Expert Consensus Recommendations for the Management of Ocular Surface Inflammation in Patients with Glaucoma.

PRECIS: We have developed via a consensus process 24 clinical recommendations for the comprehensive management of ocular surface inflammation in glaucoma patients, including diagnostic criteria, prevention measures, and treatment strategies according to ocular surface disease severity. PURPOSE: To obtain expert consensus on the diagnosis, prevention and management of ocular surface inflammation (OSI) in patients with glaucoma. METHODS: An international steering committee of glaucoma and/or ocular surface disease (OSD) experts and a wider faculty of members from the Educational Club of Ocular Surface and Glaucoma (ECOS-G) collaborated to develop clinical recommendations on best practice in the management of OSI in glaucoma patients using a non-anonymous interactive quasi-Delphi process. Clinical recommendations were formulated by the steering committee based on an analysis of the recent literature to determine unmet needs, together with a web-based interactive survey of faculty members' opinion in seven identified areas of OSI management in glaucoma. Topics included 1) diagnosis of OSD, 2) diagnosis of OSI, 3) causes of OSI, 4) impact of OSD/OSI, 5) prevention of OSI, 6) treatment of OSI, and 7) inflammation and the deep structures of the eye. Faculty members were invited to vote on the clinical recommendations, and the steering committee then determined whether consensus had been achieved. RESULTS: Consensus was obtained on 24 clinical recommendations by 80-100% of faculty members. There was consensus that OSI should be investigated in all glaucoma patients. The main prevention measure in glaucoma patients with pre-existing OSD was the elimination/minimisation of preserved medications, especially BAK-preserved eye drops. A subtractive treatment strategy rather than an additive strategy is recommended according to OSI/OSD severity to improve the ocular health and/or before glaucoma surgery. CONCLUSION: These recommendations for the management of OSI in glaucoma should be useful to guide decision-making in clinical practice.

FAST® questionnaire for identifying glaucoma patients at risk for ocular surface disease.

OBJECTIVES: To evaluate the validity and reliability of the new Fast Assessment of the Ocular Surface Trouble (FAST®) questionnaire for identifying glaucoma or ocular hypertension (OHT) patients at risk of ocular surface disease (OSD). METHODS: A multicenter, international, cross-sectional, epidemiological survey evaluated the most accurate interview items and ocular signs on the initial 14-item version of FAST® to develop a shorter version for routine, quick clinical use. Rasch analysis and least absolute shrinkage and selection operator (LASSO) method was used to reduce the number of items on the questionnaire. Sensitivity and specificity of FAST® were assessed with receiver operating characteristic (ROC) curves for the detection of OSD with the questionnaire and ophthalmic assessment. RESULTS: A total of 2308 eyes (1154 patients) were analyzed in this study by 92 ophthalmologists. The initial version of the FAST® indicated 60% of the subjects had OSD. Rasch analysis allowed removal of some clinical signs. The LASSO method allowed elimination of some items from the original questionnaire for a 9-item and a 6-item version of FAST®. For the 6-item questionnaire, the sensitivity and specificity were 71.9% and 74.3% respectively and the area under the curve was 0.815. CONCLUSIONS: The FAST® questionnaire is a valid and reliable tool for use in routine clinical practice and in clinical trials. The short versions of the questionnaire allow quick detection of the majority of patients with OHT or glaucoma at risk of dry eye.

Evaluation of the Performance of a 3D-Printed Smartphone-Based Retinal Imaging Device as a Screening Tool for Retinal Pathology in Mozambique.

Low-income countries carry approximately 90% of the global burden of visual impairment, and up to 80% of this could be prevented or cured. However, there are only a few studies on the prevalence of retinal disease in these countries. Easier access to retinal information would allow differential diagnosis and promote strategies to improve eye health, which are currently scarce. This pilot study aims to evaluate the functionality and usability of a tele-retinography system for the detection of retinal pathology, based on a low-cost portable retinal scanner, manufactured with 3D printing and controlled by a mobile phone with an application designed ad hoc. The study was conducted at the Manhiça Rural Hospital in Mozambique. General practitioners, with no specific knowledge of ophthalmology or previous use of retinography, performed digital retinographies on 104 hospitalized patients. The retinographies were acquired in video format, uploaded to a web platform, and reviewed centrally by two ophthalmologists, analyzing the image quality and the presence of retinal lesions. In our sample there was a high proportion of exudates and hemorrhages-8% and 4%, respectively. In addition, the presence of lesions was studied in patients with known underlying risk factors for retinal disease, such as HIV, diabetes, and/or hypertension. Our tele-retinography system based on a smartphone coupled with a simple and low-cost 3D printed device is easy to use by healthcare personnel without specialized ophthalmological knowledge and could be applied for the screening and initial diagnosis of retinal pathology.

