mDTC-WDT) bias -0.82 mmHg, 95% LoA -1.46 to -0.18. During the WDT, mean systolic blood pressure (±SD) increased from 140.0 ± 20.0 to 153.3 ± 24.0 mmHg (p < 0.0001), mean heart rate ( ± SD) reduced from 69.5 ± 11.3 bpm to 63.6 ± 10.0 bpm (p < 0.0001), and temporal iridocorneal angle increased from 29.2 ± 6.0° to 29.6 ± 5.2° (p = 0.04). CONCLUSION: This study presents repeated, observer-masked IOP data showing strong correlation between maximum IOP during mDTC and WDT using multimodal tonometry. This supports WDT as a meaningful alternative to mDTC when investigating diurnal IOP characteristics in clinic, with reduced time requirements and associated costs.

Cyclodiode vs micropulse transscleral laser treatment.

BACKGROUND: Continuous-wave transscleral cyclophotocoagulation (CW-TSCP) is usually reserved for advanced/refractory glaucoma. Micropulse transscleral laser therapy (MPTLT) utilises short energy pulses separated by 'off'-periods. MPTLT is postulated to have fewer complications, but its relative efficacy is not known. The National Institute for Health and Care Excellence (NICE) has deemed the evidence supporting MPTLT use of inadequate quality, limiting its use to research. This study aims to evaluate MPTLT efficacy and safety compared to CW-TSCP. METHODS: This 24-month follow-up retrospective audit included 85 CW-TSCP and 173 MPTLT eyes at a London tertiary referral centre. Primary outcome was success rate at the last follow-up; defined as at least 20% intraocular pressure (IOP) reduction with the same/fewer medications, and IOP between 6 and 18 mmHg. Secondary outcomes were acetazolamide use and success rates per glaucoma type. Safety outcomes were reported as complication rates. RESULTS: By 24-months, mean IOP reduced from 34.6[±1.4]mmHg to 19.0[ ± 3.0]mmHg post-CW-TSCP (p < 0.0001); and from 26.1[±0.8]mmHg to 19.1[±2.2]mmHg post-MPTLT (p < 0.0001). Average IOP decreased by 45.1% post-CW-TSCP, and 26.8% post-MPTLT. Both interventions reduced medication requirements (p ≤ 0.05). More CW-TSCP patients discontinued acetazolamide (p = 0.047). Overall success rate was 26.6% for CW-TSCP and 30.6% for MPTLT (p = 0.83). Only primary closed-angle glaucoma saw a significantly higher success rate following CW-TSCP (p = 0.014). CW-TSCP complication rate was significantly higher than MPTLT (p = 0.0048). CONCLUSION: Both treatments significantly reduced IOP and medication load. CW-TSCP had a greater absolute/proportionate IOP-lowering effect, but it carried a significantly greater risk of sight-threatening complications. Further prospective studies are required to evaluate MPTLT compared to CW-TSCP.

Effects of COVID-19 pandemic on glaucoma appointment scheduling in a tertiary hospital in London, UK.

