Medications for attention deficit hyperactivity disorder associated with increased risk of developing glaucoma.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) therapies including atomoxetine, methylphenidate, and amphetamines are some of the most prescribed medications in North America. Due to their sympathomimetic action, these drugs are contraindicated in patients with a history of angle closure glaucoma (ACG). This study aims to determine the risk of ACG and open angle glaucoma (OAG) among users of these treatments. METHODS: This is a retrospective cohort study with a case control analysis using the PharMetrics Plus Database (IQVIA, USA). We created a cohort of new users of atomoxetine, methylphenidate, and amphetamines and they were followed to the first diagnosis of (1) ACG or OAG; or (2) end of follow up. For each case, four age-matched controls were selected. A conditional logistic regression model was used to adjust for confounders and to calculate adjusted incidence-rate-ratios (aIRRs). RESULTS: A total of 240,257 new users of the ADHD medications were identified. The mean age was 45.0 ± 19.4 years and 55% of the cohort was female. Regular users of atomoxetine and amphetamines had a higher aIRR for developing ACG compared with non-users (aIRR = 2.55 95% CI [1.20-5.43] and 2.27 95% CI [1.42-3.63], respectively); while users of methylphenidate had a higher aIRR for developing OAG (aIRR = 1.23 95% CI [1.05-1.59]). CONCLUSIONS: Use of amphetamines and atomoxetine had a higher risk for ACG, while use of methylphenidate was associated with a higher risk for OAG. Given the prevalence of ADHD medication use (medically and recreationally), our current data on their associated risk of glaucoma have profound public health implications.

Ab interno trabeculectomy revision with 5-flourouracil for failed trabeculectomy in advanced glaucoma: 3-year outcomes.

OBJECTIVE: To describe the 3-year outcomes of patients who underwent ab interno trabeculectomy revision with a translimbal sclerostomy spatula augmented with 5-flourouracil. DESIGN: Retrospective cohort study. PARTICIPANTS: In this single-centre study, inclusion criteria included patients who were 18 years of age or older with advanced glaucoma who had undergone ab interno trabeculectomy revision with 5-flourouracil due to subconjunctival fibrosis and above-target intraocular pressure (IOP). Patients were required to have a minimum follow-up of 3 years. METHODS: The primary outcome measure was IOP. Secondary outcome measures included number of topical IOP-lowering medications, best-corrected distance visual acuity, visual field mean deviation, and postoperative complications. RESULTS: Forty-one eyes of 41 patients met the criteria for inclusion. Survival analysis demonstrated success defined by criterion A (IOP <15 mm Hg and >20% reduction) in 44% of eyes without medication (complete success) and 71% of eyes with or without medication (qualified success) at 3-year follow-up. Complete and qualified successes defined by criterion B (IOP <12 mm Hg and >20% reduction) were achieved by 31% and 44% of eyes, respectively. Early complications included transient hypotony in 26 eyes (63%) and transient hyphema in 3 eyes (7.3%). No persistent complications were reported within the 3-year study period. CONCLUSION: Ab interno trabeculectomy revision can be an effective technique for achieving a low target IOP in patients with advanced glaucoma in up to 3-year follow-up.

A unique case of glaucoma associated with heterotopic bone formation in the anterior chamber angle.

Purpose: To describe a unique case of unilateral open angle glaucoma secondary to heterotopic bone formation in the anterior chamber angle. Observations: A 57 year-old male with an unremarkable history presented with right eye pain. Anterior segment examination demonstrated a solid, white deposit overlying the trabecular meshwork and peripheral iris associated with an intraocular pressure of 44 mmHg. The left eye examination was unremarkable. Biopsy of the material surprisingly showed heterotopic bone. Removal of the material and medical treatment were unable to adequately control the intraocular pressure and a trabeculectomy was successfully performed. Conclusions and Importance: This case demonstrates a unique cause of secondary open angle glaucoma: heterotopic bone formation in the anterior chamber angle.

PreserFlo Microshunt for the management of intraocular pressure elevation in iridocorneal endothelial syndrome.