Effect of Conventional Cataract Surgery and Femtosecond Laser-Assisted Cataract Surgery on Bruch's Membrane Opening-Minimum Rim Width, Retinal Nerve Fiber Layer, and Macular Thickness.

Purpose: To evaluate the effect of conventional cataract surgery (CCS) and femtosecond laser-assisted cataract surgery (FLACS) on Bruch's membrane opening-minimum rim width (BMO-MRW), peripapillary retinal nerve fiber layer thickness (RNFL), and macular thickness (MT) using spectral-domain optical coherence tomography (SD-OCT). Methods: BMO-MRW, RNFL, and MT were measured using SD-OCT preoperatively, 1 month and 6 months after surgery in both CCS and FLACS groups. Differences between preoperative and postoperative values were evaluated in both groups. The postoperative changes were evaluated in each group and compared between groups. Results: A total of 146 eyes of 146 patients were included in this study, 65 underwent CCS, and 81 underwent FLACS. One month after surgery, there was an increase (in microns) of 20.93 in BMO-MRW, 4.26 in RNFL, and 7.85 in MT in CCS group (P < 0.001), and 17.7, 3.73, and 5.65, respectively, in FLACS group (P < 0.001). Six months after surgery, there was an increase of 12.53 in BMO-MRW, 1.42 in RNFL, and 4.72 in MT in CCS group (P < 0.001), and 13.7, 1.88, and 4.14, respectively, in FLACS group (P < 0.001). The postoperative changes in CCS group were similar to those in FLACS group. Conclusion: CCS as well as FLACS result in a slight increase in BMO-MRW, RNFL, and MT values one month and six months after surgery. Neither CCS nor FLACS lead to a deterioration in the parameters that define the structure of the optic nerve head and the macula. These results suggest that FLACS is as safe as CCS regarding the optic nerve head and the macula in normal eyes.

Cost-Effectiveness of Screening for Open Angle Glaucoma Compared With Opportunistic Case Finding.

PRCIS: The manuscript evaluates cost-effectiveness of glaucoma screening with imaging devices and telemedicine based on a screening campaign performed in Spain. The screening strategy implemented in our analysis was cost-effective compared with opportunistic case finding. INTRODUCTION: Open angle glaucoma is an asymptomatic ocular disease that represents one of the first causes of blindness. Diagnosis is currently made by opportunistic case finding, usually by community optometrists or general ophthalmologists. The aim of this study was to assess the cost-effectiveness of a screening strategy based on optical coherence tomography and fundus photographs in glaucoma detection. MATERIALS AND METHODS: A cost-effectiveness analysis was carried out to compare 2 alternative strategies: opportunistic finding versus screening. A Markov tree model was carried out with 10 health states according to disease progression. Quality-adjusted life years (QALYs) were used as a measure of effectiveness. We included short-term and long-term direct health costs and a discount rate of 3%. We performed a probabilistic sensitivity analysis and several 1-way sensitivity analyses. RESULTS: The cohort in the screening program entailed an increase in 0.097 QALYs and additional costs of €1187 versus opportunistic finding, with an incremental cost-effectiveness ratio of about €12.214/QALY. The 1-way sensitivity analysis showed that inputs related to age and screening program (cost and detection rate) were those most strongly influencing the results of the analysis. Probabilistic sensitivity analyses showed that the model was robust to significant changes in the main variables of the analysis. CONCLUSIONS: The screening strategy implemented in our analysis was cost-effective compared with opportunistic finding in patients with glaucoma in this Spanish setting.

The Effect of Oral Citicoline and Docosahexaenoic Acid on the Visual Field of Patients with Glaucoma: A Randomized Trial.

