Long-term outcomes of modified glued versus flanged intrascleral haptic fixation techniques for secondary intraocular lenses.

PURPOSE: To report the long-term refractive outcomes and complications of two scleral fixation techniques for secondary intraocular lenses (IOL). METHODS: Consecutive patients who underwent secondary IOL insertion at a tertiary care academic hospital using either modified glued ("glued") or flanged intrascleral haptic fixation (FISHF) techniques with over 12 months of follow-up were retrospectively reviewed. Pre- and postoperative corrected distance visual acuity (CDVA), postoperative complications, and refractive surprises were reported. RESULTS: Thirty-eight patients underwent "glued" fixation and 22 underwent FISHF, with mean follow-up times of 3.1 ± 0.5 and 2.0 ± 1.2 years, respectively. Aphakia secondary to trauma was the main surgical indication. MA50BM or MA60AC IOLs (Alcon Laboratories Inc., Fort Worth, TX) were implanted in 92% of "glued" patients, while CT Lucia 602 IOLs (Carl Zeiss Meditec Inc., Dublin, CA) were used in 96% of FISHF patients. Postoperative spherical equivalent significantly improved compared to preoperative values (p < 0.001). No significant difference in CDVA was seen between the two techniques. FISHF resulted in mean hyperopic surprises of + 0.81D and + 0.69D using the Holladay 2 and Barrett Universal II formulae, respectively, which was significantly greater than the "glued" patients. A higher rate of IOL dislocation was seen in the "glued" cohort (13%) compared to FISHF (0%). CONCLUSIONS: Retrospective long-term outcomes of patients with complex ocular comorbidities undergoing a modified "glued" technique demonstrated a higher rate of IOL dislocation but more predictable refractive outcomes compared to the FISHF technique. The FISHF technique resulted in a significant hyperopic shift using fourth-generation IOL calculators.

Automated Detection of Glaucoma With Interpretable Machine Learning Using Clinical Data and Multimodal Retinal Images.

PURPOSE: To develop a multimodal model to automate glaucoma detection DESIGN: Development of a machine-learning glaucoma detection model METHODS: We selected a study cohort from the UK Biobank data set with 1193 eyes of 863 healthy subjects and 1283 eyes of 771 subjects with glaucoma. We trained a multimodal model that combines multiple deep neural nets, trained on macular optical coherence tomography volumes and color fundus photographs, with demographic and clinical data. We performed an interpretability analysis to identify features the model relied on to detect glaucoma. We determined the importance of different features in detecting glaucoma using interpretable machine learning methods. We also evaluated the model on subjects who did not have a diagnosis of glaucoma on the day of imaging but were later diagnosed (progress-to-glaucoma [PTG]). RESULTS: Results show that a multimodal model that combines imaging with demographic and clinical features is highly accurate (area under the curve 0.97). Interpretation of this model highlights biological features known to be related to the disease, such as age, intraocular pressure, and optic disc morphology. Our model also points to previously unknown or disputed features, such as pulmonary function and retinal outer layers. Accurate prediction in PTG highlights variables that change with progression to glaucoma-age and pulmonary function. CONCLUSIONS: The accuracy of our model suggests distinct sources of information in each imaging modality and in the different clinical and demographic variables. Interpretable machine learning methods elucidate subject-level prediction and help uncover the factors that lead to accurate predictions, pointing to potential disease mechanisms or variables related to the disease.

Outcomes of sutureless secondary intraocular lens fixation with haptic flanging in a cohort of surgically complex eyes.