Purpose: To report on a case of angle-closure glaucoma secondary to iridocorneal endothelial (ICE) syndrome effectively managed with the PreserFlo Microshunt. Observations: We report successful implantation of a PreserFlo Microshunt in a 57-year-old patient with secondary angle-closure glaucoma in the context of ICE syndrome. Following failure of medical therapy to adequately control intraocular pressure (IOP), the patient was consented for surgical intervention and underwent combined cataract surgery and PreserFlo Microshunt implantation. IOP at the last post-operative follow-up (5 months) was 12 mmHg with the patient on brinzolamide/timolol maleate (Azarga®). We report no complications in the post-operative period. Conclusions and importance: The PreserFlo Microshunt may be a promising option for patients with ICE syndrome who fail medical therapy. Implantation of this device was well tolerated in the presented case.

Non-arteritic anterior ischemic and glaucomatous optic neuropathy: Implications for neuroretinal rim remodeling with disease severity.

PURPOSE: Post-acute non-arteritic ischemic optic neuropathy (NAION) and glaucomatous optic neuropathy (GON) can be difficult to differentiate clinically. Our objective was to identify optical coherence tomography (OCT) parameters to help differentiate these optic neuropathies. METHODS: We compared 12 eyes of 8 patients with NAION and 12 eyes of 12 patients with GON, matched for age and visual field mean deviation (MD). All patients underwent clinical assessment, automated perimetry (Humphrey Field Analyzer II; Carl Zeiss Meditec, Dublin, CA, USA), and OCT imaging (Spectralis OCT2; Heidelberg Engineering, Heidelberg, Germany) of the optic nerve head and macula. We derived the neuroretinal minimum rim width (MRW), peripapillary retinal nerve fibre layer (RNFL) thickness, central anterior lamina cribrosa depth, and macular retinal thickness. RESULTS: MRW was markedly thicker, both globally and in all sectors, in the NAION group compared to the GON group. There was no significant group difference in RFNL thickness, globally or in any sector, with the exception of the temporal sector that was thinner in the NAION group. The group difference in MRW increased with increasing visual field loss. Other differences observed included lamina cribrosa depth significantly greater in the GON group and significantly thinner central macular retinal layers in the NAION group. The ganglion cell layer was not significantly different between the groups. CONCLUSIONS: The neuroretinal rim is altered in a dissimilar manner in NAION and GON and MRW is a clinically useful index for differentiating these two neuropathies. The fact that the difference in MRW between the two groups increased with disease severity suggests distinct remodelling patterns in response to differing insults with NAION and GON.

Efficacy and safety of ab interno trabeculectomy revision with 5-fluorouracil in advanced glaucoma due to subconjunctival fibrosis.

OBJECTIVE: To describe the outcomes of patients who underwent a single ab interno trabeculectomy revision augmented with 5-fluorouracil. DESIGN: Retrospective cohort study. PARTICIPANTS: All patients who had undergone ab interno trabeculectomy revision at a single tertiary care centre during the 5-year study period. All patients had advanced glaucomatous optic neuropathy, and all treated ages and glaucoma subtypes were included. METHODS: Outcome measures included surgical success, number of topical intraocular pressure (IOP)-lowering drops, best-corrected visual acuity, visual field mean deviation, and postoperative complications. Success at 12 months was defined using 2 criteria: criterion A (IOP <15 mm Hg and >20% reduction) and criterion B (IOP <12 mm Hg and >20% reduction). Each success criterion was subdivided into patients who achieved success without topical IOP-lowering drops (complete success) or with topical therapy (qualified success). RESULTS: This study included 46 eyes of 46 patients. Of these, 34 patients were followed for 12 months or more to assess surgical success. Success defined by criterion A was achieved by 68% of these 34 patients (53% complete, 15% qualified). Success defined by criterion B was achieved by 47% of these patients (38% complete, 9% qualified). Early hypotony was noted in 68% of eyes but was not associated with negative visual acuity or visual field outcomes. CONCLUSIONS: An IOP of <12 mm Hg and a >20% IOP reduction were achieved by 47% of patients overall (with or without topical therapy) at 12 months of follow-up. Transient early postoperative hypotony should be expected following ab interno revision trabeculectomy.

Amyloid Beta Immunoreactivity in the Retinal Ganglion Cell Layer of the Alzheimer's Eye.