The role of nutraceuticals in the treatment of glaucoma remains controversial. The aim of this study was to evaluate the effect of citicoline, vitamin C, and docosahexaenoic acid (DHA) in patients with glaucoma. METHODS: This was a prospective, randomized study. Patients with glaucoma were randomized to one of four groups and treated for 3 months with vitamin C, DHA, citicoline, or a combination of DHA and citicoline. We conducted a complete ophthalmic examination and visual fields each month and calculated the slopes of field indices. Changes in visual field indices (VFIs) and their slopes were assessed in each group and compared. RESULTS: Seventy-three persons were included in the study. Mean defect (MD) significantly improved (p = 0.001) from -9.52 ± 4.36 to -7.85 ± 4.36 dB during the study period in persons taking DHA + citicoline. Similarly, the mean VFI significantly improved (p = 0.001) in this group. The only treatment group showing a statistically significant improvement (p = 0.006) in the MD (from -0.1041 ± 0.2471 to 0.1383 ± 0.2544 dB/month) and VFI slope was the group treated with DHA+citicoline. CONCLUSIONS: The combination of oral treatment with DHA + citicoline significantly improved VF indices and their slopes in patients with glaucoma after 3 months of treatment.

Validation of the Spanish version of the Low Vision Quality of Life Questionnaire

Purpose: To validate the Spanish Low Vision Qualify of Life (SLVQOL) questionnaire, a quality of life instrument specifically designed for patients with visual impairment, and evaluate its psychometric properties.Methods: The study included 170 visually impaired patients and 195 healthy subjects. Participants were administered the SLVQOL, the NEI VFQ-25, and the EQ 5D-5L questionnaires. Reliability, test–retest reproducibility, feasibility, and construct validity of the SLVQOL were assessed. The Generalized Partial Credit Model was used to fit the data and the performance of each item was characterized using category response curves and item information.Results: The reliability of the SLVQOL was 0.981 (95% CI: 0.978–0.985). Test–retest reproducibility was good (ρ=0.864, P<.001). A cut-off point of 105 or 106 was optimal to detect visual impairment, with a sensitivity of 95.4% and a specificity of 91.8%. Construct validity was shown by the corresponding convergence or divergence correlations between the score of the SLVQOL and its dimensions and the overall and partial scores of the NEI VFQ-25 and the EQ 5D-5L. Item response theory analysis showed discrimination and information parameters ranging from 0.539 to 3.063 and from −1.894 to 1.074, respectively.Conclusion:The SLVQOL was able to quantitatively assess and identify differences in the quality of life among patients with visual impairment and normal subjects. The evaluated psychometric properties suggest that this tool has excellent validity, internal consistency, and reproducibility, but may benefit from a reduction of the number of items. (AU)

Validation of the Spanish version of the Low Vision Quality of Life Questionnaire.

PURPOSE: To validate the Spanish Low Vision Qualify of Life (SLVQOL) questionnaire, a quality of life instrument specifically designed for patients with visual impairment, and evaluate its psychometric properties. METHODS: The study included 170 visually impaired patients and 195 healthy subjects. Participants were administered the SLVQOL, the NEI VFQ-25, and the EQ 5D-5L questionnaires. Reliability, test-retest reproducibility, feasibility, and construct validity of the SLVQOL were assessed. The Generalized Partial Credit Model was used to fit the data and the performance of each item was characterized using category response curves and item information. RESULTS: The reliability of the SLVQOL was 0.981 (95% CI: 0.978-0.985). Test-retest reproducibility was good (ρ=0.864, P<.001). A cut-off point of 105 or 106 was optimal to detect visual impairment, with a sensitivity of 95.4% and a specificity of 91.8%. Construct validity was shown by the corresponding convergence or divergence correlations between the score of the SLVQOL and its dimensions and the overall and partial scores of the NEI VFQ-25 and the EQ 5D-5L. Item response theory analysis showed discrimination and information parameters ranging from 0.539 to 3.063 and from -1.894 to 1.074, respectively. CONCLUSION: The SLVQOL was able to quantitatively assess and identify differences in the quality of life among patients with visual impairment and normal subjects. The evaluated psychometric properties suggest that this tool has excellent validity, internal consistency, and reproducibility, but may benefit from a reduction of the number of items.

