A Case of Bilateral Diffuse Uveal Melanocytic Proliferation Followed by Massive Unilateral Uveal Proliferation.

OBJECTIVE: To report a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) followed by massive unilateral uveal proliferation. METHODS: Retrospective case report. RESULTS: A 47-year-old female with history of metastatic ovarian carcinoma initially presented with bilateral vision loss and multifocal red patches on posterior poles consistent with BDUMP. Five years later, she presented with bilateral neovascular glaucoma and unilateral iris and ciliary body mass concerning for malignancy. Enucleation revealed diffuse uveal growth involving almost the entirety of the uveal tract. CONCLUSIONS: BDUMP can rarely be associated with uveal proliferation. Routine examinations are recommended to monitor for any changes concerning malignancy.

Predictors of Intraocular Pressure Lowering after Phacoemulsification and iStent Implantation.

PURPOSE: To explore the demographic and clinical variables associated with intraocular pressure (IOP) lowering after cataract extraction (CE) alone or CE in combination with the iStent (Glaukos Corporation) placement (CE+IS). DESIGN: Retrospective data extraction and survival analysis of consecutive patients identified over a 2-year period. PARTICIPANTS: Patients with mild to moderate glaucoma who underwent CE (48 eyes of 32 patients) or CE+IS (61 eyes of 37 patients) were analyzed. METHODS: Inability to reduce the number of medications or the IOP by at least 20% compared with baseline on 2 consecutive visits was considered surgical failure. Using Cox proportional hazards models, survival analysis was performed, and demographic and clinical variables were evaluated as risk factors. MAIN OUTCOME MEASURES: Time to failure after surgical procedure. RESULTS: CE+IS had lower odds of failure than CE alone (hazard ratio [HR], 2.01; P = 0.047). In White patients, CE+IS showed greater odds of success compared with CE alone (HR, 2.86; P = 0.007). For non-White patients, no difference was found in the outcomes for the 2 procedures (HR, 0.59; P = 0.48). In the multivariate analysis, non-White race (HR, 8.75; P = 0.0002) and longer axial length (HR, 1.61; P = 0.03) were associated with greater hazard of failure after CE+IS. In the CE group, greater odds of failure were associated with steeper corneal curvature (HR, 1.74; P = 0.008), shallower anterior chamber (HR, 0.22; P = 0.008), and longer axial length (HR, 1.58; P = 0.01). CONCLUSIONS: Addition of the iStent to CE improved the duration of IOP lowering in White patients, but not in non-White patients. Associations between IOP lowering after CE and biometric parameters may allow for leveraging these clinical parameters for better case selection for these procedures.

Pneumotonometer Accuracy Using Manometric Measurements after Radial Keratotomy, Clear Corneal Incisions and Lamellar Dissection in Porcine Eyes.

Purpose/Aim of the study: Measured intraocular pressure (IOP) after corneal incisions may not be reflective of the true IOP because of changes in corneal biomechanical properties. The purpose of this study is to investigate the effect of various corneal incisions on pneumotonometer accuracy in enucleated porcine eyes.Materials and Methods: A pneumotonometer was used to measure IOP (IOPp) at manometrically controlled pressure levels of 10, 20, 30 and 40 mmHg in enucleated porcine eyes. IOP measurements at each level were repeated after one of the following corneal incisions: radial keratotomy (8 eyes), lamellar dissection (10 eyes), clear cornea standard phacoemulsification incisions (10 eyes). The pneumotonometer error, defined as the difference between IOPp and manometric pressure (IOPm), was calculated for each pressure level. The error before the corneal incisions was compared to the error after the corneal incisions to assess the accuracy of the pneumotonometer.Results: The pneumotonometer underestimates true IOP at all pressure levels, both before and after the corneal procedures. There was a statistically significant greater underestimation of IOP after radial keratotomy incisions at pressure levels of 20, 30 and 40 mmHg (p = .013, 0.004, and 0.002, respectively). There was no statistically significant difference in the amount of pneumotonometer underestimation error after lamellar dissection or standard cataract incisions.Conclusion: The pneumotonometer underestimates true IOP in enucleated porcine eyes at all pressure levels between 10-40 mmHg. Radial keratotomy incisions caused a statistically significant greater underestimation error in pneumotonometry measurements at pressures of 20-40 mmHg. Lamellar dissection and clear corneal cataract incisions did not cause an additional error in pneumotonometry measurements in enucleated porcine eyes.

Large Capsulorhexis Related Uveitis-Glaucoma-Hyphema Syndrome Managed by Intraocular Lens Implant Exchange and Gonioscopy Assisted Transluminal Trabeculotomy.

