Pars Planectomy: Preliminary Report of a New Glaucoma Filtering Technique in Vitrectomized Eyes.

PURPOSE: To propose a new filtering technique in vitrectomized eyes with glaucoma and report its clinical results and safety. METHODS: The medical records of 13 eyes that developed glaucoma following pars plana vitrectomy and underwent pars planectomy, from 2011 to 2018, at Songklanagarind hospital, Hatyai, Songkhla, Thailand were retrospectively reviewed. The main outcome measures were visual acuity (VA), intraocular pressure (IOP), number of glaucoma medications, and postoperative complications. Surgical success was defined as IOP value at the last visit of 6-21 mmHg, regardless of anti-glaucoma medication usage, and without further glaucoma surgery. RESULTS: The mean follow-up duration was 47.7 ± 32.1 months (range, 0.3-101.1 months). Preoperative BCVA increased from LogMAR 1.01 ± 0.85 to 1.2 ± 0.91 at the last visit (p = 0.233). The mean preoperative IOP was 28.15 ± 9.17 mmHg with an average of 3.46 ± 0.52 anti-glaucoma medications. At the final visit, the mean IOP was 14.08 ± 4.89 mmHg (p = 0.006) and the mean number of anti-glaucoma medications decreased to 1.31 ± 1.38 (p = 0.000). The probability of surgical success was 58.3%, 50%, and 37.5% at 1, 2, and 6 years after pars planectomy, respectively. Postoperative complications included vitreous hemorrhage in 1 eye (7.7%). No retina and pars plicata associated complications were found. CONCLUSION: Pars planectomy is efficient and safe as well as requires a short learning curve. It should be considered as an alternative filtering surgery in glaucoma after vitrectomy, especially with an extensive limbal scar that might be a limitation in trabeculectomy and GDDs techniques and outcomes.

Clinical Characteristics and Prognostic Factors of Visual Outcomes in Childhood Glaucoma.

PURPOSE: To determine the prognostic factors for poor visual outcomes in childhood glaucoma. METHODS: The medical records of patients with childhood glaucoma diagnosed at age 4 years or younger who were treated surgically from 2002 to 2019 at Songklanagarind Hospital, Hatyai, Thailand, were retrospectively reviewed. Glaucoma subtypes, clinical characteristics, final visual acuity, and etiology of visual impairment were recorded. The generalized estimating equation for logistic regression analysis was used to determine prognostic factors for final visual acuity of worse than 20/200. RESULTS: Forty-five eyes of 31 patients were included (33.3% had primary glaucoma and 66.7% had secondary glaucoma). At the final visit (mean: 6.8 years), 20.5% had good visual acuity (20/50 or better), 15.9% had fair visual acuity (worse than 20/50 to 20/200), and 63.6% had poor visual acuity (worse than 20/200). The major cause of visual impairment (worse than 20/50) was deprivation amblyopia. Prognostic factors for poor final visual acuity (worse than 20/200) were secondary glaucoma, age at diagnosis of younger than 3 months, and interval to surgery of more than 3 months. Eyes with a final visual acuity of better than 20/200 had higher mean intraocular pressure preoperatively that tended to increase postoperatively and every visit afterward compared to the other group. CONCLUSIONS: Two-thirds of eyes with childhood glaucoma ended up with poor final vision. Early surgery to control intraocular pressure, along with amblyopia treatment, should be considered to prevent poor visual outcome. The prognostic factors for poor visual outcome can contribute to parental advice and planning of patient care. [J Pediatr Ophthalmol Strabismus. 2020;57(5):283-291.].

Efficacy of Adjunctive Subconjunctival Bevacizumab on the Outcomes of Primary Trabeculectomy With Mitomycin C: A Prospective Randomized Placebo-controlled Trial.

