A Retrospective Comparison of Phaco-tube vs. Phaco-trabeculectomy in Glaucoma Patients.

PURPOSE: To compare surgical outcomes of phacoemulsification combined with Baerveldt implantation (phaco-tube) or trabeculectomy with mitomycin-C (MMC) (phaco-trab) in patients without prior incisional ocular surgery. DESIGN: Single-center, retrospective, comparative case series. PARTICIPANTS: A total of 90 patients underwent surgical treatment, including 45 patients in the phaco-tube group and 45 patients in the phaco-trab group. METHODS: Eligible patients were identified using current procedural terminology (CPT) codes, and their medical records were retrospectively reviewed. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of surgical failure (IOP ≤5 mmHg or >21 mmHg or reduced <20% from baseline on 2 consecutive study visits after 3 months, reoperations for glaucoma, or experienced loss of light perception vision). Patients who had successful surgical outcomes without use of glaucoma medications were classified as complete successes, while those who used glaucoma medications were classified as qualified successes. Secondary outcome measures were visual acuity (VA), visual field mean deviation (VFMD), intraocular pressure (IOP), glaucoma medication use, and complications. RESULTS: The cumulative probability of failure was 6.7% in the phaco-tube group and 32.8% in the phaco-trab group after 3 years (P = 0.005; Restricted Mean Survival Time = 5.9 months, 95% CI = 1.4-10.4 months). The IOP was 13.1 ± 3.4 mmHg in the phaco-tube group and 13.3 ± 6.2 mmHg in the phaco-trab group at 3 years (P = 0.90), and the number of glaucoma medications was 2.6 ± 1.5 in the phaco-tube group and 1.7 ± 1.3 in the phaco-trab group (P = 0.015). The logarithm of the minimum angle of resolution VA was 0.39 ± 0.58 in the phaco-tube group and 0.43 ± 0.73 in the phaco-trab group at 3 years (P = 0.82), and VFMD was -18.3 ± 9.0 dB in the phaco-tube group and -14.1 ± 7.0 dB in the phaco-trab group (P = 0.16). Postoperative complications developed in 21 patients (47%) in the phaco-tube group and 15 patients (33%) in the phaco-trab group (P = 0.28). CONCLUSIONS: Phaco-tubes had a significantly lower rate of surgical failure compared to phaco-trabs after 3 years of follow-up. However, phaco-trabs used significantly fewer glaucoma medications at multiple postoperative timepoints and had a higher proportion of complete success. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Risk Factors for Flat Anterior Chamber Requiring Intervention After Glaucoma Drainage Implant: A Retrospective Case-Controlled Study.

PURPOSE: To identify risk factors for flat anterior chamber that required additional intervention in the postoperative period (90 days) after uncomplicated Baerveldt Glaucoma Implant (BGI) surgery. DESIGN: Retrospective, matched case-control study. METHODS: A total of 42 cases (eyes) that received BGI at Anne Bates Leach Eye Hospital between February 1, 2011, and January 1, 2019, and that developed flat anterior chamber were included. For each case, we matched 2 controls (84). Variables included sex, diagnosis, diabetes, hypertension, pre- and postoperative glaucoma medications, ocular conditions, and intraocular pressure (IOP). Multivariable conditional logistic regression determined odds ratios (ORs) for independent predictors. RESULTS: Case patients were more likely to be female (69.1% case patients/41.7% controls), to have a history of taking oral carbonic anhydrase inhibitors (CAIs) at tube opening (21.4%/7.1%), to be of another race/ethnicity (11.9%/0.0%), and to have pseudoexfoliation (23.8%/6.0%), and were less likely to be using cholinergic agonists (0.0%/11.9%) at baseline and to have primary open angle glaucoma (42.9%/64.3%). Case patients had greater mean age (75.9/64.9 years), earlier tube opening time (5.6/6.2 weeks), and lower IOP after tube opening (7.2/14.4 mm Hg), but IOP before opening was higher (24.7/19.5 mm Hg). We identified 3 independent predictors: older age (10-year increase OR = 3.59, P < .0001), oral CAI use at tube opening (OR = 5.65, P = .009), and higher IOP prior to tube opening (3 mm Hg increase OR = 1.30, P = .018). CONCLUSION: Risk factors for flat anterior chamber were older age, oral CAIs at tube opening, and higher IOP before tube opening. Strategies to minimize the acute IOP reduction that preceded this complication such as discontinuing oral CAI prior to tube opening may be considered.

Factors Associated With Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) Complications and Failure in Children.

