Prevalence of Glaucoma Following Paediatric Cataract Surgery in an Australian Tertiary Referral Centre.

Purpose: Secondary glaucoma following childhood cataract surgery remains the most common complication in the paediatric population. This study aimed to determine the incidence, time to progression and risk factors associated with the development of secondary glaucoma following childhood cataract surgery in a paediatric population. Outcome measures were the detection of secondary glaucoma, postoperative time frame to development of glaucoma and risk factors in its development. Patients and Methods: A retrospective case series was conducted between 2003 and 2017 at a tertiary children's hospital in Sydney. The patient population included those 16 years or less of age who underwent congenital cataract extraction, with or without an intraocular lens implantation and who had been followed up for a minimum of six months following surgery. Patients were excluded if they had cataract aetiology other than congenital idiopathic cataract. Multivariate Cox Regression analysis was used to determine relevant risk factors. Results: A total of 320 eyes in 216 patients were included in the study. Secondary glaucoma developed in 11.9% of eyes. In those that developed secondary glaucoma, the average time to onset from surgery was 3.2 years (median 2.75 years). The mean age of diagnosis of secondary glaucoma was 4.58 years (median 3.5 years, range 2.5 months to 13.23 years). Microcornea was the only adverse characteristic significantly associated with an increased risk of secondary glaucoma (HR 6.30, p 0.003). Conclusion: Despite modern surgical techniques, glaucoma remains a significant long-term sequela in children following cataract surgery.

Management of macular oedema due to retinal vein occlusion: An evidence-based systematic review and meta-analysis.

BACKGROUND: Central retinal vein occlusion and branch retinal vein occlusion are common causes of visual loss due to associated macular oedema. The aim of this review was to assess the effectiveness of interventions improving vision and treating macular oedema in central retinal vein occlusion and branch retinal vein occlusion. METHODS: Medical search engines and clinical trial registries were systematically searched. Randomised clinical trials with ≥90 eyes and real-world outcome studies with ≥100 eyes each with ≥6 months follow-up were included. RESULTS: There were 11 randomised controlled trials evaluating treatments for central retinal vein occlusion which met the inclusion criteria and 10 for branch retinal vein occlusion. There were 10 real world outcome studies of central retinal vein occlusion and 5 real world outcome studies of branch retinal vein occlusion. Meta-analysis was performed on studies that met the defined inclusion criteria. Main outcomes were change in visual acuity at 6-, 12-, 24- and 36 months by treatment. CONCLUSIONS: Intravitreal anti-vascular endothelial derived growth factor is recommended as first line treatment over intravitreal corticosteroid due to its effectiveness and lower rate of ocular adverse events. Best outcomes are achieved when intravitreal treatment is started early. Macular laser may have an adjunctive role in branch retina vein occlusion but not central retinal vein occlusion.

Infective Necrotizing Scleritis After XEN Gel Stent With Mitomycin-C.

PURPOSE: The purpose of this study was to report a case of infective necrotizing scleritis following XEN Gel Stent with mitomycin-C. METHODS: Case report. This is a case report of a 68-year-old woman. RESULTS: XEN Gel Stent glaucoma surgery enhanced with mitomycin-C 0.04% and combined with cataract surgery was performed at a regional center to manage the patient's primary open-angle glaucoma. Past medical history was significant for rheumatoid arthritis requiring treatment with methotrexate and adalimumab. Periocular pain and swelling developed 14 months after the initial operation, followed by a rapid deterioration of visual acuity to 20/60, intraocular pressure of 4 mm Hg, and worsening pain 5 months later. On initial presentation to Sydney Eye Hospital, 180 degrees of scleral necrosis was evident with a moderate anterior segment inflammatory reaction and a large temporal choroidal effusion due to hypotony. Empirical hourly topical ofloxacin and cephalothin 5% drops, with oral moxifloxacin, were initiated. Conjunctival swab grew Staphylococcus aureus and Staphylococcus lugdunensis. Significant clinical improvement occurred, but the XEN Gel Stent became exposed after 9 days of treatment with worsening hypotony. Urgent surgical revision was performed to remove the XEN Gel Stent and apply a tutoplast plug with overlying amniotic membrane graft. Intraocular pressure gradually improved over 6 weeks to 15 mm Hg with reversal of hypotonous changes, and visual acuity stabilized at 20/40. CONCLUSIONS: To our knowledge, this is the first reported case of necrotizing scleritis following XEN Gel Stent insertion. It is a reminder that infection should always be the primary differential diagnosis in patients with surgical-induced necrotizing scleritis.

