Multimodal analysis in symptomatic MIDD-associated retinopathy. A case report and literature review.

Purpose: To present results of contemporary multimodal ophthalmic imaging in a case of maternally inherited diabetes and deafness (MIDD) and a literature review of MIDD. Methods: A case of a 47-year-old female with diabetes mellitus, severe insulin resistance, familial lipodystrohy, deafness and increasing problems with vision is reported. A full ophthalmic examination was done, including best corrected visual acuity (BCVA, LogMAR), funduscopy, and imaging studies: optical coherence tomography (OCT), OCT angiography (OCT-A), fundus autofloresence (FAF), visual fields (HVF) 10-2 , electrophysiology (EP) and genetic testing were performed. Literature available on the topic was reviewed. Results: BCVA was 0.06 LogMAR in the right eye and 0.1 LogMAR in the left. Funduscopy revealed atrophy (AT) and pigmentary changes but no diabetic retinopathy. HVF confirmed corresponding defects. The imaging and diagnostic tests showed the following abnormalities: FAF: hypoautofluoresence in areas of AT and mottled appearance in the macular and peripapillary area; OCT: attenuation of outer retinal layers and retinal pigment epithelium (RPE) in the AT; OCT-A: thinning of the deep capillary plexus and choriocapillaris; EP: abnormalities on full field electroretinogram (ERG), 30 Hz flicker and single cone flash response; multifocal ERG: reduced responses; genetic testing: A-to-G transition mutation at position 3243 of the mitochondrial genome, typical for MIDD. After one year OCT ganglion cell analysis showed loss of thickness. Conclusions: Genetic testing should be considered in diabetic patients with pigmentary retinopathy. Imaging studies and diagnostic testing showed structural and functional retinal changes, confined to the macula and progressive in nature.

Six year outcomes of combined phacoemulsification surgery and endoscopic cyclophotocoagulation in refractory glaucoma.

PURPOSE: This study is to describe the 6-year results of combined phacoemulsification surgery and endoscopic cyclophotocoagulation (Phaco-ECP) surgery in patients with uncontrolled glaucoma and no previous glaucoma surgery. METHODS: This is a retrospective case series of 84 eyes. The primary outcome measure was intraocular pressure (IOP) reduction 6 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 6 years. Failure was defined as IOP higher than 21 mm Hg or lower than 6 mm Hg or IOP not reduced by 20% from baseline at the 1, 2, 3, 4, 5, or 6-year time points or further laser or other surgery to reduce IOP at any timepoint. RESULTS: There was a statistically significant decrease in mean IOP from 18.9 mmHg pre-operatively to 13.7, 12.8, 13.0, 12.7, 12.5, and 12.3 mmHg at the 1, 2, 3, 4, 5, and 6 years post-operatively respectively (p < 0.001). Fifty-seven (68%) reached criteria for failure by 6 years. In 36% of cases, this was due to inadequate IOP control, whereas 32% required further laser or surgery. When we excluded patients who only had selective laser trabeculoplasty rather than further surgery, the failure rate reduced to 51%. Eleven percent had a post-operative complication, 2.4% requiring further surgical intervention. CONCLUSIONS: At 6 years postoperatively, combined phaco-ECP achieved a significant reduction in IOP in patients with uncontrolled glaucoma and no previous drainage surgery. Significant complications were uncommon, but 68% was classified as surgical failures by the six year point.

1-year outcomes of the Xen45 glaucoma implant.

