Glaucoma triage system: results of implementing a virtual clinic.

PURPOSE: This study describes the virtual clinic triage system implementation process at Hospital Santa Maria-Centro Hospitalar Universitário Lisboa Norte (HSM-CHULN) and analyzes its results regarding healthcare outcomes for the patients and the system. METHODS: A retrospective analysis was performed, comparing two cohorts (pre-virtual cohort; virtual triage cohort). Outcomes related to waiting time, number of hospital visits, decisions at first contact, and ancillary exam-based decisions were reported. RESULTS: Two hundred and ninety-two charts were reviewed (pre-virtual cohort: 132; virtual cohort: 160). Mean waiting time between referral and the first medical contact with the glaucoma department decreased on average by 71.3 days (human contact: 286.6 days; virtual triage contact: 215.3 days). Triage system significantly decreased waiting time for glaucoma patients, with an average decrease of 326.8 days between referral and treatment decision. Triage staging allowed to label 107 (66.9; 95% confidence intervals (CI): 59.6%, 74.2%) as non-urgent; 30 (18.8%; 95% CI: 12.7%, 24.9%) as urgent, and 23 (14.3%; 95% CI: 8.9%, 19.7%) as immediate contact, with the scheduling of future appointments reflecting National Institute for Health and Care Excellence (NICE) guidelines in every patient. Moreover, the number of visits to perform the same exams and obtain the same clinical decisions was reduced by 63.6%. CONCLUSION: Our virtual screening strategy significantly decreased waiting time, number of hospital visits, and increased chances of data-assisted clinical decision. While results can be further improved, this system can add value in an overburdened healthcare system, where triage systems with remote decision-making may be valuable tools in optimizing glaucoma care, even without allocation of extra resources.

Graphene Biosensors-A Molecular Approach.

Graphene is the material elected to study molecules and monolayers at the molecular scale due to its chemical stability and electrical properties. The invention of scanning tunneling microscopy has deepened our knowledge on molecular systems through imaging at an atomic resolution, and new possibilities have been investigated at this scale. Interest on studies on biomolecules has been demonstrated due to the possibility of mimicking biological systems, providing several applications in nanomedicine: drug delivery systems, biosensors, nanostructured scaffolds, and biodevices. A breakthrough came with the synthesis of molecular systems by stepwise methods with control at the atomic/molecular level. This article presents a review on self-assembled monolayers of biomolecules on top of graphite with applications in biodevices. Special attention is given to porphyrin systems adsorbed on top of graphite that are able to anchor other biomolecules.

Graphene Oxide Thin Films with Drug Delivery Function.

Graphene oxide has been used in different fields of nanomedicine as a manager of drug delivery due to its inherent physical and chemical properties that allow its use in thin films with biomedical applications. Several studies demonstrated its efficacy in the control of the amount and the timely delivery of drugs when it is incorporated in multilayer films. It has been demonstrated that oxide graphene layers are able to work as drug delivery or just to delay consecutive drug dosage, allowing the operation of time-controlled systems. This review presents the latest research developments of biomedical applications using graphene oxide as the main component of a drug delivery system, with focus on the production and characterization of films, in vitro and in vivo assays, main applications of graphene oxide biomedical devices, and its biocompatibility properties.

XEN-augmented Baerveldt Failure: Three Different Revision Approaches for Pediatric Patients.

AIM AND OBJECTIVE: Report three different solutions in case of XEN-augmented Baerveldt fails. BACKGROUND: Drainage devices have been used for refractory pediatric glaucoma. To avoid early hypotony and corneal damage, Mermoud et al. introduced the augmentation of a XEN implant with a Baerveldt tube. In some cases, this technique fails to lead to a high intraocular pressure (IOP) and surgical revision. CASE DESCRIPTION: Three cases of children with this combined implant needed surgical revision due to high IOP. Three different approaches were performed: XEN replacement in one case, stretching the Baerveldt's tube into the anterior chamber (AC) in the second case, and explant of the device followed by an implant of a new Baerveldt-250 in the same quadrant in the third case. Successful control of IOP (>18 mm Hg) was achieved in all patients under no topical treatment. CONCLUSION: Despite the attractiveness of the XEN-augmented Baerveldt implant in refractory pediatric glaucoma as an alternative to conventional surgery, we have to learn how to deal with failures. Three different approaches are presented with good short-term results. The long-term efficacy is yet to be assessed. CLINICAL SIGNIFICANCE: Describe three possible options when faced with a need for surgical revision in XEN-augmented Baerveldt implant. HOW TO CITE THIS ARTICLE: José P, Abegão Pinto L, Teixeira FJ. XEN-augmented Baerveldt Failure: Three Different Revision Approaches for Pediatric Patients. J Curr Glaucoma Pract 2021;15(2):96-98.