PURPOSE: To identify the factors associated with the complications and failure of gonioscopy-assisted transluminal trabeculotomy (GATT) in children. DESIGN: Retrospective case series. METHODS: This study was conducted in an institutional setting in a pediatric population (aged <18 years) who had undergone GATT. Records were reviewed, and pre- and postoperative intraocular pressures (IOP), extent of angle treated, medications, complications, and failure were recorded. Failure was defined as IOP >21 mm Hg or <5 mm Hg, absence of at least 20% IOP reduction, performance of additional IOP-lowering surgery, or loss of light perception vision. RESULTS: A total of 74 eyes of 57 patients were included (mean age, 7.1 years). Over a median follow-up period of 28.5 months, 36 eyes (48.6%) failed. IOP spikes occurred in 25 eyes (33.8%) and were a significant risk factor for failure (hazard ratio [HR] = 2.17; P = .0207). Postoperative hyphema was a significant risk factor for IOP spike (HR = 4.13, P = .003) but not for failure (HR = 0.7, P = .2977). The risk of IOP spike was lowest in eyes treated with nonsteroidal anti-inflammatory drugs (NSAIDs; HR = 0.27, P = .0016). The risk of failure increased significantly in eyes that received topical corticosteroids (compared to NSAIDs; HR = 5.72, P = .0005), in eyes with <360○ incisions (HR = 4.69, P < .0001), and in younger children. CONCLUSIONS: GATT is a reasonably effective procedure in childhood glaucoma. Postoperatively, the use of topical NSAIDs (without corticosteroid) may decrease the risk of failure. Eyes with IOP spikes without hyphema are at the highest risk for failure.

Multimodal Imaging Findings in Two Children With Microphthalmos.

Microphthalmos, also called microphthalmia, is a rare developmental disorder of the eye that can be caused by genetic or chromosomal abnormalities or environmental factors. The spectrum of clinical presentation includes nanophthalmia and posterior microphthalmia. It affects approximately one in 1,000 individuals, although there is insufficient literature regarding the clinical and different imaging modalities findings. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:444-446.].

Rates of RNFL Thinning in Patients with Suspected or Confirmed Glaucoma Receiving Unilateral Intravitreal Injections for Exudative AMD.

PURPOSE: This study evaluated whether the rate of retinal nerve fiber layer (RNFL) thinning is faster in eyes receiving intravitreal injections than in fellow uninjected eyes among patients suspected of having or confirmed to have glaucoma and exudative age-related macular degeneration (AMD). DESIGN: Retrospective comparative cohort study. METHODS: Patients with a diagnosis of unilateral exudative AMD and confirmed to have or suspected of having glaucoma in both eyes receiving unilateral intravitreal injections were identified. Those with ≥3 RNFL optical coherence tomography scans and ≥6 injections were included in the study. Rates of RNFL thinning in the injected eye versus the uninjected eye were estimated using linear mixed models. The main outcome measurement was the differences in rates of RNFL thinning in the injected versus the fellow uninjected eye. The effects of postinjection elevation of intraocular pressure (IOP), injection frequency, and number of injections were also evaluated. RESULTS: A total of 53 patients met the inclusion criteria, receiving 26.4 ± 15.9 intravitreal injections. The average rate of RNFL thinning in uninjected eyes was -0.620 µm/year (P = .029). Injected eyes had an additional incremental loss of -0.385 µm/year, but this value was not statistically significant (95% confidence interval [CI]: -1.147 to 0.379 µm/year; P = .324). Subgroup analysis with only glaucoma patients (n = 33) also demonstrated a nonsignificant effect of injections (-0.568 µm/year; 95% CI: -1.454 to 0.319 µm/year; P = .212). Postinjection IOP elevation, injection frequency, and total number of injections were not associated with faster RNFL loss. CONCLUSIONS: Among exudative AMD patients with glaucoma or suspected of having glaucoma, the rate of RNFL thinning in eyes receiving intravitreal injections did not significantly differ from that of fellow uninjected eyes.

Agrobacterium radiobacter Endophthalmitis Associated with Baerveldt Tube Exposure.

Agrobacterium radiobacter is a Gram-negative bacillus and a rare cause of endophthalmitis. An 85-year-male presented with late-onset endophthalmitis associated with exposure of an inferonasal Baerveldt tube. The patient was initially treated with anterior chamber paracentesis and intravitreal antibiotics. Aqueous humor culture revealed A. radiobacter resistant to cefazolin, ceftazidime, amikacin, tobramycin, and trimethoprim-sulfamethoxazole. Subsequently, the patient underwent explantation of the glaucoma drainage implant (GDI). After initial improvement, the patient had clinical worsening and was diagnosed with recurrence. Subsequent treatment involved explantation of the second GDI in addition to pars plana vitrectomy with silicone oil infusion, intraocular lens removal, and administration of intravitreal antibiotics. Visual acuity improved but remained at count fingers at 2 weeks. This is the first reported patient with A. radiobacter endophthalmitis associated with an exposed GDI. This report illustrates the resistant nature of this organism in addition to the efficacy of silicone oil administration and intraocular prosthesis explantation.

