A Novel Tube Insertion Technique for Glaucoma Drainage Device Implantation.

PURPOSE: Early hypotony after non-valved glaucoma drainage device (GDD) implantation for complex glaucomatous eyes with labile aqueous production can lead to significant visual morbidity. We therefore sought to report the early postoperative outcomes of a novel surgical technique that allows atraumatic insertion of non-valved GDDs through a much smaller 25-gauge scleral track, to minimize entry site leakage and improve safety. METHODS: Retrospective case series of 15 consecutive cases undergoing non-valved GDD insertion into the anterior chamber using a previously unreported technique. RESULTS: All eyes underwent successful GDD insertion using our novel technique, with no intraoperative complications. The mean preoperative intraocular pressures (IOP), at day 1, week 1 and week 3 were 31.4, 22.4, 23.7, and 25.6 mm Hg, respectively. A statistically significant IOP reduction was achieved at day 1, week 1 and week 3 postoperatively ( P <0.05) without any observed leakage at the scleral entry site. One eye (6.7%) with complex panuveitic glaucoma developed early hypotony (5 mm Hg) with shallow choroidal detachments on day 1. This was successfully managed with 1 intracameral ophthalmic viscoelastic device injection given at the slit-lamp and no further intervention. CONCLUSIONS: This novel single needle-docking intraocular insertion manoeuvre is an easily adoptable technique to make GDD insertion through a smaller 25-gauge water-tight scleral track more efficient and less traumatic. The technique reduces scleral distortion and therefore improves surgical safety particularly in eyes with complex secondary glaucoma.

Glaucoma control after phacoemulsification in eyes with functioning glaucoma filtration surgeries: trabeculectomies versus glaucoma drainage devices.

PURPOSE: Several studies have demonstrated decompensation of intraocular pressure (IOP) control following phacoemulsification in eyes with a functioning trabeculectomy. Limited evidence base suggests that this effect is minimal in eyes with functioning glaucoma drainage devices (GDD). The aim of this study was to report on glaucoma control after phacoemulsification in eyes with a functioning GDD compared to eyes with a functioning trabeculectomy. METHODS: Single-centre retrospective comparative study of patients with a functioning non-valved GDD (Baerveldt 350; Johnson & Johnson Surgical Vision) or trabeculectomy undergoing phacoemulsification. Glaucoma outcomes including IOP, cup:disc ratio (CDR), global retinal nerve fibre layer (RNFL) thickness and visual field mean deviation (MD) are reported. Failure was defined as IOP rise > 20% from baseline. RESULTS: Fifteen eyes with a functioning trabeculectomy and twenty-three eyes with a functioning GDD with 24-month post-phacoemulsification data were identified. Mean IOPs were significantly lower in the trabeculectomy group at month 24 compared to the GDD group, 9.5 and 15.9 mmHg (p = 0.001) respectively. At month 12, there was significant worsening on MD in GDD group compared to trabeculectomy group, - 20.0 dB and - 11.3 dB respectively (p = 0.03). A greater proportion of eyes failed in the GDD group compared to the trabeculectomy group, N = 15 (65%) and n = 7 (47%), p = 0.26. CONCLUSION: As with functioning trabeculectomies, phacoemulsification should be approached with similar caution in eyes with functioning GDD. An existing GDD is at least as likely to fail following clear corneal phacoemulsification as an existing trabeculectomy and non-augmented GDDs may be at greater risk.

Comparison of 1-year surgical outcomes of combined cataract surgery and gonioscopy-assisted transluminal trabeculotomy (GATT) versus cataract surgery and iStent Inject.