Interobserver and Intertest Agreement in Telemedicine Glaucoma Screening with Optic Disk Photos and Optical Coherence Tomography.

Purpose: To evaluate interobserver and intertest agreement between optical coherence tomography (OCT) and retinography in the detection of glaucoma through a telemedicine program. Methods: A stratified sample of 4113 individuals was randomly selected, and those who accepted underwent examination including visual acuity, intraocular pressure (IOP), non-mydriatic retinography, and imaging using a portable OCT device. Participants' data and images were uploaded and assessed by 16 ophthalmologists on a deferred basis. Two independent evaluations were performed for all participants. Agreement between methods was assessed using the kappa coefficient and the prevalence-adjusted bias-adjusted kappa (PABAK). We analyzed potential factors possibly influencing the level of agreement. Results: The final sample comprised 1006 participants. Of all suspected glaucoma cases (n = 201), 20.4% were identified in retinographs only, 11.9% in OCT images only, 46.3% in both, and 21.4% were diagnosed based on other data. Overall interobserver agreement outcomes were moderate to good with a kappa coefficient of 0.37 and a PABAK index of 0.58. Higher values were obtained by experienced evaluators (kappa = 0.61; PABAK = 0.82). Kappa and PABAK values between OCT and photographs were 0.52 and 0.82 for the first evaluation. Conclusion: In a telemedicine screening setting, interobserver agreement on diagnosis was moderate but improved with greater evaluator expertise.

SD-OCT peripapillary nerve fibre layer and ganglion cell complex parameters in glaucoma: principal component analysis.

BACKGROUND/AIMS: To identify objective glaucoma-related structural features based on peripapillary (p) and macular (m) spectral domain optical coherence tomography (SD-OCT) parameters and assess their discriminative ability between healthy and glaucoma patients. METHODS: Two hundred and sixty eyes (91 controls and 169 glaucoma) were included in this prospective study. After a complete examination, all participants underwent the posterior pole and the peripapillary retinal nerve fibre layer (pRNFL) protocols of the Spectralis SD-OCT. Principal component analysis (PCA), a data reduction method, was applied to identify and characterise the main information provided by the ganglion cell complex (GCC). The discriminative ability between healthy and glaucomatous eyes of the first principal components (PCs) was compared with that of conventional SD-OCT parameters (pRNFL, macular RNFL (mRNFL), macular ganglion cell layer (mGCL)and macular inner plexiform layer (mIPL)) using 10-fold cross-validated areas under the curve (AUC). RESULTS: The first PC explained 58% of the total information contained in the GCC and the pRNFL parameters and was the result of a general combination of almost all variables studied (diffuse distribution). Other PCs were driven mainly by pRNFL and mRNFL measurements. PCs and pRNFL had similar AUC (0.95 vs 0.96, p=0.88), and outperformed the other structural measurements: mRNFL (0.91, p=0.002), mGCL (0.92, p=0.02) and mIPL (0.92, p=0.0001). CONCLUSIONS: PCA identified a diffuse representation of the papillary and macular SD-OCT parameters as the most important PC to summarise structural data in healthy and glaucomatous eyes. PCs and pRNFL parameters showed the greatest discriminative ability between healthy and glaucoma cases.

Angioid streaks and obstructive sleep apnea syndrome: are they related?

BACKGROUND: Sleep apnea syndrome (OSAS) has been associated with different ocular manifestations including glaucoma, floppy eye syndrome, punctate keratitis, keratoconus, and optic neuropathy. Angioid streaks are mainly associated with pseudoxanthoma elasticum (PXE) although they can appear in other systemic conditions affecting the elastic fibers. METHODS: This is a prospective, cross-sectional study. A complete ophthalmic examination was performed in 92 patients undergoing overnight polysomnography for suspicion of OSAS. Diagnosis and classification of OSAS were made based on apnea-hypopnea index (AHI). Stereoscopic optic disc photographs were taken in all patients and independently evaluated by two ophthalmologists. Patients with angioid streaks were referred to a dermatologist for axillary skin biopsy in order to rule out pseudoxanthoma elasticum or other skin abnormalities. RESULTS: Bilateral angioid streaks were observed in three patients who had been diagnosed with severe OSAS (AHI > 30/h). No clinical features characteristic of pseudoxanthoma elasticum or other pathological skin signs were observed. Skin biopsies were normal for all three patients, supporting the diagnosis of idiopathic angioid streaks. One of the patients developed bilateral choroidal neovascularization secondary to the angioid streaks over subsequent years. CONCLUSIONS: In view of the low prevalence of idiopathic angioid streaks in the general population, the finding of angioid streaks in patients with severe OSAS suggests OSAS as a possible risk factor for its development. The hypothesis of a connective tissue abnormality that could explain an association between both entities deserves further elucidation.