PURPOSE: To describe clinical outcomes of secondary intraocular lens (IOL) implantation using sutureless trans-scleral techniques in surgically complex eyes. METHODS: Retrospective surgical case series of 45 eyes that underwent secondary IOL implantation using a sutureless haptic flange technique. Demographic data of age, sex, primary diagnosis, best-corrected visual acuity (BCVA), refractive error, intraocular pressure, full ophthalmic exam findings, surgical approach, and any intraoperative complications were noted. RESULTS: The most common indication for secondary IOL implantation was aphakia, most commonly after ocular trauma. The primary outcome measures were pre-operative and post-operative BCVA, which revealed recovery of pre-operative vision levels by post-operative week 1 and improved vision by post-operative month 1 (p = 0.03). Secondary outcome measures of target refraction pre-operatively and post-operatively revealed significant reduction in post-operative spherical equivalent to achieve BCVA (p < 0.001). Targeting of the secondary IOLs using Barrett Universal II, Holladay 1, Holladay 2, and SRK/T all exhibited a hyperopic shift post-operatively in post-traumatic aphakic eyes and a myopic shift in the post complicated cataract extraction eyes. No intraoperative adverse events were noted. The most common post-operative complication was transient IOP elevation, with most patients completing 6 months of follow-up. CONCLUSION: There is rapid visual rehabilitation and reduction of spherical equivalent correction to attain BCVA in eyes with a history of ocular trauma that undergo secondary IOL implantation using a trans-scleral flange technique. Moreover, this study highlights that a specific IOL power formula can be more predictive of the desired refractive outcome depending on the indication for secondary IOL implantation.

Scleral Patch Graft With a Suture Reinforcement Technique in Surgical Management of Necrotizing Scleritis With Ectasia.

PURPOSE: To describe a technique for reducing and reinforcing scleral thinning in cases of necrotizing scleritis with ectasia. METHODS: Descriptive report of a surgical technique in 2 surgical cases with a video. RESULTS: Successful repair and reduction in uveal prolapse from scleral thinning in 2 cases of necrotizing scleritis with ectasia with a suturing technique using overlapping (weave) compressive suturing over a scleral patch. CONCLUSIONS: In cases of necrotizing scleritis with ectasia in which there is perforation or prolapsing uvea, this technique should be considered.

Trans-scleral Cyclophotocoagulation Curriculum: Lecture and Skills Practice.

INTRODUCTION: Trans-scleral cyclophotocoagulation (TS-CPC) is a laser procedure that is often used in the treatment of end-stage glaucoma and glaucoma that is refractory to medical and surgical treatments. However, formal teaching in proper indications and techniques for TS-CPC can be improved in many institutions. In an effort to standardize TS-CPC teaching, a TS-CPC lecture curriculum and a skills practice session were introduced. METHODS: The lecture and the wet-lab curriculum were developed at the University of Washington to formally teach first- and second-year ophthalmology residents the indications and techniques for TS-CPC. A global rating scale of procedural performance was also developed to assist in evaluating the trained residents on their first three TS-CPC procedures. RESULTS: Since its introduction in 2017, the course has been highly rated by seven residents (five PGY-2 and two PGY-3), with an increase in pre- versus posttest scores, as well as an increase in pre- versus postcurriculum scores for three survey questions regarding curriculum objectives. DISCUSSION: We feel that this course is valuable in improving learner knowledge of and confidence in performing TS-CPC. Knowledge about indications and technical aspects of TS-CPC improved on testing following the curriculum, as did the self-assessed confidence levels of the residents. Furthermore, there were a number of positive descriptive comments made by the residents. We plan to hold this training session every year at our institution.

Endophthalmitis Associated With Glaucoma Drainage Implants.

BACKGROUND AND OBJECTIVE: To identify the clinical features, organisms, and treatment outcomes in patients with endophthalmitis associated with glaucoma drainage implants. PATIENTS AND METHODS: A retrospective noncomparative case series. RESULTS: Of the 13 patients, exposure occurred in eight eyes, including exposure of the tube in four eyes, exposure of the patch graft in three eyes, and exposure of the plate in one eye. In the remaining five eyes, either recent implant placement or conjunctival revision occurred. The most common organism was Staphylococcus epidermidis (five eyes). Intravitreal antibiotics were administered in all eyes, with the exception of one eye (primary evisceration). Removal of the implant was performed in six eyes and evisceration or enucleation was performed in three eyes. Median pre-infection visual acuity was 20/80 (range: 20/30 to hand motion). Visual acuity at last follow-up was no light perception (five eyes), light perception (two eyes), hand motion (one eye), and better than or equal to 20/200 (five eyes). CONCLUSION: Clinical features associated with endophthalmitis include implant exposure and a history of recent surgery. Staphylococcus epidermidis was the most common isolate. Although removal of the implant was performed in many patients, successful treatment was accomplished in some patients without removal. Visual outcomes were generally poor. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:563-569.].

