Choroidal Effusions after Glaucoma Drainage Implant Surgery: Risk Factors and Surgical Management.

OBJECTIVE: To report the incidence of patients who developed choroidal effusions after glaucoma drainage implant (GDI) surgery and determine risk factors for and outcomes of surgical intervention. DESIGN: Retrospective case series. SUBJECTS: Medical records of 605 patients who underwent GDI surgery from January 1, 2017 to June 7, 2021 at New York University Langone Health and New York Eye and Ear Infirmary of Mount Sinai were reviewed. METHODS: Preoperative, intraoperative, and postoperative clinical data were obtained. Multivariate logistic regression evaluated the factors associated with the need for surgical intervention. Patient records were analyzed for effusion resolution, intraocular pressure (IOP), visual acuity (VA), and complications across treatment modalities. MAIN OUTCOME MEASURES: Incidence of choroidal effusion development and need for surgical intervention. RESULTS: Choroidal effusions developed in 110 (18%) patients (110 eyes). Surgical intervention to drain the effusion or ligate the implant tube was performed in 19 (17%) patients. The average time to surgical intervention was 47.6 days. Among patients who developed postoperative effusions, risk factors for requiring surgical intervention included history of selective laser trabeculoplasty (SLT) (P = 0.004; odds ratio [OR], 14.4), prior GDI surgery (P = 0.04; OR 8.7), 350-mm2 Baerveldt glaucoma implant placement (P = 0.05; OR, 4.8), and anterior chamber shallowing (AC; P < 0.001; OR, 25.1) in the presence of effusions. The subgroup that required multiple surgeries for effusion resolution had a significantly lower mean IOP at the most recent follow-up compared with those who received medical management only (P < 0.001). A higher percentage of patients who required surgical intervention lost VA at the most recent follow-up compared with patients whose effusions resolved with conservative management (i.e., medical management, AC viscoelastic injection). CONCLUSIONS: Choroidal effusions after GDI surgery resolved with conservative management in most patients. A history of SLT or GDI placement, implantation of a BGI-350, and the presence of a shallow chamber were risk factors for surgical intervention. Although interventions, such as surgical drainage are at times necessary, a better understanding of their impacts can help guide postoperative decisions. The risks and benefits of these procedures must be carefully considered in these high-risk eyes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Outcomes of Glaucoma Reoperations in the Primary Tube Versus Trabeculectomy Study.

PURPOSE: To describe the incidence and outcomes of reoperations for glaucoma in the Primary Tube Versus Trabeculectomy (PTVT) Study. DESIGN: Cohort study of patients in a multicenter randomized clinical trial. PARTICIPANTS: The PTVT Study enrolled 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery. METHODS: Randomization assigned 125 patients to placement of a tube shunt (350-mm2 Baerveldt glaucoma implant) and 117 patients to trabeculectomy with mitomycin C (MMC, 0.4 mg/ml for 2 minutes). Data were analyzed from patients who underwent additional glaucoma surgery. MAIN OUTCOME MEASURES: Outcome measures included intraocular pressure (IOP), use of glaucoma medications, visual acuity, surgical complications, and failure (IOP > 21 mmHg or reduced by <20%, IOP ≤ 5 mmHg, additional glaucoma surgery, or loss of light perception vision). RESULTS: Additional glaucoma surgery was performed in 21 patients in the tube group and 12 patients in the trabeculectomy group in the PTVT Study, and the 5-year cumulative reoperation rate for glaucoma was 18.0% in the tube group and 10.4% in the trabeculectomy group (P = 0.15). Follow-up (mean ± standard deviation [SD]) after additional glaucoma surgery was 35.1 ± 17.7 months in the tube group and 30.1 ± 17.6 months in the trabeculectomy group (P = 0.44). At 3 years after glaucoma reoperation, IOP (mean ± SD) was 15.5 ± 4.8 mmHg in the tube group and 16.6 ± 7.3 mmHg in the trabeculectomy group (P = 0.71). The number of glaucoma medications (mean ± SD) after 3 years of follow-up was 2.1 ± 1.7 in the tube group and 1.7 ± 1.0 in the trabeculectomy group (P = 0.58). The cumulative probability of failure at 3 years after a glaucoma reoperation was 37.8% in the tube group and 21.3% in the trabeculectomy group (P = 0.47). CONCLUSION: No significant difference in the rate of reoperation for glaucoma was observed after tube shunt implantation and trabeculectomy with MMC in the PTVT Study. Similar surgical outcomes were observed after additional glaucoma surgery, irrespective of the initial procedure to which the patient was randomized. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH HYPERCOAGULABILITY IN PREGNANCY.