PURPOSE: Evaluate the efficacy, safety, and complication rates of phacoemulsification cataract surgery when combined with either gonioscopy-assisted transluminal trabeculotomy (GATT) or iStent Inject. METHODS: This is a retrospective case-control study to compare the surgical outcomes of combined phacoemulsification cataract surgery with either GATT (phaco-GATT) or iStent Inject (phaco-iStent). Both groups had at least 1-year follow-up. The primary outcome measures were IOP and number of glaucoma medications (NGMs) at 1 year. Secondary outcomes measures were best corrected visual acuity (BCVA) and intra- or postoperative complications within the first year of follow-up. Success was defined as intraocular pressure (IOP) < 21 mmHg and ≥ 20% reduction in IOP at 1 year regardless of the NGM. RESULTS: Each group included 37 patients. The median baseline IOP (24 vs 17) and NGM (3 vs 2) were higher in the phaco-GATT group (p < 0.001). Phaco-GATT achieved a 38% (p < 0.0001) reduction in IOP compared to 13.2% (p < 0.001) in the phaco-iStent group at 1-year follow-up. The reduction in IOP and NGM was significantly higher in the phaco-GATT group (p < 0.01). After adjusting for baseline IOP, the reduction in IOP at 12 months was still significantly higher in the phaco-GATT group (p = 0.042). At 1 year, 86.4% of patients in the phaco-GATT group met the success criteria compared to 35.1% in the phaco-iStent group. Safety outcomes were slightly favourable in the phaco-iStent group. CONCLUSION: Phaco-GATT and phaco-iStent showed a significant reduction in IOP and NGM, with phaco-GATT having a significantly higher reduction. Phaco-iStent appears to have a higher safety profile and is probably preferable in monocular patients and those with a high risk of bleeding.

Four common diseases causing sudden blindness or death in the eye emergency department.

Neuro-ophthalmological emergency disorders typically present with symptoms of visual loss, diplopia, ocular motility impairment or anisocoria. The ocular manifestations of these disorders are sometimes indicative of a more serious global neurology disease rather than an isolated ocular disease. The aim of this review is to highlight four important neuro-ophthalmological emergency disorders that must not be missed by an ophthalmologist. These include acute painful Horner's syndrome, painful cranial nerve III palsy, giant cell arteritis and transient ischaemic attack with amaurosis fugax. The delayed diagnosis of these clinical entities puts the patient at risk of blindness or death. Therefore, prompt diagnosis and management of these conditions are essential. This can be acquired from understanding the main signs and symptoms of the disease presentation together with a high index of suspicion while working at a busy eye emergency department.

Gonioscopy-assisted Transluminal Trabeculotomy in Uveitic Glaucoma Secondary to Juvenile Idiopathic Arthritis.

Gonioscopy-assisted transluminal trabeculotomy (GATT) is a minimally invasive ab interno procedure, performed with guidance of an illuminating microcatheter device (iTrack). The pathophysiology of raised intraocular pressure (IOP) in uveitic glaucoma is commonly due to increased resistance at the trabecular meshwork-Schlemm canal. By removing this resistance, GATT can potentially control the IOP. In addition, the ab interno approach avoids violating the conjunctiva and reduces the risk of complications including infection, leak, and hypotony. In this series, we discuss 3 uveitic glaucoma cases secondary to juvenile idiopathic arthritis (JIA) that underwent GATT. Case 1 was a 16-year-old phakic female with a preoperative IOP of 25 to 33 mm Hg had 360-degree GATT; her IOP remained stable at 6 to 10 mm Hg over 14 months. Case 2 was a 23-year-old pseudophakic female with a preoperative IOP of 28 to 34 mm Hg had 180-degree GATT; her IOP reduced to 8 mm Hg over 10 months. Case 3 was an 8-year-old aphakic male with a preoperative IOP of 21 to 32 mm Hg had 360-degree GATT; his IOP remained stable at 13 to 15 mm Hg over 21 months. In our limited case series, GATT is very successful in controlling IOP in young uveitic patients with JIA by surgically targeting the underlying pathophysiology.

Ab interno tube ligation for refractory hypotony following non-valved glaucoma drainage device implantation.