A Retrospective Comparison of Primary Baerveldt Implantation versus Trabeculectomy with Mitomycin C.

PURPOSE: To compare the safety and efficacy of Baerveldt implantation (Abbott Medical Optics, Santa Ana, CA) and trabeculectomy with mitomycin C (MMC) in patients who have not undergone prior incisional ocular surgery. DESIGN: Retrospective, comparative case series. PARTICIPANTS: A total of 125 patients with low-risk glaucoma undergoing primary glaucoma surgery, including 55 patients who received a 350-mm(2) Baerveldt glaucoma implant and 70 patients who underwent trabeculectomy with MMC. METHODS: Eligible patients were identified using Current Procedural Terminology codes, and their medical records were reviewed retrospectively. MAIN OUTCOME MEASURES: The primary outcome measure was surgical success (intraocular pressure [IOP] ≤21 mmHg and reduced ≥20% from baseline, IOP >5 mmHg, no reoperation for glaucoma, no loss of light-perception vision). Secondary outcome measures included visual acuity, IOP, number of glaucoma medications, and complications. RESULTS: The cumulative probability of success at 3 years with or without medical therapy was 87% in the Baerveldt group and 76% in the trabeculectomy group (P = 0.23). Postoperative complications occurred in 11 patients (20%) in the Baerveldt group and 20 patients (29%) in the trabeculectomy group (P = 0.27). Mean follow-up ± standard deviation was 27±19 months in the Baerveldt group and 34±20 months in the trabeculectomy group (P = 0.053). CONCLUSIONS: Similar rates of surgical success and postoperative complications were observed in patients undergoing trabeculectomy with MMC and in those undergoing Baerveldt implantation during 3 years of follow-up. Both are viable primary glaucoma procedures in patients who have not undergone prior ocular surgery.

Adverse vitreoretinal outcomes of glaucoma drainage devices based on verified and unverified financial claims data.

BACKGROUND AND OBJECTIVE: To determine adverse vitreoretinal outcome rates after glaucoma drainage device (GDD) surgery. PATIENTS AND METHODS: Medical records from the Anne Bates Leach Eye Hospital with financial claims from 1991 to 2005 for GDD surgery coded for endophthalmitis, choroidal hemorrhage, or retinal detachment were reviewed. Cumulative incidences were calculated before and after verifying claims with chart review. RESULTS: GDD surgery was performed in 2,661 eyes. Thirty-three cases of endophthalmitis were identified, with 10 attributable to GDD (1-, 5-, and 10-year cumulative incidences: 0.22%, 0.43%, and 0.83%, respectively). Forty cases of choroidal hemorrhage were identified, with 20 attributable to GDD (1-, 5-, and 10-year incidences: 0.81% for all time points). Rhegmatogenous retinal detachments developed in 148 eyes, with 42 attributable to GDD (1-, 5-, and 10-year incidences: 1.25%, 2.02%, and 2.67%, respectively). CONCLUSION: This study's complication rates compare favorably with those previously reported. The use of claims data without chart review verification may result in overestimated event rates.

Clinical impact of 8 prospective, randomized, multicenter glaucoma trials.