PURPOSE: To investigate the impact of the delay in patient appointments caused by the COVID-19 pandemic and the triage system on the glaucomatous disease of patients in a London tertiary hospital. METHODS: Observational retrospective study that randomly selected 200 glaucoma patients with more than 3 months of unintended delay for their post-COVID visit and other inclusion and exclusion criteria. Demographic information, clinical data, number of drugs, best-corrected visual acuity (BCVA), intraocular pressure (IOP), visual field (VF) mean deviation (MD), and global peripapillary retinal nerve fibre layer (pRNFL) thickness were obtained from the pre- and post-COVID visit. At the post-COVID visit, the clinical outcomes subjective clinical concern and change of treatment or need for surgery were also annotated. The variables were stratified by glaucoma severity (according to the MD into early, moderate and advanced) and by delay time (more and less than 12 months) and analysed using SPSS. RESULTS: We included 121 eyes (from 71 patients). The median patient age was 74 years (interquartile range -IQR- 15), 54% were males and 52% Caucasians. Different glaucoma types and all glaucoma severities were included. When data was stratified for glaucoma severity, at the pre-COVID visit, significant differences in BCVA, CCT and IOP were observed and there were significantly higher values in the early glaucoma group. The median follow-up delay was 11 months (IQR 8), did not differ between the glaucoma severity groups and did not correlate to the glaucoma severity. At the post-COVID visit, significant differences in BCVA, IOP, and Global pRNFL thickness were observed between the glaucoma severity groups, as lower BCVA and higher IOP and pRNFL thickness were observed in the early glaucoma group. At the post-COVID visit there was cause for concern in 40 eyes: 5 were followed more closely, 22 had a change of treatment and 13 were booked for surgery (3 for cataract and 10 for glaucoma surgery). However, the number of eyes with causes for concern were similar between the glaucoma severity groups and there was no correlation between these clinical outcomes and the delay of the post-COVID visit. The number of topical hypotensive medications increased significantly after the post-COVID visit, higher number of medications were observed in the advanced glaucoma group. When differences of IOP, MD and pRNFL thickness between the pre and post-COVID visit, only the MD difference was significantly different between the glaucoma severity groups because it was higher in the severe group. When data was stratified for delay longer or shorter than 12 months, no differences were observed between the groups except at the pre-COVID visit, when the numbers of patients with MD deviation >-6 dB had longer delay time. When differences in IOP, MD and RNFL thickness were calculated, only the pRNFL thickness showed significant differences between the delay groups, because it was higher in the longer delay group. Finally, when paired analysis of the variables at the pre- and post-COVID visits, stratified by glaucoma severity and delay were conducted, although there were no significant differences in IOP in any group, the BCVA decreased significantly in the overall group and in the longer delay groups, the number of hypotensive drugs increased significantly overall and in the moderate and advanced glaucoma, the MD of the VF worsened significantly in the overall group and in the early glaucoma and longer delay groups and the pRNFL thickness decreased significantly in all groups. CONCLUSIONS: We document that delayed care impacts negatively on the glaucomatous disease of our patients because at the post-COVID visit there were reasons for clinical concern in a third of eyes that resulted in change of treatment or surgery. However, these clinical consequences were not related to IOP, glaucoma severity or delay time and reflect that the triage methods implemented worked adequately. The most sensitive parameter to indicate progression in our sample was the pRNFL thickness.

Comparing the Effectiveness of Phacoemulsification + Endoscopic Cyclophotocoagulation Laser versus Phacoemulsification Alone for the Treatment of Primary Open Angle Glaucoma in Patients with Cataract (CONCEPT): Study Methodology.

OBJECTIVE: To describe the methodology of the Comparing the Effectiveness of Phacoemulsification + Endoscopic Cyclophotocoagulation Laser and Phacoemulsification Alone for the Treatment of Primary Open Angle Glaucoma in Patients with Cataract (CONCEPT) study, a randomized controlled trial. DESIGN: Double-masked, randomized controlled trial. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: Participants will be recruited from 5 United Kingdom-based centers. One hundred and sixty eyes with a diagnosis of primary open-angle glaucoma and visually significant cataract will be included. Eighty eyes will be randomized to undergo cataract surgery alone and eighty to undergo cataract surgery with endoscopic cyclophotocoagulation (ECP). METHODS: The baseline diurnal washout intraocular pressure (IOP) will be measured. The participants will be randomized to undergo cataract surgery alone or cataract surgery with ECP upon completion of uncomplicated cataract surgery. At the 1- and 2-year post surgery follow-up visits, the measurements of washout diurnal IOP will be repeated. MAIN OUTCOME MEASURES: Diurnal washout IOP, use of glaucoma medications, and adverse events. CONCLUSIONS: We described the methodology of the first randomized controlled trial comparing cataract surgery alone with cataract surgery combined with ECP in the context of patients with primary open-angle glaucoma and symptomatic cataract. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

MicroShunt versus Trabeculectomy for Surgical Management of Glaucoma: A Retrospective Analysis.

