Challenges of Secondary Glaucoma Management Following Congenital Cataract Surgery, Penetrating Keratoplasty and Vitreoretinal Surgery.

Glaucoma is one of the world's leading causes of irreversible vision loss. It is often asymptomatic until it reaches an advanced stage, which can have a significant impact on patients' daily lives. This paper describes the case of a 50-year-old female patient who presented with acute onset of ocular pain, photophobia, and loss of visual acuity in her right eye (RE). The patient's medical history includes congenital cataracts, surgical aphakia, nystagmus, strabismus, amblyopia, and secondary glaucoma. Ophthalmological examination showed BCVA RE-hand movement, left eye (LE)-0.08 with an intraocular pressure (IOP) of 30 mmHg in RE and 16 mmHg in LE. Biomicroscopic examination of RE showed corneal graft, epithelial and endothelial edema, endothelial precipitates, corneal neovascularization, aphakia, and Ahmed valve superotemporally. Despite maximal topical and systemic treatment, Ahmed valve, and trabeculectomy, secondary glaucoma in the right eye remained refractory. Reimplantation of an Ahmed valve was performed. This resulted in a favorable outcome with increased visual acuity and controlled intraocular pressure. The combination of aphakia, penetrating keratoplasty, and secondary glaucoma is a challenge for any surgeon. It is important that both the perioperative risks and the possible complications are carefully assessed in each patient, especially if associated pathology is present.

Corneal Biomechanics - an Emerging Ocular Property with a Significant Impact.

Corneal biomechanical properties reflect the capacity of the cornea to respond to applied mechanical forces. They are an increasingly important domain in ocular pathology, correlated to the diagnosis and evolution of eye diseases such as refractive errors, glaucoma or corneal ectasias. Refractive errors constitute a significant etiology of decreased vision worldwide, with a particular impact in children. Myopic eyes significantly differ from emmetropic eyes in terms of morphology and biomechanics, with differences being reported in both adults and children. In the latter, corneal hysteresis (CH) and the corneal resistance factor (CRF) are significantly lower in myopic individuals, and both biomechanical parameters correlate with the central corneal thickness and axial length. Glaucoma is a progressive optic neuropathy that leads to thinning of the nerve fiber layer and specific visual field loss, in which intraocular pressure (IOP) is an important risk factor. There is an inverse correlation between IOP and CH - a low hysteresis is associated with a high IOP. Furthermore, CH is on average lower in primary open angle glaucoma (POAG) compared to ocular hypertension (OHT) for the same IOP. Significant correlations between CH and the thickness of the ganglion cell layer (GCL) and retinal nerve fiber layer (RNFL), in both POAG and OHT, have been described. Keratoconus is the most frequent corneal ectasia, which leads to a progressive thinning and protruding of the cornea. Biomechanical parameters are severely affected in keratoconus - usually, both CH and CRF are lower compared to normal eyes. The biomechanical behavior of the cornea modulates the evolution of several ocular pathologies. As research is ongoing, more data will enable us to apply this knowledge in diagnosing disease more efficiently and targeting the right treatment for the right patient, including refractive surgery.

The pathophysiology of Sumatriptan induced non-arteritic anterior ischemic optic neuropathy.

Objective: To report a case of a non-arteritic anterior ischemic optic neuropathy (NAAION) in a patient treated with Sumatriptan. Materials and methods: NAAION represents a severe affection that frequently determines irreversible visual acuity damage. The exact cause is yet to be identified, but is usually connected to the systemic status of the patient. We presented the case of a 53-year-old female patient who complained of visual acuity loss in her right eye, associated with inferior visual field (VF) damage. Patient history revealed migraine attacks, raised arterial blood pressure (BP), mitral valve insufficiency and dyslipidemia. Systemic treatment included Sumatriptan for migraine attacks and Bisoprolol for arterial hypertension. Results: A complete ophthalmologic examination was performed, including a visual field examination and optic coherence tomography. Interdisciplinary consults, along with inflammatory biomarkers, brain scan and cardiovascular Doppler echography were used to establish the final diagnosis. Considering the patient's history, systemic medication, clinical picture, paraclinical findings and interdisciplinary check-ups, NAAION was established as a diagnosis. Discussion: NAAION occurs more frequently after the age of 50 years old and may be associated with systemic factors such as nocturnal hypotension, diabetes, atherosclerosis, sleep apnea. In the present case, the association of medically induced nocturnal hypotension and vasoconstriction led to optic nerve ischemia. Conclusions: In a patient with multiple pathology, we must consider the systemic therapy when performing any clinical examination. Abbreviations: AAION = arteritic anterior ischemic optic neuropathy, AION = anterior ischemic optic neuropathy, BCVA = best corrected visual acuity, BP = blood pressure, CS = corticosteroid, IOP = intraocular pressure, LE = left eye, MRI = magnetic resonance imaging, NAAION = non-arteritic anterior ischemic optic neuropathy, OCT = optical coherence tomography, ON = optic nerve, OU = both eyes, RE = right eye.