PURPOSE: To report a case of uveitis-glaucoma-hyphema syndrome (UGHS) secondary to a large capsulorhexis with an intracaspular intraocular lens (IOL) managed with IOL exchange and gonioscopy assisted transluminal trabeculotomy (GATT). CASE REPORT: A 73-year-old male patient presented with UGHS of the right eye in the setting of an intracapsular single-piece acrylic IOL with circumferential optic and partial haptics exposure due to a large capsulorhexis. In lieu of the patient's uncomplicated surgical history, subtle symptoms, and clinical findings, the diagnosis and referral was delayed until intraocular pressure reached a peak of 50 mmHg with recurrent anterior chamber cells. The patient underwent combined IOL exchange with placement of a 3-piece sulcus IOL and GATT, which finally resolved the UGHS. CONCLUSION: With respect to the increasing prevalence of intracapsular single-piece IOL implantation, it is important to recognize UGHS and thus fashion proper sized capsulorhexis to prevent this vision threatening complication. GATT may be considered to be one of the glaucoma surgeries combined with the IOL surgical procedures in UGHS.

Variation in Prostaglandin Analog Prices Paid for Through Medicare Part D.

OBJECTIVE: Determine the prices and price variation of the prostaglandin analogs (PGAs) used in the United States and examine their trends from 2013 to 2016 using Medicare Part D data. DESIGN: This is a retrospective cross-sectional study. PARTICIPANTS: All ophthalmologists and optometrists in all 50 states and DC who prescribed any PGA purchased through Part D from 2013 through 2016. MATERIALS AND METHODS: Outcome measures were calculated using Excel 2016 based off of the 2013 to 2016 Medicare Part D Prescriber Data. MAIN OUTCOME MEASURES: The 2013 to 2016 nationwide prices of 7 PGAs, the states with the 2016 minimum and maximum average prices, the SDs in PGA prices among the cities in each state, and the nationwide average of these SDs for 2013 to 2016. RESULTS: The 2016 nationwide prices of 30-day supplies of bimatoprost, latanoprost, lumigan, travatan Z, travoprost, xalatan, and zioptan in 2016 were: $107.90±25.19, $10.16±1.52, $167.30±17.66, $171.36±19.44, $92.53±15.14, $153.41±15.16, and $162.75±13.22, respectively. Each drug's SD in city prices within each state averaged nationwide for 30-day supplies in 2016 were $10.89, $1.44, $16.68, $17.23, $10.30, $10.07, and $9.48, respectively. Spending on these drugs totaled $861,180,924 in 2016. There was less price variation within each state as compared with the whole country. No substantial decreases in price variation exist for any drug from 2013 to 2016. CONCLUSIONS: There is substantial variation in PGA prices when purchased by Medicare Part D enrollees across the United States and within each state itself. Simultaneously, the prices and total expenditure on these medications are increasing yearly. Physicians should be cognizant of this price variation for these expensive and chronically used drugs and should educate patients to optimize their Part D supplemental plan.

The Water-Drinking Test Revisited: An Analysis of Test Results in Subjects with Glaucoma.

PURPOSE: The Water-Drinking Test (WDT) has been shown to predict the diurnal IOP change. This study evaluates the factors that may affect the WDT results. METHODS: This study was conducted on 203 glaucoma patients who had undergone trabeculectomy (53) or tube surgery (31), or had a medically controlled open-angle (82) or closed-angle (37) glaucoma. IOP was measured at baseline and then every 15 minutes over a one-hour period after drinking water. The main outcome measures were IOP change (increase in IOP from baseline) at all measurement time points, IOP peak (highest IOP after drinking water), IOP fluctuation (difference between IOP peak and baseline), and assessing the association of these IOPs with a patient's demographic and management modalities. RESULTS: The mean age of the participants was 54±18 years, and 113 (56%) were male. Female patients showed greater IOP fluctuation than males (7.28 vs. 5.92 mm Hg; P=0.016), and a greater IOP peak (22.7 vs. 20.1 mm Hg; P=0.001). The observed associations between gender and IOP changes were only significant in <50 years. IOP at 60 minutes was greater in tube than trabeculectomy (5.6 vs. 3.1 mm Hg; P=0.007). The number of topical medications showed a direct independent association with IOP changes (P<0.001). Compared to other classes of topical medications, latanoprost showed lower WDT-IOP profile (P=0.0003). CONCLUSIONS: WDT-IOP change was diminished in subjects on latanoprost, and was greater in females <50 years, and those on greater number of medications.

Mechanism of Action of Selective Laser Trabeculoplasty and Predictors of Response.