Diagnostic Accuracy and Detection Rate of Glaucoma Screening with Optic Disk Photos, Optical Coherence Tomography Images, and Telemedicine.

PURPOSE: The aim of this study was to evaluate the diagnostic accuracy of optical coherence tomography (OCT) and retinography in the detection of glaucoma through a telemedicine program. METHODS: A population-based sample of 4113 persons was randomly selected. The screening examination included a fundus photograph and OCT images. Images were evaluated on a deferred basis. All participants were then invited to a complete glaucoma examination, including gonioscopy, visual field, and dilated fundus examination. The detection rate, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: We screened 1006 persons. Of these, 201 (19.9%) were classified as glaucoma suspects; 20.4% were identified only by retinographs, 11.9% only by OCT images, and 46.3% by both. On ophthalmic examination at the hospital (n = 481), confirmed glaucoma was found in 58 (12.1%), probable glaucoma in 76 (15.8%), and ocular hypertension in 10 (2.1%), and no evidence of glaucoma was found in 337 (70.0%). The detection rate for confirmed or probable glaucoma was 9.2%. Sensitivity ranged from 69.4% to 86.2% and specificity from 82.1% to 97.4%, depending on the definition applied. CONCLUSIONS: The combination of OCT images and fundus photographs yielded a detection rate of 9.2% in a population-based screening program with moderate sensitivity, high specificity, and predictive values of 84-96%.

Ocular hypertension in Axenfeld-Rieger Syndrome.

Purpose: to describe a clinical case of ocular hypertension (OHT) in Axenfeld-Rieger Syndrome (ARS). Method: Observational case report of a 43-year-old woman with background of OHT. The data was collected originally with a standardized electronic medical record. A complete ophthalmologic examination was performed. Results: In the biomicroscopy, a posterior embryotoxon, iris atrophy with absence of crypts and irregularity of pigmentation, and discoria in OU were observed. Gonioscopy revealed an open angle with a prominent and anterior displaced Schwalbe line. Ocular fundus (OF) demonstrated small and oblique papillae, with normal neurorretinal ring. Functional tests were normal. The patient did not present systemic pathologies, so the diagnosis of Rieger anomaly was made. The IOP control was achieved with aqueous humor suppressants. Conclusions: Glaucoma is the main cause of visual morbidity in patients with ARS, therefore a complete periodic ophthalmological exam is a priority. Abbreviations :ARS = Axenfeld-Rieger Syndrome, RP = retinitis pigmentosa, IOP = Intraocular Pressure, BCVA = Best Corrected Visual Acuity, OR = right eye, OS = left eye, OU = both eyes, OF = ocular fundus, OCT = optical coherence tomography, VF = visual field, TBC = trabeculectomy.

Surgical Management for Refractory Bleb Dysesthesia.