This case-control study aims to compare the efficacy, safety, and postoperative burden of MicroShunt versus trabeculectomy. The first consecutive cohort of MicroShunt procedures (n = 101) was matched to recent historical trabeculectomy procedures (n = 101) at two London hospital trusts. Primary endpoints included changes in intraocular pressure (IOP) and glaucoma medications. Secondary outcome measures included changes in retinal nerve fibre layer (RNFL) thickness, rates of complications, further theatre interventions, and the number of postoperative visits. From the baseline to Month-18, the median [interquartile range] IOP decreased from 22 [17-29] mmHg (on 4 [3-4] medications) to 15 [10-17] mmHg (on 0 [0-2] medications) and from 20 [16-28] mmHg (on 4 [3-4] medications) to 11 [10-13] mmHg (on 0 [0-0] medications) in the MicroShunt and trabeculectomy groups, respectively. IOP from Month-3 was significantly higher in the MicroShunt group (p = 0.006), with an increased number of medications from Month-12 (p = 0.024). There were greater RNFL thicknesses from Month-6 in the MicroShunt group (p = 0.005). The rates of complications were similar (p = 0.060) but with fewer interventions (p = 0.031) and postoperative visits (p = 0.001) in the MicroShunt group. Therefore, MicroShunt has inferior efficacy to trabeculectomy in lowering IOP and medications but provides a better safety profile and postoperative burden and may delay RNFL loss.

Glaucoma Rose Plot Analysis: Detecting Early Structural Progression Using Angular Histograms.

PURPOSE: To evaluate the novel Rose Plot Analysis (RPA) in the analysis and presentation of glaucoma structural progression data. DESIGN: Case-control image analysis study using retrospective retinal imaging series. SUBJECTS: Subjects with open-angle glaucoma with at least 5 registered spectral-domain OCT scans. METHODS: Glaucoma RPA was developed, combining a novel application of angular histograms and dynamic cluster analysis of circumpapillary retinal nerve fiber layer (cRNFL) OCT data. Rose Plot Analysis plots were created for each eye and each visit. Significant clusters of progression were indicated in red. Three masked clinicians categorized all RPA plots (progressing, not progressing), in addition to measuring the significant RPA area. A masked OCT series assessment with linear regression of averaged global and sectoral cRNFL thicknesses was conducted as the clinical imaging standard. MAIN OUTCOME MEASURES: Interobserver agreement was compared between RPA and the clinical imaging standard. Discriminative ability was assessed using receiver-operating characteristic curves. The time to detection of progression was compared using a Kaplan-Meier survival analysis, and the agreement of RPA with the clinical imaging standard was calculated. RESULTS: Seven hundred fourty-three scans from 98 eyes were included. Interobserver agreement was significantly greater when categorizing RPA (κ, 0.86; 95% confidence interval [CI], 0.81-0.91) compared with OCT image series (κ, 0.66; 95% CI, 0.54-0.77). The discriminative power of RPA to differentiate between eyes that were progressing and not progressing (area under the curve [AUC], 0.97; 95% CI, 0.92-1.00) was greater than that of global cRNFL thickness (AUC, 0.71; 95% CI, 0.59-0.82; P < 0.0001) and equivalent to that of sectoral cRNFL regression (AUC, 0.97; 95% CI, 0.92-1.00). A Kaplan-Meier survival analysis showed that progression was detected 8.7 months sooner by RPA than by global cRNFL linear regression (P < 0.0001) in progressing eyes but was not sooner than with sectoral cRNFL (P = 0.06). Rose Plot Analysis showed substantial agreement with the presence of significant thinning on sectoral cRNFL linear regression (κ, 0.715; 95% CI, 0.578-0.853). CONCLUSIONS: Rose Plot Analysis has been shown to provide accurate and intuitive, at-a-glance data analysis and presentation that improve interobserver agreement and may aid early diagnosis of glaucomatous disease progression.

Endocyclophotocoagulation combined with phacoemulsification in surgically naive primary open-angle glaucoma: three-year results.