Alzheimer's disease (AD) is the most prevalent form of dementia, accounting for 60-70% of all dementias. AD is often under-diagnosed and recognized only at a later, more advanced stage, and this delay in diagnosis has been suggested as a contributing factor in the numerous unsuccessful AD treatment trials. Although there is no known cure for AD, early diagnosis is important for disease management and care. A hallmark of AD is the deposition of amyloid-ß (Aß)-containing senile neuritic plaques and neurofibrillary tangles composed of hyperphosporylated tau in the brain. However, current in vivo methods to quantify Aß in the brain are invasive, requiring radioactive tracers and positron emission tomography. Toward development of alternative methods to assess AD progression, we focus on the retinal manifestation of AD pathology. The retina is an extension of the central nervous system uniquely accessible to light-based, non-invasive ophthalmic imaging. However, earlier studies in human retina indicate that the literature is divided on the presence of Aß in the AD retina. To help resolve this disparity, this study assessed retinal tissues from neuropathologically confirmed AD cases to determine the regional distribution of Aß in retinal wholemounts and to inform on future retinal image studies targeting Aß. Concurrent post-mortem brain tissues were also collected. Neuropathological cortical assessments including neuritic plaque (NP) scores and cerebral amyloid angiopathy (CAA) were correlated with retinal Aß using immunohistochemistry, confocal microscopy, and quantitative image analysis. Aß load was compared between AD and control (non-AD) eyes. Our results indicate that levels of intracellular and extracellular Aß retinal deposits were significantly higher in AD than controls. Mid-peripheral Aß levels were greater than central retina in both AD and control eyes. In AD retina, higher intracellular Aß was associated with lower NP score, while higher extracellular Aß was associated with higher CAA score. Our data support the feasibility of using the retinal tissue to assess ocular Aß as a surrogate measure of Aß in the brain of individuals with AD. Specifically, mid-peripheral retina possesses more Aß deposition than central retina, and thus may be the optimal location for future in vivo ocular imaging.

Ab interno suture tube occlusion of the Baerveldt glaucoma implant for management of postoperative hypotony: A case series

Purpose: Delayed hypotony can be a vision threatening complication following aqueous shunt surgery in patients with glaucoma. Multiple medical and surgical management strategies have been utilized, but results have been inconsistent. The present case series describes management of delayed hypotony associated with the Baerveldt glaucoma implant (BGI) by surgically introducing 4-0 polypropylene suture into the tube lumen. Observations: The cases of four patients who presented with hypotony following BGI surgery were reviewed. Following BGI tube lumen occlusion with suture, sustained intraocular pressure increase (mean 7.25 mmHg, range 4-14) was noted in all patients and visual acuity improved in three cases. Conclusions and importance: This is the first report of ab interno suture occlusion of the BGI for management of post-operative hypotony. Further studies are required to determine the utility of this procedure, but our results suggest that in select patients, ab interno suture occlusion be advantageous in managing delayed hypotony refractive to medical therapy.

Prospective analysis of emergency ophthalmic referrals in a Canadian tertiary teaching hospital.

OBJECTIVE: This study was conducted to analyze data from emergency ophthalmology referrals after hours from different hospitals to identify the most common pathologies and compare accuracy of diagnoses. Additionally, examination findings, including visual acuity (VA), intraocular pressure (IOP), and pupils from referring service and ophthalmic examination, were compared to assess agreement. DESIGN: This was a prospective study that reviewed information collected from referring services to the emergency on-call ophthalmology service and compared it with ophthalmic examination between February 2017 and July 2017. METHODS: The number of referrals from each hospital was reviewed. Referring physician provisional diagnosis, VA, IOP, and pupil assessment were collected to analyze the agreement between ophthalmic examination and diagnosis. RESULTS: The observed agreement rate was 67.0% between referring source and ophthalmic diagnosis. Posterior vitreous detachment (12.2%) was the most common diagnosis, followed by corneal abrasion (7.4%) and retinal detachment (5.3%). Referring services measured VA to be worse than on-call ophthalmology service (right eye Z = -5.47, p < 0.001; left eye Z = -5.44, p < 0.001), and IOP measurement by referring services was significantly higher (p < 0.05). The observed agreement rate of pupillary assessment was 91% between referring services and ophthalmology services. CONCLUSION: Data suggest that there is moderate agreement for diagnostic category between referring service and ophthalmology examination in regard to provisional diagnosis and pupillary assessment. Both VA and IOP were measured to be higher by referring services. This study highlights common emergency ophthalmic referrals and suggests potential areas for teaching initiatives for primary care physicians assessing ophthalmic emergency patients.