PURPOSE: To present long-term results of modified bleb-limiting conjunctivoplasty as a successful treatment for intractable bleb dysesthesia and to review the literature on the surgical management of dysesthetic bleb. METHODS: Consecutive case series and literature review. We present four cases of surgically reduced painful blebs. Our technique consisted of the following steps: (1) conjunctival, radial incision to the bare sclera in the desired limit of the bleb; (2) suturing with buried, interrupted sutures at the nearest edge of the filtering bleb; (3) lower limbal peritomy including unwanted area of the extended bleb; (4) dissection and removal of the underlying fibrous tissue when present; (5) conjunctival and resorbable sutures. In addition, a systematic literature review was performed. Only reports presenting outcomes of surgical treatment of bleb dysesthesia after filtering procedure were included in review. RESULTS: Four eyes were included consecutively in the study in a period of 4 years. On average, they developed circumferential bleb dysesthesia 9.3 ± 4.7 months after uneventful combined phacotrabeculectomy with Mitomycin C as primary procedure. Surgical reduction was decided after failure of lubricants in controlling ocular discomfort. Two cases showed a dense fibrous tissue beneath the conjunctiva that was excised to ensure filtration. In all cases, a rapid disappearance of symptoms with very good aesthetic and functional outcome was observed. After 12-month follow-up, patients remained asymptomatic and maintained intraocular pressure of 10.7 ± 1.2 mmHg without treatment. A systematic review of the literature obtained 15 eligible case series (n = 123) with rates of success within 46-100%, favoring less aggressive approaches to reduce bleb size. CONCLUSION: Bleb dysesthesia is a rare complication of filtering glaucoma surgery. This modified bleb-limiting conjunctivoplasty technique (with removal of subjacent fibrous tissue if present) is able to target the underlying etiology providing ocular discomfort relief while maintaining bleb function and may be considered as first-choice surgical treatment.

Automatic glaucoma classification using color fundus images based on convolutional neural networks and transfer learning.

Glaucoma detection in color fundus images is a challenging task that requires expertise and years of practice. In this study we exploited the application of different Convolutional Neural Networks (CNN) schemes to show the influence in the performance of relevant factors like the data set size, the architecture and the use of transfer learning vs newly defined architectures. We also compared the performance of the CNN based system with respect to human evaluators and explored the influence of the integration of images and data collected from the clinical history of the patients. We accomplished the best performance using a transfer learning scheme with VGG19 achieving an AUC of 0.94 with sensitivity and specificity ratios similar to the expert evaluators of the study. The experimental results using three different data sets with 2313 images indicate that this solution can be a valuable option for the design of a computer aid system for the detection of glaucoma in large-scale screening programs.

The EX-PRESS glaucoma shunt versus nonpenetrating deep sclerectomy with Esnoper implant in combined surgery for open-angle glaucoma: a prospective randomized study.

PURPOSE: To report 1-year treatment outcomes of P50 EX-PRESS implant versus nonpenetrating deep sclerectomy (NPDS) with Esnoper V2000 combined with phacoemulsification. DESIGN: Randomized, prospective and multicentre clinical trial. METHODS: Settings: Six clinical centres. POPULATION: Patients 54-89 years of age without previous filtering surgery with cataract and glaucoma who required lower levels of intraocular pressure (IOP). INTERVENTIONS: Phaco-EX-PRESS P50 or Phaco-NPDS with Esnoper V2000, both groups with mitomycin C (0.2 mg/ml for 2 min). MAIN OUTCOME MEASURES: IOP, complete success rate (IOP: ≥6 and ≤18 mmHg), visual acuity, use of medical therapy and systematic assessment of complications and postoperative interventions. RESULTS: A total of 98 eyes were enrolled, including 50 in the EX-PRESS group and 48 in the NPDS group. At 12 months, IOP (mean ± SD) was 13.9 ± 3.3 mmHg in EX-PRESS group and 13.3 ± 3.6 mmHg in NPDS group (p = 0.38). Success rate was 75% and 80% in EX-PRESS and NPDS groups, respectively (p = 0.53). The number of glaucoma medications (mean ± SD) was 0.2 ± 0.55 in EX-PRESS group and 0.17 ± 0.44 in NPDS group (p = 1.00). The total number of complications was 66 in 35 subjects in EX-PRESS group and 39 in 23 subjects in NPDS group (p = 0.02). The incidence of more than one complication was n = 13 (26%) versus n = 9 (18.8%) in EX-PRESS and NPDS groups, respectively (p = 0.38). The total number of required postoperative interventions was 59 and 26 in EX-PRESS and NPDS groups, respectively (p = 0.01). Visual acuity was similar in both groups at month 12 (p = 0.13). Surgical time (mean ± SD) was 52.6 ± 13.6 min in EX-PRESS group and 63.3 ± 19.4 min in NPDS group (p = 0.01). CONCLUSION: Phaco-EX-PRESS surgery had similar success rate compared to Phaco-NPDS during 1 year of follow-up. Both procedures were associated with similar IOP reduction and use of additional medical therapy at 12 months. EX-PRESS surgery required more postoperative interventions and had more complications, but needed less surgical time compared to NPDS.