Cataract Surgery in Short Eyes, Including Nanophthalmos: Visual Outcomes, Complications and Refractive Results.

BACKGROUND: To report the visual outcomes, complications and refractive results of phacoemulsification surgery and intraocular lens implantation in a large series of adult patients with short and nanophthalmic eyes. METHODS: The records of all patients with axial length <21.0 mm undergoing phacoemulsification with intraocular lens implantation at an adult teaching hospital were retrospectively reviewed. The main outcome measures were corrected distance visual acuity and refraction at 90 days after surgery and intra- and postoperative complications occurring during the follow-up period. RESULTS: A total of 71 eyes of 51 patients (median age 71 years, interquartile range 62-75.5) were included. Surgery resulted in an improvement in corrected distance visual acuity in 53 eyes (74.6%) (95% confidence interval, logMAR 0.11-0.29) and was logMAR 0.30 or better in 47 eyes (66.2%). Worsening of corrected distance visual acuity occurred in 9 eyes (12.7%). Median postoperative refractive error was -0.75 dioptres. SRK/T and Kane formula were more accurate in predicting postoperative refraction than Barrett Universal II and Hoffer Q when based on mean absolute error (P < 0.005). Complications occurred in 18 eyes (25.4%). The most frequent complications were iris prolapse, Descemet's membrane and/or endothelial trauma, transient severe corneal edema and cystoid macular edema. There was no statistically significant difference in complication rates between senior surgeons and senior trainees (P = 0.66). CONCLUSION: Cataract surgery in short and nanophthalmic eyes is challenging with a higher complication rate than routine cataract surgery, but frequently results in good visual outcomes. Postoperative refractive outcomes are more difficult to predict in this cohort.

Recommendations for the management of childhood juvenile idiopathic arthritis-type chronic anterior uveitis.

IMPORTANCE: Australian- and New Zealand-based, uveitis-specialized ophthalmologists have produced recommendations for the management of juvenile idiopathic arthritis (JIA)-type chronic anterior uveitis. BACKGROUND: Historically, the visual prognosis of JIA-type chronic anterior uveitis has been poor. New medical advances are likely to improve outcomes, but recently published guidelines are tailored for ophthalmic care in Europe and the United States. DESIGN: This work involved a consensus survey and a panel meeting. PARTICIPANTS: The Australian and New Zealand JIA-Uveitis Working Group (29 ophthalmologists) participated in the work. METHODS: The Delphi technique was used to achieve consensus. MAIN OUTCOME MEASURES: This work yielded consensus statements. RESULTS: The Working Group achieved consensus around 18 statements related to clinical evaluation, use of topical and regional corticosteroids, use of systemic corticosteroid and non-corticosteroid immunomodulatory drugs, and management of secondary cataract and glaucoma in childhood JIA-type uveitis. CONCLUSIONS AND RELEVANCE: Recommendations of the Australian and New Zealand JIA-Uveitis Working Group provide current and regionally applicable advice for managing chronic anterior uveitis in children with JIA.

Surgical Treatment for SWS Glaucoma: Experience From a Tertiary Referral Pediatric Hospital.