Ultrasound Cyclo Plasty for Treatment of Surgery-Naïve Open-Angle Glaucoma Patients: A Prospective, Multicenter, 2-Year Follow-Up Trial.

BACKGROUND: The purpose of this prospective study was to evaluate the efficacy and safety of the Ultrasound Cyclo Plasty (UCP) procedure using high-intensity focused ultrasound in surgery-naïve open-angle glaucoma patients. METHODS: prospective, non-randomized, single-arm, multicenter clinical trial. Sixty-six eyes with primary open-angle glaucoma, intraocular pressure (IOP) ≥21 mmHg and with no history of filtering surgery were enrolled. Patients were treated by UCP with a therapy probe comprising six piezoelectric transducers, consecutively activated for 8 s each. Complete ophthalmic examination was performed before the procedure, 1 day after the procedure, and 1, 3, 6, 12, 18 and 24 months after the procedure. Primary outcomes were complete success (defined as IOP lowering from baseline ≥20% without additional glaucoma medications) and vision-threatening complications. Secondary outcomes were the presence of complications and the reduction of the number of medications used. RESULTS: IOP was significantly reduced after one procedure (p < 0.05), from a mean pre-operative value of 24.3 ± 2.9 mmHg (n = 2.3 hypotensive medications) to a mean value of 15.9 ± 3.6 mmHg (n = 2.2 hypotensive medications) at 2 years (mean IOP lowering of 33%). Surgical success was achieved in 74% of eyes. Notwithstanding side effects such as transient anterior chamber inflammation, refractive error changes, transient hypotony and macular edema, no major intra or post-operative complications such as phthisis, induced cataract, neovascularization or significant vision loss were observed. CONCLUSIONS: Ultrasound Cyclo Plasty is a valuable, effective and well-tolerated procedure to lower IOP in patients with open-angle glaucoma without previous filtering surgery.

Automated Gonioscopy Assessment of XEN45 Gel Stent Angle Location After Isolated XEN or Combined Phaco-XEN Procedures: Clinical Implications.

PRéCIS:: Angle location of the XEN implant both in isolated and in combined procedures did not appear to influence long-term outcomes. However, more posterior stent placements seem to be associated with increased early postoperative complications. PURPOSE: The purpose of this study was to assess success and safety outcomes of different levels of insertion of the XEN45 gel stent in the angle in standalone and combined procedures. METHODS: This was a cross-sectional study of patients in whom XEN had been implanted without intraoperative gonioscopy. Automated gonioscopy was used for postoperative analysis of the XEN location, classified as anterior or posterior relative to the scleral spur. Absolute success was defined as ≥20% intraocular pressure decrease from baseline and ranging from 6 to 21 mm Hg without medication and qualified success if medicated. The need for additional drainage surgery was considered failure, but needling was allowed. Clinical data were retrieved from patient files. RESULTS: Gonioscopy-assisted XEN location was performed on 42 eyes of 33 patients (14 isolated and 28 combined procedures) on average 18±9 months after surgery. Absolute (32% vs. 35%; P>0.99) and qualified (44% vs. 65%; P=0.22) success was similar in both anterior and posterior placements, respectively. Kaplan-Meier survival analysis yielded similar median survival times for both groups. The distribution of XEN insertion level in the angle was similar in standalone and combined procedures (P=0.75). Although overall safety outcome measures did not differ significantly, the proportion of intraoperative and early postoperative complications was higher in posterior XEN placements (P=0.03). CONCLUSIONS: Different locations of XEN45 did not seem to significantly impact late success and safety outcomes, although stents inserted more posteriorly may be associated with a higher rate of early complications. Combined implantation of XEN with phacoemulsification does not seem to influence stent location in the iridocorneal angle in a setting without intraoperative gonioscopy.

Choroidal binarization analysis: clinical application.