Ultrasound biomicroscopy in glaucoma assessment.

Ultrasound biomicroscopy (UBM) is an important tool in the diagnosis, evaluation and follow up of glaucoma patients. Even if we are dealing with a primary angle closure glaucoma (PACG) or a primary open angle glaucoma (POAG) patient, the mechanism of angle closure can be revealed by performing an UBM. The device can help differentiate between the two types of glaucoma even in patients with opaque corneas when gonioscopy cannot be performed. Knowing the type of glaucoma is vital, especially regarding an individualized treatment, since each patient is unique and needs to be treated accordingly, in order to prevent glaucomatous optic neuropathy and visual field loss. Abbreviations: AC = anterior chamber, ICE = iridocorneal endothelial syndrome, IOP = intraocular pressure, NTG = normal tension glaucoma, PACG = primary angle closure glaucoma, PC = posterior chamber, PEX = pseudoexfoliation syndrome, POAG = primary open angle glaucoma, UBM = ultrasound biomicroscopy.

The Relationship Between Corneal Hysteresis and Retinal Ganglion Cells - A Step Forward in Early Glaucoma Diagnosis.

BACKGROUND Glaucoma is a major cause of irreversible visual field (VF) loss across the world. Many studies have assessed the accuracy of glaucoma diagnostic tests for a more precise diagnosis to quickly identify patients with higher risk of progression. MATERIAL AND METHODS We conducted a study that included 214 eyes divided into 3 groups: 79 eyes from patients diagnosed with primary open-angle glaucoma (POAG), 68 eyes from patients diagnosed with ocular hypertension (OH), and 67 eyes from normal individuals (normal eyes, NE). All patients included in the study received a complete checkup. RESULTS In POAG patients, means of central corneal thickness (CCT), corneal hysteresis (CH), corneal resistance factor (CRF), mean defect (MD), visual field index (VFI), peripapillary retinal nerve fiber layer (pRNFL), and ganglion cell complex (GCC) are lower than in OH patients, and in NE are higher than in both groups. Also, we found a statistically significant direct correlation between CH and GCC thickness. Further statistical analysis revealed that both pRNFL thickness and GCC thickness are significantly influenced by CH value in a precise manner. CONCLUSIONS The first cell type affected in glaucoma is the retinal ganglion cell. We found a positive correlation between GCC thickness and CH, suggesting that CH might be a parameter to consider in the evaluation of all glaucoma patients from their first examination. Moreover, both pRNFL thickness and GCC thickness are influenced by CH, suggesting the utility of monitoring the value of CH at every checkup to detect its decrease in glaucoma patients.

Update on Myopia Risk Factors and Microenvironmental Changes.

The focus of this update is to emphasize the recent advances in the pathogenesis and various molecular key approaches associated with myopia in order to reveal new potential therapeutic targets. We review the current evidence for its complex genetics and evaluate the known or candidate genes and loci. In addition, we discuss recent investigations regarding the role of environmental factors. This paper also covers current research aimed at elucidating the signaling pathways involved in the pathogenesis of myopia.

Ultrasound biomicroscopy as a vital tool in occult phacomorphic glaucoma.