PRECIS: Glaucoma associated with Sturge-Weber syndrome (SWS) often requires surgical intervention. Our study shows that trabeculectomy is efficacious in treating this condition. PURPOSE: The purpose of this study was to describe the surgical outcomes of glaucoma associated with SWS in children presenting to the tertiary Paediatric Ophthalmology Department at The Children's Hospital at Westmead. MATERIALS AND METHODS: A retrospective study of patients with SWS referred to the Department of Ophthalmology at The Children's Hospital at Westmead between 2003 and 2016 with at least 2 years of follow-up were identified, and information was collected from the clinical notes of all subjects. RESULTS: A total of 27 patients with SWS were evaluated for glaucoma in which 8 were excluded due to inadequate follow-up. In total, 19 patients with SWS were included in this study in which glaucoma was diagnosed in 15 patients and 19 eyes, of which 13 eyes required glaucoma surgery. A total of 21 surgical procedures were performed with a median follow-up of 85 months. A primary trabeculotomy was performed in 5 eyes of which 4 required re-do trabeculotomy, and 3 of these eyes underwent a Baerveldt tube (BVT) shunt as a third procedure. One eye with a primary trabeculotomy underwent a BVT as a secondary procedure. A BVT was inserted in a total of 6 eyes in which it was a primary procedure in 2 eyes. Of the 6 eyes undergoing a BVT insertion, 5 achieved success (2 complete and 3 qualified), and 1 failed. One case underwent intraluminal stent removal. Six eyes underwent a primary trabeculectomy and needed no further surgical intervention. In the trabeculectomy group, 4 eyes achieved complete success and 2 eyes achieved qualified success. CONCLUSIONS: Glaucoma affects a significant proportion of patients with SWS and is associated with the presence of an ipsilateral port-wine stain in most cases. In our study, trabeculectomy was the most efficacious procedure for controlling intraocular pressure and reducing the burden of ongoing treatment in SWS-associated glaucoma.

Post-surgical versus post-intravitreal injection endophthalmitis: changing patterns in causative flora.

IMPORTANCE: Endophthalmitis is a serious complication of intraocular procedures: knowledge of its causative organisms and outcomes may guide prevention and treatment. BACKGROUND: To determine the outcomes and spectrum of causative organisms in acute post-procedural endophthalmitis. DESIGN: A retrospective observational case series performed at a tertiary referral hospital during the period 1 July 2012 to 31 July 2017. PARTICIPANTS: Two hundred and forty-eight patients diagnosed with acute (≤ 6 weeks post-inciting event) endophthalmitis. METHODS: Chart review of microbiological and clinical data. MAIN OUTCOME MEASURES: The main outcome measure was odds of any improvement in visual acuity (3 months versus presentation). Secondary outcomes included causative organism, likelihood of vitrectomy and likelihood of evisceration. RESULTS: One hundred and ninty cases were post-cataract surgery or post-intravitreal injection (49 and 141, respectively). Causative organisms were identified in 45% of post-cataract surgery and 54% of post-injection cases (OR = 0.69; P = 0.61). Staphylococcus epidermidis was the most frequent causative organism. Streptococcus species accounted for 32% of post-surgical and 7% of culture-positive post-injection cases (OR = 6.63; P = 0.02). At 3 months, 81% of post-surgical and 84% of post-injection cases had improved BCVA over presentation (OR 0.59; P = 0.61). CONCLUSIONS AND RELEVANCE: S. epidermidis is the most common causative organism. In contrast to other studies, we did not find evidence for an increased odds of Streptococcus spp. endophthalmitis following intravitreal injection. This may in turn reflect guideline-driven changes in practice.

Etiology and Clinical Features of Ocular Inflammatory Diseases in a Tertiary Referral Centre in Sydney, Australia.