Risk Factors for Complications and Failure after Gonioscopy-Assisted Transluminal Trabeculotomy in a Young Cohort.

PURPOSE: To determine the risk factors for failures and complications of gonioscopy-assisted transluminal trabeculotomy (GATT) in a young cohort. DESIGN: Retrospective case series. PARTICIPANTS: Eyes that underwent GATT at Bascom Palmer Eye Institute. METHODS: Preoperative and postoperative intraocular pressure (IOP), extent of angle treated, postoperative IOP spike, postoperative drop regimen, and postoperative failure were recorded. Failure was defined as (1) IOP of more than 21 mmHg or less than 5 mmHg after postoperative month 3, (2) absence of at least 20% reduction from the preoperative IOP baseline after postoperative month 3, or (3) performance of additional IOP-lowering surgery before postoperative month 3. Intraocular pressure spike complication was defined as an increase in IOP in the operated eye at any postoperative visit to higher than preoperative IOP within the first 3 months. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to assess the time to events (failure and IOP spike). MAIN OUTCOME MEASURES: Risk of failure associated with any of the preoperative, intraoperative, or postoperative variables. RESULTS: A total of 102 eyes of 88 patients were included. The median follow-up time was 7.4 months, with an interquartile range of 3.3 to 13.1 months (standard deviation, 8.7 months). Patients who used corticosteroids after surgery were more likely to experience IOP spikes than those using nonsteroidal anti-inflammatory drugs (NSAIDs) alone (hazard ratio, 3.34; P = 0.042), and patients who underwent noncircumferential trabeculotomy were 2.56 times more likely to experience treatment failure (P = 0.002) compared with those who underwent circumferential surgery. CONCLUSIONS: Eyes that received postoperative corticosteroids were more likely to experience an IOP spike complication than those that received postoperative NSAIDs alone, which may suggest corticosteroid-mediated outflow obstruction distal to the trabecular meshwork. Achieving a circumferential trabeculotomy and using only NSAIDs may be more likely to result in surgical success when compared with noncircumferential trabeculotomy or using postoperative corticosteroids.

Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Patients With Secondary Open-Angle Glaucoma Following Vitreoretinal Surgery.

PURPOSE: To examine the short-term efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in a series of patients who developed glaucoma following vitreoretinal surgery. PATIENTS AND METHODS: Retrospective case series of consecutive patients aged above 18 years with secondary open-angle glaucoma following vitreoretinal surgery who had undergone GATT between January 2015 and June 2019. Eyes were excluded if there is<1 month of follow-up or glaucoma before vitreoretinal surgery. RESULTS: Eight eyes of 8 patients were included, with age range 18 to 72 years (median 43.5 y). Mean pretreatment intraocular pressure (IOP) was 32.7±5.1 mm Hg with a mean of 4.8±0.9 medications. Following GATT, mean IOP improved to 13.6±1.8 mm Hg (P<0.001) with a reduction to 1.6±1.4 medications after a mean follow-up of 8.6 months (range 1 to 25 mo). Five of the 8 eye (62.5%) had silicone oil in the vitreous cavity during GATT, none of which had concurrent oil removal. CONCLUSIONS: GATT is a safe and effective procedure for eyes with secondary open-angle glaucoma following vitreoretinal surgery. Further studies are needed to elucidate long-term benefits of angle surgery on eyes with high pressure following vitreoretinal surgery.

Implementing enhanced education to improve the UCLA Preschool Vision Program.

PURPOSE: To examine whether educational pamphlets and videos for adults can increase follow-up rates for eye examinations among preschool children. METHODS: The target population was 3- to 5-year-olds attending preschools within Los Angeles County and receiving services from the UCLA Preschool Vision Program (UPVP). Preschools were randomly assigned to standard and enhanced-education groups. The same procedures were followed in each group, except that preschool personnel and parents of children referred for eye examinations in the enhanced-education group received education materials and watched a 3-minute informational video on the screening day. The outcome measure was the follow-up rate for comprehensive examinations performed by the UPVP on a second date. RESULTS: The follow-up rate for receiving a complete eye examination was 75.3% (438/582) in the enhanced-education group and 65.1% (430/661) in the standard group (P < 0.0001 [Fisher exact test]; OR = 1.63; 95% CI, 1.28-2.09). CONCLUSIONS: Educating adults during the screening session can increase follow-up rates. Further studies are recommended to understand barriers to seeking eye care for children and to devise initiatives to help increase targeted awareness.