PURPOSE: To evaluate the efficacy of subconjunctival bevacizumab (ScB) as adjuvant therapy to primary trabeculectomy with mitomycin C (MMC) in primary open-angle glaucoma. MATERIALS AND METHODS: Forty-six eyes of primary open-angle glaucoma patients were randomized to receive ScB (1.25 mg/0.05 mL) injections (the MMC+ScB group) at the end of the operations, or sham-treated controls (the MMC group). Intraocular pressure (IOP) was the primary outcome and secondary outcomes included bleb appearance, visual acuity, number of medications, complications, and proportion of eyes achieving successful outcomes at the 12-month follow-up. RESULTS: Of 39 eyes, 20 eyes from the MMC+ScB group, and 19 eyes from the MMC group completed the follow-up. The mean postoperative IOP was 15.5±4.1 mm Hg in the MMC+ScB group (P<0.01; 40% reduction), and 14.7±4.3 mm Hg in the MMC group (P<0.01; 44% reduction). The differences in IOPs, at all follow-up visits, were not significant (P>0.05). The mean bleb vascularity score, at 1 month, in the MMC+ScB group was lower than the MMC group (1.55±0.51 vs. 2.26±0.6, respectively, P=0.01), but was not retained at follow-ups. The success rates at 12 months after surgery were 85% in the MMC+ScB group and 89.5% in the MMC group (P=0.53). The cumulative probabilities of surgical success were 80% and 73.7% in the MMC+ScB and in the MMC group, respectively (P=0.52). CONCLUSION: Single adjunctive ScB injection did not appear to have an additive benefit on outcomes of MMC trabeculectomy, in terms of IOPs and success rates.

Correlation between central corneal thickness and visual field defect, cup to disc ratio and retinal nerve fiber layer thickness in primary open-angle glaucoma patients.

OBJECTIVE: To assess the correlation between central corneal thickness (CCT) and visual field parameters, cup-to-disc ratio and retinal nerve fiber layer (RNFL) thickness in primary open-angle glaucoma (POAG) patients in Songklanagarind Hospital. MATERIAL AND METHOD: A Retrospective analytical study of the medical records of primary open-angle glaucoma patients, between January 2006 and April 2008, were reviewed. All subjects underwent a complete eye examination. The CCT measurement was performed by ultrasonic pachymeter Mean deviation (MD), pattern standard deviation (PSD), cup-to-disc ratio, and the RNFL thickness of each patient were collected. The correlation coefficient between CCT and MD, PSD, cup-to-disc ratio and RNFL thickness was analyzed. RESULTS: Twenty-six POAG patients (47 eyes) were eligible for the study. Mean age was 60.96 +/- 7.44 years. Average CCT was 511.15 +/- 29.66 microm. Mean AMD and PSD were--10.01 +/- 8.20 and 7.52 +/- 4.43 decibel respectively. Mean cup-to-disc ratio was 0.7 1+/- 0.17. Mean RNFL thickness of superior inferior temporal, nasal quadrants and all quadrants were 101.60 +/- 28.68, 87.15 +/- 32.56, 60.64 +/- 14.14, 61.83 +/- 13.96 and 77.80 +/-17.58 microm, respectively. There were significant correlations between CCT and MD (r = 0.532, p < 0.001), PSD (r = -0.288, p = 0.05), cup-to-disc ratio (r = -0.478, p = 0.001), and average RNFL thickness (r = 0.487, p = 0.001). CONCLUSION: There were significant correlations between CCT and visual field parameters, cup-to-disc ratio, and RNFL thickness.

Performance of optical coherence tomography for distinguishing between normal eyes, glaucoma suspect and glaucomatous eyes.

OBJECTIVE: Evaluate the diagnostic performance of spectral-domain optical coherence tomography (OCT) parameters to distinguish between healthy, glaucoma suspect, and glaucomatous eyes. MATERIAL AND METHOD: Forty-eight eyes of glaucoma, 48 glaucoma suspect eyes, and 35 healthy eyes were included. The circumpapillary and macular retinal nerve fiber layer (RNFL) thickness were measured using the Cirrus OCT (Carl Zeiss Meditec, Inc., Dublin, CA, USA). One-way analysis of variance was used to compare the different parameters among groups. Calculating areas under receiver operating characteristic (AROC) curves evaluated the discriminating power of each parameter RESULTS: The average circumpapillary RNFL thickness in normal, glaucoma suspects, and glaucomatous eyes were 100.31 +/- 7.69 microm, 90.27 +/- 9.22 microm, and 71.40 +/- 13.08 microm, respectively (p < 0.001). The largest AROC curve among the circumpapillary parameters was the inferior quadrant thickness (0.974, p < 0.001). The macular volume had the largest AROC curves (0.898, p < 0.001) of all macular parameters. For glaucoma suspect eyes versus early glaucomatous eyes, the best value of circumpapillary parameters was inferior quadrant thickness (0.835, p < 0.001). Among the macular parameters, the best value was the macular cube volume (0.766, p < 0.001). CONCLUSION: Circumpapillary parameters have better diagnostic performance than macular parameters especially the inferior quadrant thickness that has the best discriminating power

Neovascular glaucoma: a retrospective review of 5-year experience in Songklanagarind Hospital.