PURPOSE: To report the 2-year outcomes of a novel surgical technique allowing reduction of the intraluminal diameter of the tube without total tube occlusion in order to allow enough increase in outflow resistance to permit resolution of hypotony whilst also achieving adequate IOP control. METHODS: This was a single-surgeon retrospective case note review of all non-valved GDD cases over an 8-year period (2008-2015) that underwent ab interno ligation of the drainage tube in order to manage post-operative hypotony (Baerveldt or Molteno). Twelve eyes of 12 patients (4.4%) developing refractory hypotony that did not respond to multiple intracameral ophthalmic viscoelastic device (OVD) injections were included in this retrospective case series and were treated with our ab interno tube ligation technique. The post-ligation management algorithm consisted of re-instating topical anti-glaucoma agents, laser suture lysis (LSL), or further ab interno ligation. RESULTS: Mean IOP increased from 2.8 mmHg at baseline to 7.8 mmHg, 7.1 mmHg, 9.0 mmHg, 13.6 mmHg, 10.9 mmHg, 13.9 mmHg and 13.6 mmHg at day 1, week 1, month 1, month 3, month 6, year 1 and year 2 respectively, with or without additional topical anti-glaucoma medications. Although hypotony resolution following our technique was achieved in all eyes at 2 years, 8.3% of cases required reinstatement of topical medications to maintain IOP control within the target range. CONCLUSIONS: We propose ab interno partial tube tying as an effective surgical option to achieve an immediate, predictable and sustained IOP elevation either as a primary procedure or when traditional methods have failed to resolve hypotony in eyes with non-valved GDDs.

The outcome of transscleral cyclophotocoagulation for the management of acute angle closure.

PURPOSE: To investigate the outcome of transscleral cyclophotocoagulation (TCP) in the treatment of acute angle closure (AAC) refractory to medical treatment. METHODS: This is a retrospective interventional case series. The inclusion criteria include patients diagnosed with AAC who had TCP. Pre-TCP and post-TCP intraocular pressure (IOP), visual acuity, and AAC treatment were analyzed. The complications and the results of subsequent treatments including lens extraction if performed were also assessed. RESULTS: Thirteen eyes (13 patients) met the study criteria. The median time to TCP from presentation was 5 days (range 3-30 days). The mean presenting IOP was 56 ± 6 mm Hg (range 48-70 mm Hg) and the medically treated mean IOP before TCP was 40 ± 5 mm Hg (range 34-52 mm Hg). All patients (100%) responded to TCP. The mean post-TCP IOP at day 1 and months 1, 3, 6, 12, and 24 were 19, 23, 19, 19, 18, and 17 mm Hg. There was 1 case of hyphema post-TCP. Lens extraction ± goniosynechialysis was performed in 10 patients (77%) from 1 month post-TCP onwards. The mean IOP prior to lens extraction was 26 mm Hg (range 19-32 mm Hg). The mean IOP 3 months after lens extraction was 15 mm Hg (range 8-19 mm Hg). The mean number of topical IOP-lowering medications 12 months post-TCP was 1.1. CONCLUSIONS: Transscleral cyclophotocoagulation is effective and safe in reducing IOP in patients with AAC refractory to medical and laser peripheral iridotomy treatments. We advocate that TCP should be considered early in the management of AAC refractory to medical treatment to avoid irreversible optic neuropathy.

Gonioaspiration for refractory glaucoma secondary to traumatic hyphema in patients with sickle cell trait.

The authors describe a new surgical method for treating disproportionately high intraocular pressures secondary to small traumatic hyphemas in three patients with the sickle cell trait. A novel technique was performed in all three cases to clear the hyphema from the anterior chamber angle. A Lewicky anterior chamber maintainer cannula was placed at the superior limbus to maintain infusion into the anterior chamber. Under direct visualization using a Koeppe goniotomy lens, a 23-gauge single-port cannula was used to aspirate the hyphema from the anterior chamber angle until it was free of blood. There were no intraoperative complications. Measurements of intraocular pressure were normal 2 hours after the procedure and at every subsequent visit. There was an improvement in visual acuity to 6/9 or better in all three of the cases. Therefore, gonioaspiration is an effective treatment of persistently raised intraocular pressures in patients with sickle cell trait.