INTRODUCTION: Image processing of optical coherence tomography scans through binarization techniques represent a non-invasive way to separately asses and measure choroidal components, in vivo. In this review, we systematically search the scientific literature regarding binarization studies published so far. METHODS: A systematic research was conducted at PubMed database, including English literature articles for all of the following terms in various combinations: binarization, choroid/al, enhanced depth spectral domain/swept source optic coherence tomography, and latest publications up to November 2018 were reviewed. RESULTS: Thirty-seven articles were included and analyzed regarding studied disease, binarization method, studied variables, and outcomes. Most of the studies have focused on the more common retinal pathologies, such as age-related macular degeneration, central serous chorioretinopathy and diabetic retinopathy but binarization techniques have also been applied to the study of choroidal characteristics in ocular inflammatory diseases, corneal dystrophies and in postsurgical follow-up. Advantages and disadvantages of binarization techniques are also discussed. CONCLUSION: Binarization of choroidal images seems to represent a promising approach to study choroid subcomponents in an increasingly detailed manner.

Nanotechnology-Ocular Devices for Glaucoma Treatment: A Literature Review.

Nanotechnology enabled the development of materials and devices with great utility in different fields of medicine. By using engineered-based nano-devices and structures, human biological systems may be controlled and repaired at a molecular scale, ultimately leading to a biological benefit. In particular, in the field of glaucoma treatment, nanotechnology may, for example, enhance drug residence time on the ocular surface and ocular bioavailability, as well as improve surgical success by both optimizing postoperative scarring and providing a wider safety window. Further studies are still needed to entirely explain the pharmacodynamics of nanotechnology-based therapeutic approaches and prove their biological consequences in human eyes. This review aims to summarize the literature concerning the advances in nanotechnology, specifically regarding ocular devices applied to the treatment of glaucoma.

High-intensity Focused Ultrasound Cycloplasty: Analysis of Pupil Dynamics.

AIM: High-intensity focused ultrasound cystoplasty (UCP) aims to noninvasively and selectively target the ciliary body, thus lowering intraocular pressure (IOP). To be used on a large scale, the safety of the UCP procedure should be studied. Therefore, its effect on pupil behavior is important to better inform patients and to help physicians predict possible treatment side effects. This study aimed to evaluate to what extent UCP procedure (EyeOP-1®) affects pupil dynamics. MATERIALS AND METHODS: Consecutive glaucoma patients with uncontrolled IOP despite optimal medication scheduled for UCP treatment were recruited and followed for 6 months. Pupillometry (PlusoptiX® S04) was performed at baseline, and 1, 3 and 6 months after UCP procedure at scotopic and mesopic conditions. The difference between pupil diameter (PD) in both lighting conditions was calculated at the three follow-up visits. Demographic, clinical characteristics and specific ocular parameters (anterior chamber depth and volume, white-to-white measurement, axial length, phakic status) were registered. Statistical analysis was performed using STATA 14.1. RESULTS: Sixteen eyes of 16 patients with a mean age of 69 ± 11 years were included. Mean preoperative IOP and number of medications were 23.6 ± 3.0 mm Hg and 2.4 ± 1.3, respectively. Mean baseline scotopic and mesopic PD were 4.8 ± 0.8 mm and 4.4 ± 0.9 mm, respectively (difference = 0.38 ± 0.30 mm; range 0.1 to 1.2 mm). At month-1, the pupil diameter (PD) change between scotopic (4.6 ± 0.7 mm) and mesopic (4.5 ± 0.8 mm) conditions decreased to 0.03 ± 0.34 mm, p = 0.01. On the longer follow-up periods, however, the amplitude difference in PD compared to baseline was no longer significant (month-3: 0.28 ± 0.49 mm; month 6: 0.23 ± 0.41 mm; p >0.05). At the end of follow-up, mean scotopic and mesopic PD were 4.7 ± 1.0 mm and 4.4 ± 0.9 mm, respectively. CONCLUSION AND CLINICAL SIGNIFICANCE: In the early postoperative period after UCP treatment, most patients present with a less light-reactive pupil, which seems to normalize with time. HOW TO CITE THIS ARTICLE: Sousa DC, Ferreira NP, Marques-Neves C, Somers A, Vandewalle E, Stalmans I, Pinto LA. High-intensity Focused Ultrasound Cycloplasty: Analysis of Pupil Dynamics. J Curr Glaucoma Pract 2018;12(3):102-106.