Ultrasound is a fundamental tool used in all medical specialties, including ophthalmology. Nowadays, ultrasound biomicroscopy (UBM), a method with higher resolution, allows the investigation of in vivo details of the anterior segment of the eye at microscopic resolution. The examination is especially useful in patients with secondary glaucoma that involves a lens component such as phacomorphic glaucoma and occult phacomorphic glaucoma (OPG). The purpose of this paper was to familiarize audience with UBM and the importance of this investigation in OPG, by presenting a series of cases in which performing an UBM was vital because it provided the information needed in order to safely accomplish a curative surgical treatment that preserved our patients' visual acuity.

The importance of corneal assessment in a glaucoma suspect - a review.

Glaucoma represents the main cause of irreversible blindness in the world and for this consideration, the interest in a quick and precise diagnosis and progression of the disease, prior to the appearance of irreversible damage, has been continuously rising. Glaucoma risk factors are already well known, but current studies reveal that it is necessary to make a proper analysis of the intraocular pressure (IOP) to obtain an accurate diagnosis, so we must take into consideration corneal properties that might affect IOP measurements. Starting from corneal geometrical properties represented by central corneal thickness (CCT) and continuing with biomechanical properties represented by corneal hysteresis (CH) and corneal resistance factor (CRF) we reviewed the value of investigating corneal properties in ocular hypertension (OH), primary open angle glaucoma (POAG) and normal tension glaucoma (NTG) patients. We can now say that CCT plays an important role in diagnosing glaucoma because it may mask the real value of the IOP and also, in setting the target for the IOP needed to stop disease progression. Also, CH is a factor that needs to be screened from the first consult of a glaucoma patient or suspect because it is correlated to the response to treatment, visual field (VF) and retinal nerve fiber layer (RNFL) progression and could anticipate the future evolution and patients prognosis. Both CCT and CH are factors that must be thought-about when we encounter a glaucoma suspect. CCT has a predictive role in OH and NTG patients, while CH has on the other hand a prognostic role in POAG, OH and NTG patients.

Goldenhar Syndrome - ophthalmologist's perspective.

Goldenhar syndrome (oculo-auriculo-vertebral dysplasia, OAVS) is a rare, congenital disease arising from the abnormal development of the first and second branchial arches. The incidence is between 1:3500 and 1:5600, with a male: female ratio of 3:2. The etiopathogenesis is multifactorial and dependent on genetic and environmental factors but there are still many unknown aspects. The classic features of Goldenhar syndrome include ocular anomalies - epibulbar dermoids, microphthalmia and coloboma, ENT features such as preauricular tragi, hearing loss, low implantation of the auricular pavilion, micrognathia, and vertebral anomalies such as scoliosis or hemivertebrae. The abnormalities are unilateral in 85% of the cases. Ocular features, especially bilateral dermoids are seen in 60% of the cases. The treatment varies with age and systemic associations, from mainly cosmetic, in uncomplicated cases, to complex reconstructive surgeries in severe cases. While the oculoplastic surgeon manages the oculo-palpebral defects, severe forms require a multidisciplinary approach. Treatment should be individualized, adapted to age, as well as to the extent and severity of the disease. The paper is based on the editorial team cases and experience.

The importance of corneal biomechanics in assessing first degree family members of keratoconus patients.

Aim: to determine the values of biomechanical parameters (corneal hysteresis - CH, corneal resistance factor - CRF and keratoconus match index - KMI) in patients with keratoconus and their first degree family members. The purpose of the present study was to investigate the importance of assessing corneal biomechanics in subjects at risk of developing the primary ectasia. Materials and methods: 48 participants divided into three groups were analyzed in an observational study after a complete ophthalmological exam with the primary focus on Ocular Response Analyzer. Results: The mean values of CH, CRF, and KMI in the group of relatives were lower compared with the controls but higher when compared with keratoconus patients. We noted significant differences of CH and CRF between all three groups, while in the case of KMI, only the keratoconus group presented statistically significant differences compared with the relatives, respectively with the healthy subjects. Conclusions: the decreased values of CH and CRF may raise the question whether corneal biomechanics could be an adjuvant tool in the screening of a first-degree family member of a keratoconus patient in the attempt of the early detection of a possible forme fruste keratoconus.

Overexpression of Tear Inflammatory Cytokines as Additional Finding in Keratoconus Patients and Their First Degree Family Members.