Evaluation of RETICs Glaucoma Diagnostic Calculators in Preperimetric Glaucoma.

PURPOSE: To evaluate two glaucoma diagnostic calculators (GDC) in a group of eyes with preperimetric glaucoma (PPG). METHODS: All eyes (n = 265) included in this study had ocular hypertension with normal visual fields (VFs) on repeated VF tests. PPG was defined as progression in the Guided Progression Analysis software from Cirrus-optical coherence tomography (GPA-OCT). Three PPG types were defined according to the GPA-OCT software as follows: (1) GPA-OCT with one or more red boxes in two or more columns; (2) GPA-OCT with two or more red boxes in two or more columns; and (3) GPA-OCT with two or more red boxes in two or more columns (definition 2), and in the last scan one or more red box in the RNFL average or quadrants. Nonparametric tests, areas under the receiver operating characteristic curve (AUC), and Bland-Altman tests were assessed. RESULTS: Definitions one, two, and three were met by 44 (16.6%), 29 (10.9%), and 11 (4.2%) eyes, respectively. The GDC indices (means ± standard deviations) were, respectively, 14.49 ± 21.55% and 26.06 ± 22.50% using the combined and quantitative GDC (P < 0.001) in all eyes. Both GDC showed higher glaucoma probability in the PPG group (P < 0.04; combined GDC AUCs, 0.720-0.833; quantitative GDC AUCs, 0.700-0.839). GDC values were higher (P < 0.01) with greater GPA progression. CONCLUSIONS: The values of both GDC were higher in the PPG group than the ocular hypertension group. The GDC were higher when more columns in the GPA software indicated progression. Both GDC showed a similar ability to detect PPG. TRANSLATIONAL RELEVANCE: These calculators facilitate diagnosis of PPG in ocular hypertensive eyes.

Supraciliary Implant Placement and Postoperative Suprachoroidal Hemorrhage After Nonpenetrating Deep Sclerectomy.

PURPOSE: The purpose if this study was to evaluate the clinical characteristics and risk factors of 3 eyes (3 patients), with primary open-angle glaucoma (POAG), in whom a postoperative suprachoroidal hemorrhage (SCH) occurred after a previous nonpenetrating deep sclerectomy (NPDS) augmented with a supraciliary nonabsorbable implant placement. METHODS AND SURGICAL TECHNIQUE: This is a report of 3 eyes of the 3 patients who underwent NPDS in 3 different centers, by 3 experienced surgeons, and were the only ones to develop postoperative SCH in the last 18 years. All were operated with a one-third thickness outer scleral flap measuring 5×5 mm dissected until it reached 1 to 2 mm into the clear cornea. Mitomycin C (MMC, 0.02%) was applied for 1 minute and an inner scleral flap measuring 4×4 mm was dissected leaving only 10% of scleral thickness below. Then, the inner wall of Schlemm canal was removed. A supraciliary implant, T-flux (Carl Zeiss Meditec, Zeiss, Spain) in case 2 and Esnoper (AJL Ophthalmics SA, Miñano, Spain) in cases 1 and 3, was placed through a full-thickness escleral incission 2 mm behind the scleral spur. RESULTS: Three eyes with uncontrolled primary open-angle glaucoma had a delayed SCH after an uneventful NPDS. Time lapse from filtering surgery to the SCH ranged from 12 hours in case number 1, to 3 weeks in case 3. Several risk factors for DSH were present, but the only common clinical feature for all of them, was the nonabsorbable implant that was placed in the supraciliary space. A Hema implant (Esnoper) was used in 2 eyes (cases 1 and 3), and T-flux, was implanted in the case 2. Case 1 required vitreoretinal surgery and had poor visual outcome, but cases 2 and 3 recovered with conservative treatment. CONCLUSIONS: Although taking the potential bias arising from the nature of the current cases report into consideration, supraciliary placement of the implant in NPDS could be a risk factor for SCH. Consequently, it seems reasonable to avoid it, especially in the presence of other best recognized factors.