Association of Repeated Intravitreous Bevacizumab Injections With Risk for Glaucoma Surgery.

Importance: Intravitreous injections of anti-vascular endothelial growth factor (VEGF) agents are associated with a sustained increase in intraocular pressure. This sustained elevated intraocular pressure could lead to higher rates of glaucoma surgery to lower this pressure. Objective: To determine the risk of glaucoma surgery following repeated intravitreous bevacizumab injections. Design, Setting, Participants: This nested, case-control study acquired and analyzed data from large, population-based, linked health databases supported by the British Columbia Ministry of Health in Canada. Study participants included all patients with ophthalmic issues in British Columbia, such as those of the Provincial Retinal Diseases Treatment Program, who had received intravitreous bevacizumab injections for exudative age-related macular degeneration between January 1, 2009, and December 31, 2013. Cases were identified using glaucoma surgical codes for trabeculectomy, complicated trabeculectomy, glaucoma drainage device, and cycloablative procedure. For each case, 10 controls were identified and matched for age, preexisting glaucoma, calendar time, and follow-up time. The number of intravitreous bevacizumab injections received per year-3 or fewer, 4 to 6, or 7 or more-was determined for both cases and controls. Data analysis was performed from February 23, 2016, to November 14, 2016. Main Outcomes and Measures: Risk of glaucoma surgery compared with the number of intravitreous bevacizumab injections per year in cases and controls. Rate ratios were adjusted for covariates (diabetes mellitus, myocardial infarction, stroke, and verteporfin use). Results: Seventy-four cases of glaucoma surgery and 740 controls were identified, with a mean (SD) age of 81.3 (8.4) years for cases and 81.4 (7.9) for controls. The case group had more males than the control group (38 [51.4%] vs 272 [36.8%]). The adjusted rate ratio of glaucoma surgery among those who received 7 or more injections per year was 2.48 (95% CI, 1.25-4.93). There was a 10.3% higher number of 7 or more injections among cases compared with controls. The adjusted rate ratio for those who received 4 to 6 injections per year compared with those who received 3 or fewer was 1.65% (95% CI, 0.84-3.23). Conclusions and Relevance: Findings from this large, pharmacoepidemiologic study suggest that 7 or more intravitreous injections of bevacizumab annually is associated with a higher risk of glaucoma surgery and that 4 to 6 injections per year show a nonstatistically significant rate ratio in the same direction.

Iritis, glaucoma and corneal decompensation associated with BrightOcular cosmetic iris implant.

PURPOSE: NewColorIris cosmetic iris implants have a record of high ocular morbidity and are no longer in use. Newer generation of iris implants, BrightOcular, have patented posterior grooves in order to decrease iris touch and facilitate aqueous flow around the implant. However, little is known about their safety despite their implantations in 10 countries. METHODS: Collaborative case series of patients who had bilateral implantation of cosmetic iris implants solely for cosmetic reasons. RESULTS: 12 cases were collected being distributed as Caucasian (10) and Asian (2), women (11) and man (1) and with a mean age of 32 years. Ocular manifestations were present in 11 subjects and included anterior uveitis (10 of 12; 83.3%), glaucoma (7 of 12; 58.3%) and corneal decompensation (6 of 12; 50%). Visual acuity was normal in seven, decreased in five with two having visual recovery following explantation of the implant. Glaucoma could not be controlled medically in two patients. CONCLUSIONS: Cosmetic iris implants carry the risk of ocular damage when implanted in the anterior chamber of normal phakic eyes.

Risk for uveitis with oral moxifloxacin: a comparative safety study.