OBJECTIVE: To assess the safety and efficacy of endocyclophotocoagulation with phacoemulsification (phaco-ECP) in surgically naive, primary open-angle glaucoma (POAG). METHODS: A retrospective case series of patients undergoing phaco-ECP between 2007 and 2017 at a single centre in London, UK. The primary outcome was intraocular pressure (IOP). Secondary outcomes were visual acuity, visual field global indices, topical medications and surgical complications. Failure criteria were: (1) IOP > 21 mmHg or <20% reduction at two consecutive visits, (2) IOP <5 mmHg and (3) further IOP-lowering surgery. RESULTS: Eighty-three eyes from 83 patients were eligible. Pre-operatively, mean IOP (±SD) was 18.4 ± 5.2 mmHg. The mean number of topical agents (±SD) was 2.7 ± 0.9. Mean IOP (±SD) significantly reduced to 14.3 ± 4.7 at 1 year, 14.1 ± 4.0 at 2 years and 13.6 ± 3.7 at 3 years (p < 0.0001). Topical medications were significantly reduced to 1.3 ± 1.2 at 1 year, 1.7 ± 1.2 at 2 years and 1.8 ± 1.3 at 3 years (p < 0.0001). Annual IOP 'survival' was 70%, 54% and 45% at year 1, 2 and 3, respectively. Complications included uveitis (6%), macular oedema (2%), IOP spikes (1%) and corneal decompensation (1%) with no episodes of hypotony or retinal detachment. One patient underwent filtration surgery within 3 years (1%). CONCLUSION: Phaco-ECP facilitates significant IOP lowering and reduction of medication burden in surgically naive POAG requiring cataract extraction. The procedure is relatively safe and without the use of implants and their associated risks.

A CNN-aided method to predict glaucoma progression using DARC (Detection of Apoptosing Retinal Cells).

BACKGROUND: A key objective in glaucoma is to identify those at risk of rapid progression and blindness. Recently, a novel first-in-man method for visualising apoptotic retinal cells called DARC (Detection-of-Apoptosing-Retinal-Cells) was reported. The aim was to develop an automatic CNN-aided method of DARC spot detection to enable prediction of glaucoma progression. METHODS: Anonymised DARC images were acquired from healthy control (n=40) and glaucoma (n=20) Phase 2 clinical trial subjects (ISRCTN10751859) from which 5 observers manually counted spots. The CNN-aided algorithm was trained and validated using manual counts from control subjects, and then tested on glaucoma eyes. RESULTS: The algorithm had 97.0% accuracy, 91.1% sensitivity and 97.1% specificity to spot detection when compared to manual grading of 50% controls.  It was next tested on glaucoma patient eyes defined as progressing or stable based on a significant (p<0.05) rate of progression using OCT-retinal nerve fibre layer measurements at 18 months. It demonstrated 85.7% sensitivity, 91.7% specificity with AUC of 0.89, and a significantly (p=0.0044) greater DARC count in those patients who later progressed. CONCLUSION: This CNN-enabled algorithm provides an automated and objective measure of DARC, promoting its use as an AI-aided biomarker for predicting glaucoma progression and testing new drugs.

Micropulse transscleral cyclophotocoagulation: initial results using a reduced energy protocol in refractory glaucoma.

PURPOSE: This study evaluates the 6-month safety and efficacy of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in cases of uncontrolled glaucoma/ocular hypertension using a reduced energy protocol. METHODS: Retrospective analysis of patients undergoing MP-TSCPC from January-April 2018 was carried out. Patients received up to 90 s of laser with settings of 2000 mW/Cm2 and a duty cycle of 31.3%. RESULTS: A total of 29 patients were included, with a mean age of 64.7 ± 15.1 years. The most common diagnosis was primary open angle glaucoma (41.4%) with a mean Logmar visual acuity of 1.5 ± 1.2. All subjects had either undergone intraocular surgery (58.6% filtration surgery) or continuous wave diode laser prior to micropulse treatment. Mean pre-laser IOP was 26.2 ± 11.1 mmHg. There was a significant reduction (p < 0.05) in IOP at 1 month to 15.8 ± 5.4 mmHg (39.7% reduction), at 3 months to 15.04 ± 5.25 mmHg (42.6% reduction) and at 6 months to 18.19 ± 7.47 mmHg (30.6% reduction). There was also a corresponding reduction (p < 0.05) in the number of topical agents required to control pressure from a baseline of 3.31 ± 0.97, to 2.72 ± 0.88 at 1 month, 2.76 ± 0.91 at 3 months and 2.90 ± 1.08 at 6 months. Requirements for oral acetazolamide reduced from 41.3% (1/29) at baseline to 3.4% (1/29) at 6 months. Success rates were 75.9% at 1 month, 79.3% at 3 months and 58.6% at 6 months. There was no drop in the visual acuity, no change in central retinal thickness and no cases of intraocular inflammation. CONCLUSIONS: MP-TSCPC at a decreased duration is effective at reducing intraocular pressure in ethnically diverse glaucoma patients refractory to previous glaucoma laser or surgeries at 6 months follow-up, with no significant complications. Further work is needed to confirm efficacy in the long term and to determine optimal settings.