Corneal properties and glaucoma: a review of the literature and meta-analysis.

PURPOSE: Studies have suggested that corneal biomechanical properties influence intraocular pressure (IOP) measurements, namely central corneal thickness (CCT) and corneal hysteresis (CH). The present study aimed to investigate the associations of CH and CCT with glaucoma development. METHODS: We performed a review of the literature and meta-analysis of observational studies (2006-2016) that included both adult glaucoma patients and controls and reported CCT and CH as outcomes. Nineteen studies were conside red eligible, and the mean difference (MD) between groups (patient and control) for both variables was used for statistical analyses. RESULTS: A total of 1,213 glaucoma and 1,055 healthy eyes were studied. Quan titative analysis suggested that CH was significantly lower in the glaucoma group than in the control group (MD=-1.54 mmHg, 95% CI [-1.68, -1.41], P<0.0001). Additionally, CCT was significantly lower in the glaucoma group than in the control group (MD=-8.49 µm, 95% CI [-11.36, -5.62], P<0.001). CONCLUSION: Corneal properties appear to differ between glaucoma patients and healthy controls. Our results emphasize the importance of corneal biomechanical properties in IOP interpretation and should support further studies on the influence of CH and CCT in glaucoma screening and diagnosis.

Corneal properties and glaucoma: a review of the literature and meta-analysis / Propriedades da córnea e glaucoma: revisão da literatura e meta-análise

ABSTRACT Purpose: Studies have suggested that corneal biomechanical properties influence intraocular pressure (IOP) measurements, namely central corneal thickness (CCT) and corneal hysteresis (CH). The present study aimed to investigate the associations of CH and CCT with glaucoma development. Methods: We performed a review of the literature and meta-analysis of observational studies (2006-2016) that included both adult glaucoma patients and controls and reported CCT and CH as outcomes. Nineteen studies were conside red eligible, and the mean difference (MD) between groups (patient and control) for both variables was used for statistical analyses. Results: A total of 1,213 glaucoma and 1,055 healthy eyes were studied. Quan titative analysis suggested that CH was significantly lower in the glaucoma group than in the control group (MD=-1.54 mmHg, 95% CI [-1.68, -1.41], P<0.0001). Additionally, CCT was significantly lower in the glaucoma group than in the control group (MD=-8.49 µm, 95% CI [-11.36, -5.62], P<0.001). Conclusion: Corneal properties appear to differ between glaucoma patients and healthy controls. Our results emphasize the importance of corneal biomechanical properties in IOP interpretation and should support further studies on the influence of CH and CCT in glaucoma screening and diagnosis.

RESUMO Objetivo: A literatura sugere que as propriedades biomecânicas da córnea, nomeadamente a espessura central da córnea (ECC) e a histerese corneana (HC), influenciam a medição da pressão intraocular (PIO). Este estudo teve como objetivo investigar a associação entre a ECC e a HC e o desenvolvimento de glaucoma. Métodos: Revisão da literatura e meta-análise. Foram incluídos estudos observacionais, publicados entre 2006 e 2016, que integrassem um grupo controle e um grupo de pacientes com glaucoma em que estes dois grupos apresentassem, igualmente, a ECC e a HC como parâmetros. Dezenove estudos foram considerados elegíveis e a diferença média (MD) daqueles parâmetros nos dois grupos foi utilizada para análise estatística. Resultados: Estudaram-se um total de 1.213 olhos com glaucoma e 1.055 olhos saudáveis. A análise quantitativa revelou que a HC é significativamente mais baixa no grupo de doentes com glaucoma quando comparada com o grupo controle (MD=-1,54 mmHg, intervalo de confiança de 95% [-1,68-1,41], P<0,00001). A ECC foi, também, significativamente mais baixa no grupo glaucoma quando comparada com os indivíduos saudáveis MD=-8,49 µm, intervalo de confiança de 95% [-11,36, -5,62], P<0,001). Conclusão: Os pacientes com glaucoma parecem possuir propriedades corneanas diferentes das que apresentam os indivíduos saudáveis. Os resultados enfatizam a importância das propriedades biomecânicas da córnea na interpretação da PIO e devem contribuir para novos estudos sobre a influência da HC e da ECC no rastreio e diagnóstico do glaucoma.