PURPOSE: To determine the impact of 8 multicenter randomized clinical trials (RCTs) on glaucoma practice. METHODS: An electronic survey was distributed to the members of the American Glaucoma Society (AGS). Each participant was asked 2 study-specific questions and 1 standard question common to all 8 RCTs assessing the study's impact on clinical practice. RCTs included in the survey were the Advanced Glaucoma Intervention Study (AGIS), Collaborative Initial Glaucoma Treatment Study (CIGTS), Collaborative Normal Tension Glaucoma (CNTG) Study, European Glaucoma Prevention Study (EGPS), Early Manifest Glaucoma Trial (EMGT), Glaucoma Laser Trial (GLT), Ocular Hypertension Treatment Study (OHTS), and Tube Versus Trabeculectomy (TVT) Study. A 5-point Likert scale was used for rating all responses. The practice setting and duration of glaucoma practice was determined for all AGS members who responded. RESULTS: A total of 206 (23.0%) of 894 AGS members participated in the survey. Among those who responded, 46.4% were self classified as academic practitioners and 53.6% worked in a private practice setting. Mean Likert scores for the standard question evaluating the overall impact of the RCT were OHTS 4.47, CNTG Study 4.13, AGIS 3.78, TVT Study 3.53, EMGT 3.48, CIGTS 3.44, GLT 3.39, and 2.69 EGPS. CONCLUSIONS: Substantial differences were observed in the clinical impact of several RCTs in glaucoma. The reported impact of each study likely reflects several factors including study timing, design, conduct, and interpretation of results.

Factors affecting DSAEK graft lenticle adhesion: an in vitro experimental study.

PURPOSE: The aim of this study was to evaluate different factors that affect Descemet stripping automated endothelial keratoplasty (DSAEK) donor graft lenticle adhesion to the recipient cornea. METHODS: This experimental study included 10 eye bank recipient corneas and 10 donor DSAEK lenticles. Recipient corneas were mounted on an artificial anterior chamber (AC), whereas donor lenticles were placed beneath the host cornea. Using optical coherence tomography and imaging software, the interface gap (IG) between the donor and recipient cornea was quantified to evaluate the effect of variations in AC air fill pressure, AC air fill duration, corneal massage, and corneal venting incisions on DSAEK donor graft lenticle adhesion. RESULTS: Different intraocular pressures (IOP) under air for the same time intervals, do not significantly correlate with the IG; nevertheless, it was noticed that the IG decreases as the IOP increases. With respect to the magnitude of AC IOP, there was no statistically significant difference when comparing 10 mm Hg with 30 mm Hg and assessing IG (P = 0.4). Complete air-fluid exchange resulted in significantly higher IG when compared with AC air bubble of 10 and 30 mm Hg that was sustained for 1 hour (P < 0.05). Furthermore, corneal surface massage did not facilitate DSAEK graft adhesion (P = 0.59). Finally, paracentral venting incisions followed by interface fluid aspiration seemed to significantly decrease the IG (P = 0.014). CONCLUSIONS: Corneal venting incisions and higher AC IOP values seem to facilitate DSAEK donor graft lenticle adhesion to the recipient cornea.

Transscleral diode laser cyclophotocoagulation after baerveldt glaucoma implant surgery.

PURPOSE: To evaluate the safety and efficacy of transscleral cyclophotocoagulation (TSCPC) in patients requiring intraocular pressure (IOP) reduction despite prior Baerveldt glaucoma implant (BGI) surgery. PARTICIPANTS AND METHODS: Twenty eyes of 20 patients who had previously undergone BGI placement and subsequently underwent TSCPC with the red (810 nm) diode laser between April 2005 and January 2010 were retrospectively reviewed. RESULTS: All patients underwent BGI placement an average of 34.7±24.2 months before TSCPC. The mean follow-up period after TSCPC was 25.6±17.4 months (range, 2.3 to 56.5 mo). IOPs were reduced from a mean of 21.8±4.6 to 10.8±3.2 mm Hg at the most recent follow-up, which represents a 50.2% reduction in mean IOP. Successful postoperative IOP control was achieved in 16 (80%) of 20 patients. The number of glaucoma medications decreased from 4.2±0.6 to 2.2±1.2. The life-table success rate was 78.6% at 12, 24, and 36 months. Postoperative complications included persistent corneal edema in 1 patient and both persistent corneal edema and cystoid macular edema in another patient. Both patients sustained a >2 line reduction in Snellen visual acuity. CONCLUSIONS: TSCPC is safe and effective in the management of patients requiring IOP reduction after BGI surgery. Although our sample size was limited, the safety profile of TSCPC after BGI seems promising.

Diplopia after glaucoma drainage device implantation.