Purpose: This study was designed to evaluate the changes in aqueous humor dynamics (AHD) produced by selective laser trabeculoplasty (SLT) and to explore if baseline AHD parameters are predictive of IOP response to SLT. Methods: Thirty-one consecutive subjects diagnosed with ocular hypertension or primary open-angle glaucoma scheduled to undergo SLT as their primary IOP-lowering therapy were enrolled in this prospective observational study. Subjects underwent baseline assessment of AHD in both eyes. Variables assessed were IOPs at 9 AM and noon, aqueous humor flow rate (fluorophotometry), episcleral venous pressure (EVP, venomanometry), outflow facility (pneumatonography and fluorophotometry) and uveoscleral outflow (calculated using modified Goldmann equation). All subjects underwent 360 degrees SLT and AHD measurements were repeated 3 months later. Results: Compared with baseline, IOPs after SLT were significantly lower at 9 AM (22.9 ± 5.1 vs. 19.7 ± 3.0 mm Hg; P = 0.001) and noon (23.4 ± 4.6 vs. 20.0 ± 3.5 mm Hg; P < 0.001). Outflow facility by fluorophotometry was significantly increased from 0.17 ± 0.11 µL/min/mm Hg at baseline to 0.24 ± 0.14 µL/min/mm Hg at 3 months (P = 0.008). Outflow facility by tonography (baseline: 0.16 ± 0.07 µL/min/mm Hg vs. 3 months: 0.22 ± 0.16 µL/min/mm Hg; P = 0.046) was similarly increased. No change in aqueous flow or EVP was observed. There were no changes in IOP or AHD in the contralateral untreated eye. Using multiple linear regression models, higher baseline aqueous flow, lower baseline outflow facility, and possibly lower uvescleral outflow were associated with more IOP lowering with SLT. Conclusions: The IOP-lowering effect of SLT is mediated through an increase in outflow facility. There is no contralateral effect. Higher aqueous flow and lower outflow facility may be predictive of better response to SLT.

Trabeculectomy bleb-associated infections.

Trabeculectomy with antimetabolites is the most commonly performed surgery worldwide for glaucoma patients with progressive optic nerve head injury and visual field loss despite maximum pharmacologic intraocular pressure-lowering therapy. Trabeculectomy bleb-associated infections remain one of the most feared early and long-term complications of trabeculectomy surgery because of their poor prognosis and variable response to antimicrobial therapy. Several studies have evaluated how surgical technique, conjunctival incision location, comorbid ocular pathology, concurrent medication use, and bleb morphology affect the risk of bleb-associated infection. New surgical techniques and devices aim to achieve a similar intraocular pressure reduction profile to trabeculectomy while avoiding the presence of a conjunctival bleb. We provide a comprehensive review of studies evaluating risk factors for bleb-associated infection after trabeculectomy and propose a diagnostic and therapeutic approach to bleb-associated infection.

Neovascular Glaucoma.

Neovascular glaucoma (NVG) is a secondary ocular pathological condition resulting from a myriad of ocular and systemic conditions with retinal ischemia as a mediator in over 95% of cases. NVG is caused by the growth of a fibrovascular membrane secondary to a local angiogenic stimulus over the trabecular meshwork obstructing aqueous outflow. This results in an initial secondary open-angle glaucoma stage that may be amenable to intraocular pressure (IOP)-lowering medications and modulation of the underlying ischemic process, often in combination with panretinal photocoagulation and adjunctive use of vascular endothelial growth factor inhibitors. In the more advanced stages of neovascularization, connective tissue myofibroblasts associated with new vessel growth contract causing progressive synechial closure of the anterior-chamber angle. Elevation of IOP, once significant secondary angle closure is established, tends to be refractory to topical and oral IOP-lowering medications and often requires glaucoma surgical interventions.

Listeria monocytogenes panophthalmitis: a novel strain follows a virulent course.

PURPOSE: To describe the findings and clinical course of a case of Listeria endophthalmitis as it progressed to panophthalmitis despite vitrectomy and intravitreal and systemic antibiotic therapy. METHODS: A case report of Listeria endophthalmitis progressing to panophthalmitis with a brief retrospective review of the literature pertaining to Listeria-related eye infections and endogenous endophthalmitis. RESULTS: A 70-year-old man presented with fulminant, hypertensive endophthalmitis and underwent pars plana vitrectomy, vitreous tap for Gram stain and culture, with intravitreal antibiotic injection and systemic intravenous antibiotic therapy, given the concern for an endogenous source. Despite this treatment, the patient progressed to no light perception vision with progressive orbital inflammatory signs. He then required enucleation with pathology, demonstrating an acute necrotizing panophthalmitis. DISCUSSION: This case demonstrates the importance of a high index of suspicion for endophthalmitis in the setting of progressive uveitis despite titration of topical corticosteroid therapy while describing the preferred management and antibiotic regimen for patients with Listeria-related infections. Previous reported cases of Listeria endophthalmitis characteristically present as a hypertensive endophthalmitis with pigment dispersion and a dark hypopyon. If endophthalmitis is suspected, an anterior chamber paracentesis with Gram stain and culture can aid in earlier diagnosis, thus allowing for prompt, targeted therapy and improved outcomes.