A Rare Manifestation of Uveitis-glaucoma-hyphema Syndrome.

AIMS: To report a case of a patient who developed uveitis-glaucoma-hyphema (UGH) syndrome after an uneventful cataract surgery and to discuss risk factors, diagnostic challenges, management options, and clinical implications. BACKGROUND: Uveitis-glaucoma-hyphema syndrome is a rare but potentially serious cataract surgery complication. Clinical manifestations include increased intraocular pressure (IOP), anterior chamber inflammation, and recurrent hyphema or microhyphema. Uveitis-glaucoma-hyphema Plus syndrome also includes accompanying vitreous hemorrhage. Although classically associated with rigid anterior chamber intraocular lenses (lOLs), cases of malpositioning and subluxated posterior chamber lOLs have also been described as possible triggers. CASE DESCRIPTION: We report a case of a 70-year-old Caucasian man who developed UGH Plus syndrome after an uneventful cataract surgery with an lOL implanted in the capsular bag. During postoperative follow-up, persistent intraocular inflammation, increased IOP, hyphema, and vitreous hemorrhage were consistent with this diagnosis. Slit-lamp examination demonstrated progressive localized iris atrophy, compatible with chafing of the posterior iris by the IOL haptic as the trigger for UGH syndrome. A pars plana vitrectomy was performed and a retropupillary intraocular lens was implanted. No further complications occurred during follow-up. CONCLUSION AND CLINICAL SIGNIFICANCE: Given the increasing prevalence of single-piece lOLs implanted in the capsular bag, it is important to recognize UGH syndrome as a rare but potentially serious complication. How to cite this article: Sousa DC, Leal I, Faria MY, Pinto LA. A Rare Manifestation of Uveitis-glaucoma-hyphema Syndrome. J Curr Glaucoma Pract 2016;10(2):76-78.

The Conjunctiva in Normal Tension Glaucoma Patients is Thinner Than in Primary Open-Angle Glaucoma Patients: A Comparative Histologic Study.

PURPOSE: To compare histologically the thickness of conjunctival specimens of normal tension glaucoma (NTG) patients with primary open-angle glaucoma (POAG) patients. MATERIALS AND METHODS: In this prospective study, 54 patients scheduled for trabeculectomy were categorized into NTG and POAG based on their maximum untreated intraocular pressure at any time (IOPmax) as measured by Goldmann applanation tonometry. Sixteen patients with NTG (IOPmax≤21 mm Hg) and 36 patients with high tension POAG (IOPmax>21 mm Hg) were included in the study. Biopsies were taken from the superior bulbar conjunctiva during trabeculectomy. The specimens were fixed in formalin, embedded in methacrylate, histologically sectioned, stained with toluidine blue, and analyzed with a light microscope. The stromal conjunctival thickness (CT) was measured in a standardized way and compared between the 2 groups. Intergroup comparisons were performed using the Mann-Whitney U test for continuous variables and the Fisher exact test for categorical variables. The correlation between the central cornea thickness (CCT) and the CT was investigated by the Spearman test. RESULTS: The stromal CT was significantly thinner in NTG compared with POAG (64±31 vs. 103±44 µm, respectively; P=0.002). Stromal CT of the whole group was positively correlated with IOPmax (r=0.41; P=0.002; 95% confidence interval, 0.15-0.62) but not with central cornea thickness (r=-0.005; P=0.97; 95% confidence interval, -0.28 to 0.27). CONCLUSIONS: The conjunctiva in patients with NTG was thinner than in POAG patients. This finding is an additional feature in the pattern of thinner ocular structures in patients with NTG.

Magnetic Resonance Imaging Study on Blebs Morphology of Ahmed Valves.