A new paradigm for delivering personalised care: integrating genetics with surgical interventions in BEST1 mutations.

BACKGROUND: The availability and reduced cost of genotyping has improved gene susceptibility testing and our scientific understanding of disease pathophysiology. Whilst several personalised translational models exist within medical frameworks, genetic-based surgical therapy is a translational application not widely used in surgical specialties. METHOD: We present a clinical series of five patients with genetically confirmed bestrophinopathy and malignant glaucoma (MG). Patients were followed up for 12 months or more after receiving surgical intervention to manage refractory intraocular pressure (IOP) resistant to medical treatment. FINDINGS: Patients with BEST1 gene mutations are at higher risk of MG after filtration surgery. A multi-disciplinary approach after four patients experienced poor outcomes concluded that traditional first-line glaucoma surgery was not sufficient to prevent visual loss. A fifth patient presenting with the identified at-risk phenotype underwent primary pars plana vitrectomy, with pars plana Baerveldt tube insertion, successfully preventing MG and had no glaucoma progression after 5 years. INTERPRETATION: We provide proof-of-principle that genetic analysis can be used to inform the selection of surgical therapy to improve outcomes. In this case, a refinement of current surgical methods to avoid MG. Although challenges remain, personalised surgery has the potential to improve clinical outcomes beyond the scope of current surgical practice.

"Minimally Invasive Glaucoma Surgery (MIGS) Is a Poor Substitute for Trabeculectomy"-The Great Debate.

Surgical treatment for glaucoma has undergone a dramatic change over the last decade. Trabeculectomy has been the main surgical procedure worldwide for almost 50 years. However, there is a growth in development of new novel devices and surgical techniques designed to lower intraocular pressure in a less invasive fashion. The term minimally invasive glaucoma surgery (MIGS) has been coined and is the subject of investment, debate and, increasingly, research. The position of MIGS in the glaucoma treatment paradigm is yet to be clearly defined and its ability to replace conventional filtration surgery remains debatable. In this paper two glaucoma specialists were invited to debate the motion that "MIGS is a poor substitute for trabeculectomy".

A comparison between tube surgery, ND:YAG laser and diode laser cyclophotocoagulation in the management of refractory glaucoma.

PURPOSE: To compare the results of intraocular pressure (IOP) reduction by 3 treatment modalities, (a) glaucoma tube implants, (b) noncontact YAG laser cyclophotocoagulation (cycloYAG), and (c) contact transscleral diode laser cyclophotocoagulation (cyclodiode), in cases of advanced glaucoma refractory to alternative treatments. METHODS: A consecutive group of 45 eyes that received cycloYAG were matched against two control groups of patients who had received tube surgery or cyclodiode, each control group having been derived from a database of patients. RESULTS: Mean pretreatment IOP improved from 41.3, 38.6, and 32.0 mmHg for the tube, cycloYAG, and cyclodiode groups, respectively, to 16.4, 22.1, and 19.3 mmHg, respectively. Treatment success was achieved in 78%, 69%, and 71% of the tube, cycloYAG, and cyclodiode groups, respectively. Visual acuity deteriorated 2 or more Snellen lines in 16%, 7%, and 9% of the patients in the tube, cycloYAG, and cyclodiode groups, respectively. Complications included retinal detachment, hypotony, and phthisis. CONCLUSIONS: All 3 methods provided acceptable IOP lowering in the short and medium term. Control of IOP was best in patients receiving tube surgery. Cyclodiode and cycloYAG treatments were similarly effective in lowering IOP. Tube surgery was associated with a greater incidence of sight threatening complications.