PURPOSE: To report a case of paracentral acute middle maculopathy in an otherwise healthy young, multiparous woman in her second trimester of pregnancy. METHODS: A case report. RESULTS: A 38-year-old woman in her twentieth week of pregnancy presented with a four-day history of an acute paracentral scotoma in her left eye. Fundoscopic examination of the left eye was significant for a white-gray lesion inferonasal to the fovea which corresponded with spectral-domain optical coherence tomography hyperreflectivity at the outer plexiform layer-inner nuclear layer junction and optical coherence tomography angiography nonperfusion. A diagnosis of paracentral acute middle maculopathy was made. The patient was sent for a hypercoagulability workup that revealed elevated Factor VIII activity, which has been associated with increased risk of complications during pregnancy. CONCLUSION: Paracentral acute middle maculopathy in pregnancy may be secondary to an underlying hypercoagulable condition. We recommend systemic evaluation and referral to a high-risk pregnancy specialist if paracentral acute middle maculopathy is diagnosed during pregnancy. In addition, optical coherence tomography angiography in paracentral acute middle maculopathy may demonstrate reperfusion of the affected vessels.

A novel glaucoma approach: Stem cell regeneration of the trabecular meshwork.

Glaucoma is the leading cause of global irreversible blindness, necessitating research for new, more efficacious treatment options than currently exist. Trabecular meshwork (TM) cells play an important role in the maintenance and function of the aqueous outflow pathway, and studies have found that there is decreased cellularity of the TM in glaucoma. Regeneration of the TM with stem cells has been proposed as a novel therapeutic option by several reports over the last few decades. Stem cells have the capacity for self-renewal and the potential to differentiate into adult functional cells. Several types of stem cells have been investigated in ocular regenerative medicine: tissue specific stem cells, embryonic stem cells, induced pluripotent stem cells, and adult mesenchymal stem cells. These cells have been used in various glaucoma animal models and ex vivo models and have shown success in IOP homeostasis and TM cellularity restoration. They have also demonstrated stability without serious side effects for a significant period of time. Based on current knowledge of TM pathology in glaucoma and existing literature regarding stem cell regeneration of this tissue, we propose a human clinical study as the next step in understanding this potentially revolutionary treatment paradigm. The ability to protect and replace TM cells in glaucomatous eyes could change the field forever.

Myositis of an Extraocular Muscle, a Possible Drug Reaction: Histopathologic and Immunopathologic Analysis.

A 58-year-old man presented with left-sided orbital inflammation, including chemosis and a lateral rectus abduction defect. Initially presumed to represent cellulitis, the condition responded poorly to oral and intravenous antibiotics. CT showed the epicenter of an infiltrate to involve the lateral rectus. The patient improved dramatically when oral prednisone was added. Lateral rectus biopsy displayed intramuscular polyclonal lymphoid infiltrates, rich with eosinophils. Complete resolution of the inflammatory process was confirmed by a follow-up CT. The presumptive diagnosis was idiopathic orbital myositis, an uncommon condition of unknown etiology. However, the patient had taken rosuvastatin, which has been rarely associated with diplopia and ophthalmoplegia, raising the question of whether this case was truly idiopathic.

Racial differences in neighborhood disadvantage, inflammation and metabolic control in black and white pediatric type 1 diabetes patients.

BACKGROUND: Racial variation in the relationship between blood glucose and hemoglobin A1c (HbA1c) complicates diabetes diagnosis and management in racially mixed populations. Understanding why HbA1c is persistently higher in blacks than whites could help reduce racial disparity in diabetes outcomes. OBJECTIVE: Test the hypothesis that neighborhood disadvantage is associated with inflammation and poor metabolic control in a racially mixed population of pediatric type 1 diabetes patients. METHODS: Patients (n = 86, 53 white, 33 black) were recruited from diabetes clinics. Self-monitored mean blood glucose (MBG) was downloaded from patient glucose meters. Blood was collected for analysis of HbA1c and C-reactive protein (CRP). Patient addresses and census data were used to calculate a concentrated disadvantage index (CDI). High CDI reflects characteristics of disadvantaged neighborhoods. RESULTS: HbA1c and MBG were higher (p < 0.0001) in blacks [10.4% (90.3 mmol/mol), 255 mg/dL] than whites [8.9% (73.9 mmol/mol), 198 mg/dL). CDI was higher in blacks (p < 0.0001) and positively correlated with HbA1c (r = 0.40, p = 0.0002) and MBG (r = 0.35, p = 0.0011) unless controlled for race. CDI was positively associated with CRP by linear regression within racial groups. CRP was not different between racial groups, and was not correlated with MBG, but was positively correlated with HbA1c when controlled for race (p = 0.04). CONCLUSIONS: Neighborhood disadvantage was associated with inflammation and poor metabolic control in pediatric type 1 diabetes patients. Marked racial differences in potential confounding factors precluded differentiation between genetic and environmental effects. Future studies should recruit patients matched for neighborhood characteristics and treatment regimen to more comprehensively assess racial variation in HbA1c.