PURPOSE: To determine the morphometric parameters of filtration blebs of a valved aqueous humor drainage device. MATERIALS AND METHODS: Orbital magnetic resonances imaging (MRI) was taken after implantation of an Ahmed valve (FP7 model). Outcomes of the analysis were intraocular pressure (IOP) and the bleb's morphometric analysis (volume, height, major and minor axis). Associations between IOP and the imaging-related study variables were explored by Spearman's correlation test. RESULTS: Eleven patients underwent orbital MRI examination. Recordings were taken after a mean of 2.7 months (1-6 months) after surgery. IOP was significantly lower than its preoperative values (17.6 ± 6.4 mm Hg vs 36.1 ± 6.4 mm Hg, p < 0.01). Mean bleb volume was 856.9 ± 261 mm(3) and its height, major and minor axis were 5.77 ± 1.9, 14.8 ± 2.9 and 8.14 ± 3.6 mm, respectively. A positive correlation was detected between IOP and mean height (r = 0.77, p = 0.048) and major axis (r = 0.83, p = 0.03). Interestingly, the overall bleb volume was related to IOP levels immediately prior to surgery (r = 0.75, p < 0.01). Additionally, the posterior part of the plate was found to be displaced from the scleral surface in five cases (45%). CONCLUSION: Ahmed valve's bleb morphology seems to correlate with both the pre- and postoperative IOP, which might suggest a clinical benefit of administering aqueous suppressants pre- as well as postoperatively. The plate of the device may show a significant dislocation from its initial surgical implantation site. How to cite this article: Ferreira J, Fernandes F, Patricio M, Brás A, Rios C, Stalmans I, Pinto LA. Magnetic Resonance Imaging Study on Blebs Morphology of Ahmed Valves. J Curr Glaucoma Pract 2015;9(1):1-5.

Surgical Management of Iatrogenic Pigment Dispersion Glaucoma.

INTRODUCTION: Iatrogenic pigment dispersion syndrome generally originates from a repetitive, mechanical trauma to the pigmented posterior epithelium of the iris. This trauma can arise after intraocular surgery, most commonly due to an abnormal contact between the intraocular lens (IOL) and the iris. Whether surgical removal of this primary insult can lead to a successful intraocular pressure (IOP) control remains unclear. METHODS: Case-series. Patients with IOP elevation and clinical signs of pigment dispersion were screened for a diagnosis of iatrogenic IOL-related pigment dispersion. RESULTS: Three patients in which the IOL or the IOL-bag complex caused a pigment dispersion through a repetitive iris chafing were selected. In two cases, replacement of a sulcus-based single-piece IOL (patient 1) or a sub-luxated in-the-bag IOL (patient 2) by an anterior-chamber (AC) iris-fixed IOL led to a sustained decrease in IOP. In the third case, extensive iris atrophy and poor anatomical AC parameters for IOL implantation precluded further surgical intervention. CONCLUSION: IOL-exchange appears to be a useful tool in the management of iatrogenic pigment dispersion glaucoma due to inappropriate IOL implantation. This cause-oriented approach seems to be effective in controlling IOP, but should be offered only if safety criteria are met. How to cite this article: Van Mierlo C, Abegao Pinto L, Stalmans I. Surgical Management of Iatrogenic Pigment Dispersion Glaucoma. J Curr Glaucoma Pract 2015;9(1):28-32.

Diabetes Mellitus as a Risk Factor in Glaucoma's Physiopathology and Surgical Survival Time: A Literature Review.

Glaucoma is a multifactorial condition under serious influence of many risk factors. The role of diabetes mellitus (DM) in glaucoma etiology or progression remains inconclusive. Although, the diabetic patients have different healing mechanism comparing to the general population and it has a possible-negative role on surgical outcomes. This review article attempts to analyze the association of both diseases, glaucoma and DM, before and after the surgery. The epidemiological studies, based mainly in population prevalence analyzes, have shown opposite outcomes in time and even in the most recent articles also the association remains inconclusive. On the contrary, the experimental models based on animal induced chronic hyperglycemia have shown an important association of both diseases, explained by common neurodegenerative mechanisms. Diabetic patients have a different wound healing process in the eye viz-a-viz other organs. The healing process is more and it results in lower surgical survival time, higher intraocular pressure (IOP) levels and, therefore, these patients usually need more medication to lower the IOP. Both randomized and nonrandomized retrospective and experimental molecular studies have shown the association between DM and glaucoma. Further studies are needed to get better explanations about outcomes on more recent surgical procedures and with the exponential use of antifibrotics. How to cite this article: Costa L, Cunha JP, Amado D, Pinto LA, Ferreira J. Diabetes Mellitus as a Risk Factor in Glaucoma's Physiopathology and Surgical Survival Time: A Literature Review. J Curr Glaucoma Pract 2015;9(3):81-85.