PURPOSE: To report the pattern of uveitis in patients attending a tertiary uveitis service in Sydney, Australia. METHODS: The charts of patients seen between January 2009 and December 2015 were retrospectively reviewed. Data pertaining to patient demographics, eye examination on presentation, work-up and final diagnoses were collected. RESULTS: The total number of patients with uveitis seen over this period was 1165. There were 650 males (56%) and 515 females (44%). There were 838 patients aged 17-60 years (72%) and 327 patients aged >60 years (28%). Uveitis was anterior in 735 patients (63%), posterior in 234 patients (20%), pan in 109 patients (9%), and intermediate in 87 patients (8%). The most common associations were HLA-B27+ve (264 patients; 22.8%), sarcoidosis (78 patients; 6.7%) and Fuchs (33 patients; 2.8%), while VZV (51 patients; 4.4%), HSV (49 patients; 4.2%), tuberculosis (49 patients; 4.2%) and toxoplasmosis (48 patients; 4.1%) were the most common infectious causes of uveitis. No identifiable association was found in 389 patients (33.4%). HLA-B27 was more common in the younger age group compared with the older age group (p<0.001, χ2-test), but there was no difference between the age groups for no identifiable cause (p value 0.24) and sarcoidosis (p value 0.08). CONCLUSIONS: This retrospective case review reveals a broad spectrum of uveitis in a tertiary referral service in Sydney, Australia. It is comparable with other major studies around the world.

Primary congenital glaucoma outcomes: lessons from 23 years of follow-up.

PURPOSE: To determine in primary congenital glaucoma whether age of presentation influences surgical success, the degrees of angle surgery needed to achieve glaucoma control, and whether there are critical ages where glaucoma progresses, requiring further surgical management. DESIGN: Retrospective cohort study. METHODS: The medical records of patients with primary congenital glaucoma over a 23-year period were reviewed: 192 procedures were performed on 117 eyes (70 patients). The number and age of angle procedures and final visual acuity was analyzed. Surgical success was defined as stable intraocular pressure and optic disc appearance. RESULTS: Procedures involving 83 of the 110 eyes (75.5%) undergoing angle surgery were successful, with 2-, 4-, 6-, and 10-year success rates of 92%, 86%, 84%, and 75%, respectively. Subgroup analysis (<3 months; 3-6 months; >6 months) comparing age of diagnosis to visual outcome (<20/200, 20/200-20/40, >20/40) was significant (P = .04). The age at first operation (P = .94), the number of angle operations (P = .43), and their effect on angle surgery success was not significant. Seven of 192 operations were performed after the age of 8 years (3.6%). After the initial angle surgeries within the first year of life, the third procedure occurred at a median age of 2.4 years (interquartile ratio [IQR] 0.6-3.8 years) and the fourth procedure occurred at a median age of 5.3 years (IQR 2.5-6.1 years). CONCLUSIONS: Children diagnosed at <3 months of age had a visual outcome of <20/200 despite successful glaucoma control. Age of presentation did not affect surgical success. A total of 78.9% of cases undergoing primary trabeculotomy were controlled with 1 operation: 4 clock hours of angle (120 degrees). Analysis of glaucoma progression suggests critical ages where further glaucoma surgery is required at around 2 and 5 years of age.

Ocular manifestations of seronegative spondyloarthropathies.

PURPOSE OF REVIEW: This article reviews recent advances in the understanding of the ocular manifestations of seronegative spondyloarthropathies. RECENT FINDINGS: Ocular inflammatory disorders are common and important disease manifestations in patients with seronegative spondyloarthropathy, with anterior uveitis being the most common. There is a strong association between affected patients and the human leukocyte antigen B27. Local corticosteroid treatment is usually effective, but chronic or refractory uveitis responds well to immunosuppressive drugs that are effective for arthritis. Recent studies have highlighted the possible benefits of a number of biologic agents, including tumor necrosis factor-alpha inhibitors in such patients. SUMMARY: Uveitis is the most common ocular manifestation in patients affected by seronegative spondyloarthropathies. Both genetic and environmental factors play a role in its pathogenesis. As it tends to affect the young adult population, it carries a significant personal and population burden. Immunomodulatory therapy that also acts as a corticosteroid sparing therapy can be effective in controlling chronic uveitis in patients with spondyloarthropathy.