Keratoconus is a progressive corneal ectasia that may lead to severe visual impairment due to the irregular astigmatism caused by corneal thinning. In addition to its association with atopy, eye rubbing, or genetic component, late reports suggest the involvement of inflammation in the pathogenesis of the disease. Our aim was to determine the concentration of IL-4, IL-6, IL-10, RANTES, IFN gamma, and TNF alpha in the tear film of patients with keratoconus and their first degree family members. We analyzed forty-eight participants in an observational cross-sectional study. The diagnosis of keratoconus had to be confirmed in addition to a minimum of 47 D corneal refractive power by corneal topography readings provided by a Placido-based topography system and analysis of the pattern: irregular astigmatism with an asymmetric "bow-tie." As for the other groups, the most important diagnosis criteria were a normal topographic pattern with a regular astigmatism. 17 keratoconus patients, 16 relatives, and 15 controls were recruited after clinical assessment as part of the research. The cytokine's mean values were similar in the keratoconus group and the relatives' samples but significantly higher compared to the controls. Important differences were found in IL-4 levels between keratoconus patients and relatives and between relatives and controls (mean difference of 302.42, p < 0.0016 and 219.16, p < 0.033, Tukey's HSD procedure). In the keratoconus group, using the CORR procedure, we found statistically strong correlations of IL-6 lacrimal concentrations with the disease stage (r = 0.56, p < 0.01), keratometry (r = 0.55, p < 0.02), pachymetry (r = -0.64, p < 0.048), and corneal hysteresis (r = -0.53, p < 0.02). Cytokine overexpression may be relevant for the inflammatory etiology of keratoconus. In conclusion, in the case of some first degree family members, the elevated tear biomarkers may represent a supplementary risk factor.

The ganglion cell complex as an useful tool in glaucoma assessment.

Glaucoma is known as an optic neuropathy prone to progression that determines characteristic not only structural (loss of the ganglion cells as well as their axons) but also functional defects (visual field loss). Objective: To evaluate the possibility of applying ganglion cell complex analysis (GCC) in patients who associate ocular hypertension with tilted disc and marked peripapillary atrophy. Methods: In order to evaluate its components, GCC can be investigated using the Optical Coherence Tomography (OCT) revealing: ganglion cell layer (cells bodies), inner plexiform layer (dendrites and synapses), and nerve fiber layer (axons). Our study included 196 eyes divided into 3 groups: 52 diagnosed with primary open angle glaucoma (POAG), 63 with ocular hypertension (OH), and 81 healthy (normal) eyes (NE). All eyes were submitted to a complete ophthalmologic checkup that involved advanced optic nerve and GCC evaluation. Results: A positive statistically significant correlation was identified between the GCC thickness and the RNFL in all three categories taken into account: R=0,6, p<0,0001 for glaucoma group, R=0,66, p<0,0001 for OH group and R=0,46, p<0,0001 for normal group. Conclusions: GCC has been proved useful for the assessment of the retinal nerve fiber layer (RNFL) in eyes with OH that associate tilted disc or peripapillary atrophy where the optic disc edges might not be certainly determined by the OCT.

The importance of ganglion cell complex investigation in myopic patients.

Glaucoma is an optic neuropathy that affects the ganglion cell complex in all its components: cell bodies, dendrites, and axons, the dendritic arbor being the first one damaged. This is the reason why the thickness of the ganglion cell and internal plexiform layers can be taken into account as an early predictor of the glaucomatous changes, along with the retinal nerve fiber layer (RNFL) thickness. However, due to disc tilting and peripapillary atrophy, the RNFL evaluation may be prone to errors in myopic patients. We presented the cases of two myopic patients, who, after a routine examination, were identified as glaucoma suspects. The Optical Coherence Tomography (OCT) scan revealed a nerve fiber loss which was not confirmed by the ganglion cell complex scan. Thereafter we manually adjusted the optic disc margins according to the patients' myopic changes and this time the retinal nerve fiber layer was also normal. We observed that the ganglion cell complex evaluation led to fewer errors than the retinal nerve fiber layer evaluation, particularly in front of a myopic patient. Nevertheless, various investigations should be considered in the attempt to issue a diagnosis of glaucoma.