Predictors of Pain Management among American Indian Cancer Survivors.

There is little research on cancer symptom management among Indigenous populations. This paper reports on the predictors of cancer pain management among American Indian cancer patients/survivors and their caregivers/family. The intervention was a symptom management toolkit delivered via traditional talking circles vs. standard care (control) at eight randomized reservation and urban clinic sites in the Southwest. Participants (N=184) were American Indian adults diagnosed with cancer and/or caregiver/family members. The primary outcome measure collected via pre-test and post-test questionnaires was the ability to manage cancer pain. Significant differences at post-test were the ability to manage cancer-related pain (p=.02) and a close relationship (p=.0018) that proved significant for intervention participants and was instrumental in fostering their ability to manage pain. The study also showed improvement in the desire and ability to improve cancer pain management among intervention participants. Programs targeting American Indians should use culturally appropriate education to improve management of cancer-related symptoms.

Retinal vein-to-vein anastomoses in Sturge-Weber syndrome documented by ultra-widefield fluorescein angiography.

We report the case of a 6-year-old boy with Sturge-Weber syndrome and unilateral glaucoma in his left eye. He was born with a port wine mark involving his upper left eyelid. On ultra-widefield fluorescein angiography, he was found to have several vein-to-vein anastomoses in his left retina. To our knowledge, this is the first documentation of retinal vein-to-vein anastomoses in Sturge-Weber syndrome.

The effect of rectus muscle recession, resection and plication on anterior segment circulation in humans.

BACKGROUND: Plication is an alternative tightening procedure to resection. In monkeys, plication has been shown to preserve anterior segment circulation compared with full-tendon tenotomy, but this is unconfirmed in humans. PURPOSE: To evaluate anterior segment circulation by iris angiography before and after strabismus surgery in humans. METHODS: Prospective, blinded study of 14 patients (mean age (SD), 58.6 (14.3)) undergoing plication and/or full tendon tenotomy (resection or recession) from August 2013 to March 2014. Eight patients (mean age (SD), 59.0 (13.3)) underwent plication of one muscle with or without recession of a second muscle on the same eye and six patients (mean age (SD), 58.2 (16.8)) underwent tenotomy of one to two muscles on the same eye. Preoperative and postoperative iris angiograms were compared for changes in perfusion by a masked examiner. In patients undergoing binocular surgery, one eye was chosen preoperatively to be the study eye. RESULTS: Postoperative iris filling defects were present in four patients (67%) after tenotomy and one patient (12.5%) after plication (p=0.09). Of the seven total vertical rectus muscles operated (three tenotomies and four plications), filling defects were present after three tenotomies and one plication (100% vs 25%; p=0.14). Of the 13 total horizontal rectus muscles operated (eight tenotomies and five plications), filling defects were present after one tenotomy and none of the plications (13% vs 0%; p=0.99). CONCLUSIONS: Rectus muscle plication spares the ciliary vessels and may be considered a safer alternative to resection for patients at risk for anterior segment ischaemia, especially when surgery involves a vertical rectus muscle.

Phthisis bulbi after lensectomy in retinopathy of prematurity eyes previously treated with laser photocoagulation.

PURPOSE: On rare occasions, patients with retinopathy of prematurity develop anterior segment ischemia after laser photocoagulation treatment. The purpose of this investigation was to describe the visual outcomes and the risk of phthisis bulbi after lensectomy in patients with history of retinopathy of prematurity laser photocoagulation and attached retinas at the time of lensectomy. METHODS: A retrospective case series including 3 patients who underwent diode laser photocoagulation for retinopathy of prematurity and developed unilateral anterior segment ischemia with subsequent cataract formation, and then phthisis bulbi after uncomplicated lensectomy. RESULTS: Three eyes became phthisical with total retinal detachment after uncomplicated cataract extraction. Signs of anterior segment ischemia were present in all 3 eyes before the cataract extraction, including shallow anterior chamber, corneal edema, iris atrophy, and posterior synechiae. Features of phthisis bulbi did not occur until after cataract extraction. CONCLUSION: Premature patients who require laser photocoagulation for retinopathy of prematurity and develop cataract presumably related to anterior segment ischemia are at high risk for poor visual outcomes. It is important to determine risks when performing lensectomy, especially because of the amblyogenic risk of cataract in an infant and the required visualization for retinal follow-ups.