IMPORTANCE: Numerous case reports have suggested that the recent use of moxifloxacin may lead to uveitis. This epidemiologic study is, to our knowledge, the first to explore the relationship between oral moxifloxacin hydrochloride use and uveitis. OBSERVATIONS: We conducted a case-control study within a cohort of men aged 40 to 85 years followed up from January 2001 through December 2011. All cases with a new diagnosis of uveitis were identified. For each case, 10 control subjects were matched by age, cohort entry date, and follow-up duration. For identified uveitis cases, current use of moxifloxacin, levofloxacin, or ciprofloxacin hydrochloride was compared with nonuse. Rate ratios were adjusted for potential confounding variables. We identified 13,313 uveitis cases and 133,130 corresponding controls. Compared with nonusers of fluoroquinolones, current first-time users of moxifloxacin demonstrated the highest risk for uveitis (adjusted rate ratio, 2.98 [95% CI, 1.80-4.94]). Current first-time users of ciprofloxacin (adjusted rate ratio, 1.96 [95% CI, 1.56-2.47]) showed an increased risk for uveitis, while current first-time users of levofloxacin (adjusted rate ratio, 1.26 [95% CI, 0.90-1.77]) did not show a significant association with uveitis. CONCLUSION AND RELEVANCE: Current use of moxifloxacin or ciprofloxacin appears to increase the risk for uveitis. A statistically significant association of current first-time use of levofloxacin with uveitis could not be identified. Levofloxacin may pose the least risk for uveitis compared with moxifloxacin and ciprofloxacin.

GluN2A-/- Mice Lack Bidirectional Synaptic Plasticity in the Dentate Gyrus and Perform Poorly on Spatial Pattern Separation Tasks.

The different secondary subunits of the N-methyl-d-aspartate (NMDA) receptor each convey unique biophysical properties to the receptor complex, and may be key in determining the functional role played by NMDA receptors. In the hippocampus, the GluN2A and GluN2B subunits are particularly abundant; however, their exact roles in synaptic plasticity and behavior remain controversial. Here, we show that mice carrying a deletion for the GluN2A subunit (GluN2A(-/-)) demonstrate a severely compromised NMDA to AMPA receptor current ratio in granule cells from the dentate gyrus (DG), while granule cell morphology is unaltered. This deficit is accompanied by significant impairments in both LTP and LTD in the DG, whereas only minor impairments are observed in the CA1. In accordance with these hippocampal region-specific deficits, GluN2A(-/-) mice show impaired performance on the DG-associated task of spatial pattern separation. In contrast, GluN2A(-/-) mice show no deficit in temporal pattern separation, a process associated with CA1 functioning. Thus, our results establish the GluN2A subunit as a significant contributor to both bidirectional synaptic plasticity and spatial pattern separation in the DG.

Who knows more about immunization?: Survey of public health nurses and physicians.

OBJECTIVE: To report the findings of a knowledge survey of nurse and physician immunization providers. DESIGN: Cross-sectional postal survey assessing demographic characteristics and vaccine knowledge. SETTING: British Columbia (BC). PARTICIPANTS: Nurse and physician immunization providers in BC. MAIN OUTCOME MEASURES: Knowledge of vaccine-preventable diseases, vaccines in general, and vaccine administration and handling practices. RESULTS: Survey responses were received from 256 nurses and 292 physicians (response rates of 48.6% and 18.3%, respectively). Most nurses (98.4%) reported receiving immunization training outside of the academic setting compared with 55.6% of physicians. Overall, nurse immunizers scored significantly higher than physician immunizers on all 3 domains of immunization knowledge (83.7% vs 72.8%, respectively; P < .001). Physicians scored highest on the vaccine-preventable disease domain and least well on the general vaccine domain. Nurses with more experience as health care providers scored higher. Physicians scored higher if they were female, served patient populations predominantly younger than 5 years, or received immunization training outside of academic settings. CONCLUSION: In BC, nurse immunizers appear to have higher overall immunization knowledge than physicians and are more likely to receive immunization training when in practice. Physician immunizers might benefit most from further training on vaccines and vaccine administration and handling.

NMDA receptor hypofunction in the dentate gyrus and impaired context discrimination in adult Fmr1 knockout mice.