OBJECTIVE: To review causes, treatment modalities, and success of neovascular glaucoma treatment in the past five years at Songklanagarind Hospital. MATERIAL AND METHOD: Neovascular glaucoma of any causes between February 2005 and January 2010 were retrospectively reviewed. The patients were divided into six major treatment subgroups. A medical treatment group, an intraocular bevacizumab injection group (IOB), a trabeculectomy with mitomycin C group, a trabeculectomy with mitomycin C plus adjunctive intraocular bevacizumab injection group, a glaucoma drainage device group, and a transscleral cyclophotocoagulation group. All treatment outcomes were compared and classified as success or failure according to the specific criteria. RESULTS: One hundred and sixty-six eyes were reviewed. The mean age at the time of diagnosis was 60 +/- 16 years and the average follow-up duration was 21 +/- 18 months. The most common etiology was central retinal vein occlusion (47%) followed by proliferative diabetic retinopathy (42%) and ocular ischemic syndrome (5%). The mean pressure was reduced from 38.1 +/- 12.5 mmHg at baseline to 17.8 +/- 12.3 mmHg at the final visit. After treatment, visual acuity was worse, remained stable, and improved in 45%, 37%, and 18% of the patients, respectively. In the trabeculectomy with mitomycin C plus intraocular bevacizumab injection group 54% of eyes were classified as a complete success, which was significantly higher than the other groups (p < 0.001). Although filtering surgeries with adjunctive bevacizumab showed no benefit over standard filtering surgeries in terms of VA change, pressure reduction, and success criteria but complications were found to be less in eyes treated with adjuvant bevacizumab. CONCLUSION: Key factors are treatment of the underlying disease responsible for ischemic triggers and treatment of the increased intra-ocular pressure. Even treatment with bevacizumab cannot increase the success rate but this seems to reduce the surgical complications.

Effects of phacoemulsification and intraocular lens implantation on intraocular pressure in primary angle closure glaucoma (PACG) patients.

OBJECTIVE: To investigate the effect of cataract surgery by phacoemulsification on the intraocular pressure (IOP) in primary angle closure glaucoma (PACG) patients. MATERIAL AND METHOD: Sixty PACG patients who underwent phacoemulsification between January 2004 and May 2009 were retrospectively reviewed. Pre- and post-operative visual acuity, IOP and number of anti-glaucoma medications were recorded. Lens thickness and anterior chamber depth (ACD) of pre-operative were also recorded. Patients who had previous intraocular surgeries or complicated cataract surgeries were excluded. RESULTS: Visual acuity logMAR improved significantly (0.17, p < 0.01). Mean IOP after cataract surgery decreased significantly (4.50 mmHg, p < 0.01). There was no significant relationship between the decrease in IOP and lens thickness or ACD. Twenty percent of PACG patients were free of antiglaucoma medication after cataract surgery. CONCLUSION: Phacoemulsification not only improves the visual acuity in PACG patients but also reduces IOP and number of anti-glaucoma medications required significantly. The change in IOP does not significantly correlate with lens thickness or ACD.

The impact of central corneal thickness on intraocular pressure measured by non-contact tonometry.