Management of inflammatory glaucomas.

PURPOSE OF REVIEW: To review the epidemiology, pathogenesis and management of uveitic glaucoma in the light of significant studies published during the review period (October 2002-2003). RECENT FINDINGS: The visual prognosis of glaucoma secondary to certain types of uveitis, for example Juvenile Idopathic Arthritis, remains poor because of late presentation and a high rate of corticosteroid responsiveness. Production of Myocilin is intimately linked with outflow resistance and corticosteroid responsiveness. Although Myocilin gene expression is widespread in the eye, corticosteroid-induction is specific for trabecular meshwork. The hypotensive effect of some glaucoma medications such as Latanoprost and Brimonidine may be partially blocked by concurrent administration of NSAIDs, though the risk of redcrudescence of uveitis with Latanoprost appears to be much lower than initially feared. Use of Mitomycin C in uveitic trabeculectomy has not clearly translated into better long-term IOP control, though this may be due to an absence of prospective studies. Glaucoma drainage devices appear to be more successful in uveitic glaucoma than in other recalcitrant types. SUMMARY: The management of uveitic glaucoma requires a careful balance between adequate anti-inflammatory therapy and appropriate intraocular pressure (IOP)-lowering to prevent long-term visual loss. In the foreseeable future, successful elucidation of the function of Myocilin is most likely to lead to improvements in the management of corticosteroid-induced and hence uveitic glaucoma.

Agreement in assessing optic discs with a digital stereoscopic optic disc camera (Discam) and Heidelberg retina tomograph.

AIMS: To assess the intraobserver agreement, interobserver agreement, and the agreement between a digital stereo optic disc camera (Discam) and Heidelberg retina tomograph (HRT) in measuring area cup-disc ratio (ACDR) and radial cup-disc ratio (RCDR) by two observers. METHODS: The optic discs of 78 eyes of 39 people (17 cases of primary open angle glaucoma, eight normal tension glaucoma, two ocular hypertension, and 12 normal subjects) were imaged with Discam and HRT. Two observers independently drew the disc margins on the HRT mean topography images and the disc and cup margins on the Discam images. ACDR and the RCDR at various angles were measured with the two systems. Intraobserver agreement, interobserver agreement, and the agreement between the two systems were assessed by 95% tolerance limit of changes (TC) and intraclass correlation coefficient (ICC). RESULTS: Eight eyes were excluded due to poor image quality (six Discam and two HRT). 70 eyes were analysed. The intraobserver ACDR agreement was almost perfect in both systems (ICCs = 0.97 and 0.92, and TCs = 11.0% and 15.1% in HRT and Discam respectively). The interobserver ACDR agreement was almost perfect in HRT (ICC = 0.97) and substantial in Discam (ICC = 0.79), (TCs = 10.5% and 24.5% respectively). The ACDR agreement between the two systems was substantial in observer A (ICC = 0.67) and moderate in observer B (ICC = 0.53), (TCs = 24.8% and 46.7% respectively). The HRT measured the ACDR significantly larger than the Discam (p <0.001), and the differences were significantly larger in the glaucomatous group (p <0.001). RCDR agreement between the two systems was fair to substantial in observer A (ICC = 0.36 to 0.74) and slight to moderate in observer B (ICC = 0.12 to 0.45). Both observers achieved the best RCDR agreement between the two systems at the inferior optic disc position. CONCLUSION: There is almost perfect intraobserver agreement in each system. The interobserver agreement was better with the HRT than the Discam. There was substantial variation in ACDR and RCDR agreement between the two systems measured by the two observers. The variation in ACDR and RCDR measurements between the two systems may be too large for interchangeable use in a clinical setting.