OBJECTIVES: To describe the 12-month outcomes of the Xen45 glaucoma stent. METHODS: Non-comparative retrospective study of all cases who underwent Xen glaucoma surgery in April 2017 or earlier and completed 12 months of follow-up. The primary outcome measures were intraocular pressure (IOP) reduction and number of glaucoma medications at 12 months postoperatively. The secondary outcome measures were surgical complications and the success rate of surgery at 1 year. Success rate was defined according to the multiple IOP thresholds of 15 mmHg, 18 mmHg, and 21 mmHg with all requiring a drop of 20% and no additional glaucoma surgery. Revision or needling of the Xen conjunctival bleb was not considered to constitute a surgical failure. RESULTS: Sixty-eight eyes were included in the study. Mean IOP dropped from 22.1 mmHg preoperatively to 14.8 mmHg at 12 months, a 33% drop (p < 0.0001). Mean number of glaucoma medications reduced from 2.9 preoperatively to 1.1 at 12 months (p < 0.0001). In total, 54.4% of cases were back on glaucoma medications by 12 months. Success rate varied from 32.4% when defined as IOP ≤ 15 mmHg and ≥ 6 mmHg and ≥ 20% reduction without medications to 70.6% when defined as IOP ≤ 21 mmHg and ≥ 6 mmHg and ≥ 20% reduction with or without medications. Thirty cases (44.1%) required bleb needling or surgical revision. CONCLUSIONS: The Xen45 is effective at reducing IOP and glaucoma medication use at 12 months postoperatively. Patients considering this procedure should be warned that by 12 months postoperatively there is a significant chance of requiring postoperative bleb intervention and glaucoma drops.

Phacoemulsification and endocyclophotocoagulation in uncontrolled glaucoma: Three-year results.

PURPOSE: To describe the 3-year outcomes of combined cataract surgery and 360-degree endocyclophotocoagulation (ECP) in eyes with uncontrolled glaucoma and no previous glaucoma drainage surgery. SETTING: University Hospital Eye Department, Exeter, United Kingdom. DESIGN: Retrospective case series. METHODS: The study included patients who had combined cataract surgery and 360-degree ECP. The primary outcome measure was intraocular pressure (IOP) reduction at 3 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 3 years and the complications of surgery. Failure was defined by 1 of 2 criteria: (1) IOP higher than 21 mm Hg or lower than 6 mm Hg or not reduced by 20% from baseline at the 1-, 2-, or 3-year timepoint and (2) further laser or other surgery to reduce IOP at any timepoint. RESULTS: The study comprised 84 patients (84 eyes). The mean IOP dropped from 18.7 mm Hg preoperatively to 13.3 mm Hg, 13.8 mm Hg, and 14.0 mm Hg at 1, 2, and 3 years postoperatively, respectively. By the 3-year timepoint, 58.3% had met the criteria for failure. The mean number of glaucoma medications was similar at 2.5 at 3 years postoperatively compared with 2.6 preoperatively. Nine patients (10.7%) had a significant complication, but all resolved without long-term sequelae. CONCLUSIONS: At 3 years postoperatively, combined cataract surgery and 360-degree ECP achieved a modest but significant drop in IOP in phakic patients with uncontrolled glaucoma and no previous drainage surgery. There was a low incidence of serious side effects but nearly 60% were classified as failures by 3 years.

Long-term effect of cataract surgery on intraocular pressure after trabeculectomy: extracapsular extraction versus phacoemulsification.

PURPOSE: To compare the effect of phacoemulsification with intraocular lens (IOL) implantation on long-term intraocular pressure (IOP) control in glaucoma patients who had previous trabeculectomy with the effect on IOP control in similar patients after extracapsular cataract extraction (ECCE) with IOL implantation. SETTING: Oxford Eye Hospital, Oxford, England. METHODS: Twenty-eight consecutive patients who had phacoemulsification with IOL implantation (phaco group) at least 3 months after trabeculectomy were identified from hospital records, and 28 patients who had ECCE with IOL implantation (ECCE group) were matched retrospectively to the phaco group with respect to age, sex, diagnosis, and IOP. In both groups, the IOP before cataract extraction was compared with the IOP at intervals up to 2 years after cataract extraction. A Kaplan-Meier survival analysis was performed. RESULTS: The mean IOP in the phaco group did not differ significantly from the mean IOP before cataract extraction at any interval. Twelve months after cataract extraction, the mean IOP in the ECCE group was significantly higher than preoperatively (P =.01); however, the mean IOP did not differ between groups over time (P =.704). There was significantly better long-term IOP control in the phaco group as determined by Kaplan-Meier survival analysis and the log-rank test (P =.038). CONCLUSION: After trabeculectomy, phacoemulsification provided better long-term IOP control than ECCE; however, the mean IOP was not significantly lower.