Fragile X syndrome (FXS) is the most common form of inherited intellectual disability in humans. This X-linked disorder is caused by the transcriptional repression of a single gene, Fmr1. The loss of Fmr1 transcription prevents the production of Fragile X mental retardation protein (FMRP) which in turn disrupts the expression of a variety of key synaptic proteins that appear to be important for intellectual ability. A clear link between synaptic dysfunction and behavioral impairment has been elusive, despite the fact that several animal models of FXS have been generated. Here we report that Fmr1 knockout mice exhibit impaired bidirectional synaptic plasticity in the dentate gyrus (DG) of the hippocampus. These deficits are associated with a novel decrease in functional NMDARs (N-methyl-D-aspartate receptors). In addition, mice lacking the Fmr1 gene show impaired performance in a context discrimination task that normally requires functional NMDARs in the DG. These data indicate that Fmr1 deletion results in significant NMDAR-dependent electrophysiological and behavioral impairments specific to the DG.

Overexpression of the cell adhesion protein neuroligin-1 induces learning deficits and impairs synaptic plasticity by altering the ratio of excitation to inhibition in the hippocampus.

Trans-synaptic cell-adhesion molecules have been implicated in regulating CNS synaptogenesis. Among these, the Neuroligin (NL) family (NLs 1-4) of postsynaptic adhesion proteins has been shown to promote the development and specification of excitatory versus inhibitory synapses. NLs form a heterophilic complex with the presynaptic transmembrane protein Neurexin (NRX). A differential association of NLs with postsynaptic scaffolding proteins and NRX isoforms has been suggested to regulate the ratio of excitatory to inhibitory synapses (E/I ratio). Using transgenic mice, we have tested this hypothesis by overexpressing NL1 in vivo to determine whether the relative levels of these cell adhesion molecules may influence synapse maturation, long-term potentiation (LTP), and/or learning. We found that NL1-overexpressing mice show significant deficits in memory acquisition, but not in memory retrieval. Golgi and electron microscopy analysis revealed changes in synapse morphology indicative of increased maturation of excitatory synapses. In parallel, electrophysiological examination indicated a shift in the synaptic activity toward increased excitation as well as impairment in LTP induction. Our results demonstrate that altered balance in the expression of molecules necessary for synapse specification and development (such as NL1) can lead to defects in memory formation and synaptic plasticity and outline the importance of rigidly controlled synaptic maturation processes.

Cognition, learning behaviour and hippocampal synaptic plasticity are not disrupted in mice over-expressing the cholesterol transporter ABCG1.

BACKGROUND: Cognitive deficits are a hallmark feature of both Down Syndrome (DS) and Alzheimer's Disease (AD). Extra copies of the genes on chromosome 21 may also play an important role in the accelerated onset of AD in DS individuals. Growing evidence suggests an important function for cholesterol in the pathogenesis of AD, particularly in APP metabolism and production of A beta peptides. The ATP-Binding Cassette-G1 (ABCG1) transporter is located on chromosome 21, and participates in the maintenance of tissue cholesterol homeostasis. RESULTS: To assess the role of ABCG1 in DS-related cognition, we evaluated the cognitive performance of mice selectively over-expressing the ABCG1 gene from its endogenous regulatory signals. Both wild-type and ABCG1 transgenic mice performed equivalently on several behavioral tests, including measures of anxiety, as well as on reference and working memory tasks. No deficits in hippocampal CA1 synaptic plasticity as determined with electrophysiological studies were apparent in mice over-expressing ABCG1. CONCLUSION: These findings indicate that although ABCG1 may play a role in maintaining cellular or tissue cholesterol homeostasis, it is unlikely that excess ABCG1 expression contributes to the cognitive deficits in DS individuals.

Exercising our brains: how physical activity impacts synaptic plasticity in the dentate gyrus.

Exercise that engages the cardiovascular system has a myriad of effects on the body; however, we usually do not give much consideration to the benefits it may have for our minds. An increasing body of evidence suggests that exercise can have some remarkable effects on the brain. In this article, we will introduce how exercise can impact the capacity for neurons in the brain to communicate with one another. To properly convey this information, we will first briefly introduce the field of synaptic plasticity and then examine how the introduction of exercise to the experimental setting can actually alter the basic properties of synaptic plasticity in the brain. Next, we will examine some of the candidate physiological processes that might underlay these alterations. Finally, we will close by noting that, taken together, this data points toward our brains being dynamic systems that are in a continual state of flux and that physical exercise may help us to maximize the performance of both our body and our minds.