The dark phase intraocular pressure elevation and retinal ganglion cell degeneration in a rat model of experimental glaucoma.

Intraocular pressure (IOP) elevation is considered as a major risk factor causing the progression of vision deterioration in glaucoma. Although it is known that the IOP level changes widely throughout the day and night, how the dark or light phase IOP elevation contributes to retinal ganglion cell (RGC) degeneration is still largely unclear. To examine the profile of IOP, modified laser photocoagulation was applied to the trabecular meshwork of Brown Norway rats and both light and dark phase IOPs were monitored approximately 1-2 times a week. The relationship between IOP elevation and RGC degeneration was investigated while RGC body loss was analyzed with Rbpms immunolabeling on retinal wholemount and axonal injury in the optic nerve was semi-quantified. The baseline awake dark and light IOPs were 30.4 ± 2.7 and 20.2 ± 2.1 mmHg respectively. The average dark IOP was increased to 38.2 ± 3.2 mmHg for five weeks after the laser treatment on 270° trabecular meshwork. However, there was no significant loss of RGC body and axonal injury. After laser treatment on 330° trabecular meshwork, the dark and light IOPs were significantly increased to 43.8 ± 4.6 and 23 ± 3.7 mmHg respectively for 5 weeks. The cumulative dark and light IOP elevations were 277 ± 86 and 113 ± 50 mmHg days respectively while the cumulative total (light and dark) IOP elevation was 213 ± 114 mmHg days. After 5 weeks, regional RGC body loss of 29.5 ± 15.5% and moderate axonal injury were observed. Axonal injury and loss of RGC body had a high correlation with the cumulative total IOP elevation (R(2) = 0.60 and 0.65 respectively). There was an association between the cumulative dark IOP elevation and RGC body loss (R(2) = 0.37) and axonal injury (R(2) = 0.51) whereas the associations between neuronal damages and the cumulative light IOP elevation were weak (for RGC body loss, R(2) = 0.01; for axonal injury, R(2) = 0.26). Simple linear regression model analysis showed statistical significance for the relationships between the total cumulative IOP elevation and RGC body loss (P = 0.009), and axonal injury (P = 0.016). To examine the role of light and dark IOP elevation in RGC body loss and axonal injury, analyses for the association between different light/dark IOP factors and percentage of RGC body loss/axonal injury grading were performed and only the association between the cumulative dark IOP elevation and axonal injury showed statistical significance (P = 0.033). The findings demonstrated that the cumulative total (light and dark) IOP elevation is a risk factor to RGC degeneration in a rat model of experimental glaucoma using modified partial laser photocoagulation at 330° trabecular meshwork. Further investigations are required to understand the role of longer term light and dark phase IOP elevation contributing to the progression of degeneration in different compartments of RGCs.

Quantitative analysis of retinal ganglion cell survival with Rbpms immunolabeling in animal models of optic neuropathies.

PURPOSE: To investigate whether a recently described retinal ganglion cell (RGC) marker Rbpms (RNA binding protein with multiple splicing) could be used for RGC quantification in various models of RGC degeneration. METHODS: Optic nerve crush, excitotoxicity, and elevated intraocular pressure (IOP) rat models were used. Topographic analysis of Rbpms immunolabeling was performed on retinal wholemounts. Retrograde labelings with Fluorogold (FG) and III ß-tubulin immunohistochemistry were compared. RESULTS: In the optic nerve crush model, 37%, 87%, and 93% of Rbpms-positive cells were lost 1, 2, and 4 weeks, respectively. Significant loss of Rbpms-positive cells was noted 1 week after intravitreal injection of 12, 30, and 120 nmol N-methyl-d-aspartate (NMDA), whereas coinjection of 120 nmol of NMDA along with MK-801 increased the cell number from 10% to 59%. Over 95% of Rbpms-positive cells were FG- and III ß-tubulin-positive after injury caused by optic nerve crush and NMDA injection. In rats with elevated IOP, induced by trabecular laser photocoagulation, there was a significant loss of Rbpms-positive cells compared with that of contralateral controls (P = 0.0004), and cumulative IOP elevation showed a strong linear relationship with the quantification of RGCs by Rbpms immunolabeling and retrograde labeling with FG. More than 99% of the remaining Rbpms-positive cells were double-labeled with FG. CONCLUSIONS: Rbpms can reliably be used as an RGC marker for quantitative evaluation in rat models of RGC degeneration, regardless of the nature and the location of the primary site of the injury and the extent of neurodegeneration.