OBJECTIVE: To investigate the impact of central corneal thickness (CCT) on the intraocular pressure (IOP) measurement by non-contact tonometry (NCT). MATERIAL AND METHOD: Eye examination data of normal volunteers aged between 18-96 years and intraocular pressure less than 22 mmHg were retrospectively reviewed. Subjects with possible conditions that affected the results of CCT and IOP measurement by NCT were excluded. The data of CCT and IOP measurements by NCT were obtained. Linear and multiple regression analysis were used to evaluate the influence of CCT and age on IOP measurement by NCT. RESULTS: Four hundred and thirty seven eyes of 437 subjects were enrolled. The mean age was 49.05 +/- 18.84 years. The average CCT was 524.56 +/- 32.40 microns and the mean IOP measurement by NCT was 13.85 +/- 2.81 mmHg. Linear regression model showed a significant negative correlation between CCT and subject age (p < 0.001), but had a positive correlation between CCT and IOP measurement by NCT (p = 0.006). CONCLUSION: CCT has a significant impact on IOP measurement by NCT. The finding suggests that CCT is an important parameter for interpretation of IOP measurement by NCT.

A variety of atypical manifestations in giant cell arteritis.

Giant cell arteritis (GCA) is a chronic granulomatous vasculitis of large and medium size vessels in the elderly. A new-onset headache is the most frequent symptom. An anterior ischemic optic neuropathy (AION) is one of the most common causes of permanent visual loss. There are four cases with unusual presentation of giant cell arteritis, scalp abscess, prolonged transient monocular visual loss (TMVL), bilateral central retinal artery occlusion (CRAO), and chronic ear pain. All patients had pathologically proven giant cell arteritis, and three of them progressed to blindness in the end. Scalp abscess is a rare sign in GCA. Delay in diagnosis because confusion of the abscess after scalp ischemia with other cutaneous lesions may result in death. TMVL is the forewarning symptom of AION or CRAO in GCA. Early recognition of TMVL is important to make early diagnosis of GCA to prevent blindness. Spontaneous ear pain is extremely rare, and reports have documented delay in diagnosis of GCA resulting in irreversible blindness.

The effects of optic disc drusen on the latency of the pattern-reversal checkerboard and multifocal visual evoked potentials.

PURPOSE: To determine the effect of optic disc drusen on the latency of the pattern-reversal checkerboard visual evoked potentials (VEPs) and multifocal (mf)VEPs and to better understand the pathophysiology of the condition. METHODS: Eighteen eyes with optic disc drusen (10 patients) and 38 control eyes (19 subjects) underwent VEP, mfVEP, and visual field testing. Only one eye of each individual, the one with the more affected visual field, was used in the analyses. The VEPs were recorded with a 15' and 60' reversing checkerboard pattern, and the mfVEPs were elicited by a 60-sector dartboard display. RESULTS: Unlike the VEP results, the mfVEP revealed a significant increase in the average monocular latency of the optic disc drusen group compared with that of the control group. The average mfVEP relative latency for the optic disc drusen group (4.1 ms) was greater than that (0.8 ms) in the control group. For monocular and interocular analyses, the average percentage of points delayed in the drusen group was significantly greater than that in the control group. CONCLUSIONS: Optic disc drusen produced significant latency delays on the mfVEP test but not on the VEP test, presumably due to the mfVEP's ability to detect the effects of local changes. The results are consistent with the hypothesis that local mechanical compression by optic disc drusen leads to abnormal retinal ganglion cell activity.

A method to detect progression of glaucoma using the multifocal visual evoked potential technique.

PURPOSE: To describe a method for monitoring progression of glaucoma using the multifocal visual evoked potential (mfVEP) technique. METHODS: Eighty-seven patients diagnosed with open-angle glaucoma were divided into two groups. Group I, comprised 43 patients who had a repeat mfVEP test within 50 days (mean 0.9 +/- 0.5 months), and group II, 44 patients who had a repeat test after at least 6 months (mean 20.7 +/- 9.7 months). Monocular mfVEPs were obtained using a 60-sector pattern reversal dartboard display. Monocular and interocular analyses were performed. Data from the two visits were compared. The total number of abnormal test points with P < 5% within the visual field (total scores) and number of abnormal test points within a cluster (cluster size) were calculated. Data for group I provided a measure of test-retest variability independent of disease progression. Data for group II provided a possible measure of progression. RESULTS: The difference in the total scores for group II between visit 1 and visit 2 for the interocular and monocular comparison was significant (P < 0.05) as was the difference in cluster size for the interocular comparison (P < 0.05). Group I did not show a significant change in either total score or cluster size. CONCLUSION: The change in the total score and cluster size over time provides a possible method for assessing progression of glaucoma with the mfVEP technique.