Combining phacoemulsification with endoscopic cyclophotocoagulation to manage cataract and glaucoma.

BACKGROUND: To examine the outcome and complications of combined phacoemulsification and endoscopic cyclophotocoagulation as surgical management of cataract and glaucoma. DESIGN: Retrospective uncontrolled case series from the glaucoma unit, Western Eye Hospital, London, UK. PARTICIPANTS: Sixty-three eyes from 59 patients with coexisting cataract and glaucoma. METHODS: Patients underwent routine phacoemulsification followed by 270-360 degree endoscopic cyclophotocoagulation as a single procedure. MAIN OUTCOME MEASURES: Intraocular pressure, number of intraocular pressure-lowering medications, logMAR visual acuity, recorded complications. RESULTS: Baseline characteristics included mean age (77.3 ± 11.1 years), mean logMAR visual acuity (1.01 ± 0.98), mean intraocular pressure (21.13 ± 6.21 mmHg) and mean number of intraocular pressure-lowering medications, (2.71 ± 1.06). Twelve months after phacoemulsification and endoscopic cyclophotocoagulation, mean intraocular pressure had reduced to 16.09 ± 5.27 mmHg (P < 0.01), number of intraocular pressure-lowering medications reduced to 1.47 ± 1.30 (P < 0.01) and mean logMAR acuity improved to 0.33 ± 0.22 (P < 0.01). Success, defined as an intraocular pressure reduction > 20% with intraocular pressure 6-21 mmHg, was achieved in 55.5% of eyes at 12 months. Complications included fibrinous uveitis, elevated intraocular pressure, posterior vitreous detachment and induced astigmatism. CONCLUSION: Phacoemulsification and endoscopic cyclophotocoagulation is both safe and effective as surgical management for cataract and glaucoma. Larger intraocular pressure reductions can be achieved in older patients and those with higher baseline intraocular pressure.

Injectable 1-piece hydrophilic acrylic toric intraocular lens for cataract surgery: efficacy and stability.

PURPOSE: To evaluate the efficacy and rotational stability of an injectable 1-piece hydrophilic acrylic toric intraocular lens (IOL). SETTING: Department of Ophthalmology, Hillingdon Hospital, Uxbridge, Middlesex, United Kingdom. DESIGN: Cohort study. METHODS: This study enrolled consecutive patients who had 2.00 diopters (D) or more of preexisting corneal astigmatism. Patients had phacoemulsification with implantation of a T-flex 623T toric IOL through a 2.8 mm astigmatically neutral incision. Uncorrected (UDVA) and corrected (CDVA) distance visual acuities (logMAR), refraction, keratometry, and the cylinder axis of the toric IOL were measured. RESULTS: Thirty-three eyes of 25 patients were evaluated. The mean preoperative refractive astigmatism was 3.35 D ± 1.20 (SD) and the mean keratometric astigmatism, 3.98 ± 1.89 D, respectively. Four months postoperatively, the mean UDVA was 0.28 ± 0.23 D logMAR, improving to 0.19 ± 0.23 D logMAR CDVA. The mean refractive astigmatism was 0.95 D ± 0.66 D; vector analysis using the Holladay-Cravy-Koch method showed that the mean reduction in refractive astigmatism was 2.94 ± 0.89 D. The mean difference between the intended and the actual final IOL cylinder axis was 3.44 degrees (range 0 to 12). CONCLUSIONS: The toric IOL reduced visually significant keratometric astigmatism and increased spectacle independence after cataract surgery. There were no cases of significant IOL rotation in the capsular bag 4 months postoperatively.

Heart block following topical latanoprost treatment.

The authors report a case of second degree heart block associated with topical latanoprost treatment. The authors discuss the possibility of a causative effect as the cessation of this treatment resulted in improvement of the arrhythmia. The authors highlight previous reports and research in humans and animals which demonstrate an association of arrhythmias with prostaglandin analogues. This report draws attention to the possibility that an extremely commonly prescribed topical drug may trigger arrhythmias in susceptible individuals. It is important that prescribers are aware of this possible side-effect.