PURPOSE: To determine incidence of diplopia after glaucoma drainage device (GDD) surgery and to report treatment outcomes. METHODS: Financial claims data were used to identify patients who underwent GDD surgery (CPT [Current Procedural Terminology] 66180) at the Bascom Palmer Eye Institute from January 2, 1991, through December 31, 2005. After a second claims data search, the medical records of patients diagnosed with diplopia (International Classification of Diseases, 9th Revision code 368.2) and those who underwent extraocular muscle surgery (CPT-4 code 67311-67335) after GDD implantation were reviewed retrospectively. RESULTS: A total of 2,661 patients underwent GDD surgery during the study period. Charges were submitted for 59 patients for strabismus surgery or office visits relating to diplopia. Of these, 27 patients were excluded because medical records did not document diplopia or included pre-existing diplopia, cranial nerve palsy, or diplopia attributed to another ocular procedure. The remaining 32 patients developed diplopia secondary to GDD. Superotemporal quadrant GDDs were identified in 23 eyes and inferonasal quadrant placement in 9 eyes. The 1-year cumulative incidence of diplopia was 1.4%. No patient developed diplopia after 1 year. The mean follow-up after diagnosis for patients with diplopia was 48 ± 27 months (range, 1-124 months). The mean time of onset of diplopia after GDD implantation was 66 ± 62 days, with median onset of 42 days (range, 8-278 days). Treatment of diplopia included prisms in 17 cases (53.1%), no treatment in 13 (40.6%), other therapies in 2 (6.3%), and surgery after prismatic treatment failed in 3 (9.4%). CONCLUSIONS: The incidence of diplopia after GDD surgery is low, and most patients are treated with prisms.

Progressive loss of retinal ganglion cell function precedes structural loss by several years in glaucoma suspects.

PURPOSE: We determined the time lag between loss of retinal ganglion cell function and retinal nerve fiber layer (RNFL) thickness. METHODS: Glaucoma suspects were followed for at least four years. Patients underwent pattern electroretinography (PERG), optical coherence tomography (OCT) of the RNFL, and standard automated perimetry testing at 6-month intervals. Comparisons were made between changes in all testing modalities. To compare PERG and OCT measurements on a normalized scale, we calculated the dynamic range of PERG amplitude and RNFL thickness. The time lag between function and structure was defined as the difference in time-to-criterion loss between PERG amplitude and RNFL thickness. RESULTS: For PERG (P < 0.001) and RNFL (P = 0.030), there was a statistically significant difference between the slopes corresponding to the lowest baseline PERG amplitude stratum (≤50%) and the reference stratum (>90%). Post hoc comparisons demonstrated highly significant differences between RNFL thicknesses of eyes in the stratum with most severely affected PERG (≤50%) and the two strata with least affected PERG (>70%). Estimates suggested that the PERG amplitude takes 1.9 to 2.5 years to lose 10% of its initial amplitude, whereas the RNFL thickness takes 9.9 to 10.4 years to lose 10% of its initial thickness. Thus, the time lag between PERG amplitude and RNFL thickness to lose 10% of their initial values is on the order of 8 years. CONCLUSIONS: In patients who are glaucoma suspects, PERG signal anticipates an equivalent loss of OCT signal by several years.

Effect of pupil dilation on macular choroidal thickness measured with spectral domain optical coherence tomography in normal and glaucomatous eyes.

To compare choroidal thickness before and after pupil dilation. Macular subfoveal, nasal, temporal and average choroidal thicknesses were measured in one eye of 17 healthy individuals and 40 glaucoma patients using enhanced depth imaging optical coherence tomography before and after pupil dilation. Comparisons were made between pre- and post-dilation measurements, and between normal and glaucomatous eyes. No statistically significant differences were found between pre- and post-dilation choroidal thickness measurements both in normal (p = 0.361 for subfoveal, 0.760 for nasal, 0.941 for temporal, 0.881 for average) and glaucomatous eyes (p = 0.687 for subfoveal, 0.340 for nasal, 0.913 for temporal, and 0.642 for average). After adjusting for age, the comparison between normal and glaucomatous eyes showed no significant differences in measurements both before (p = 0.701-0.907) and after pupil dilation (p = 0.757-0.988). Similar results were obtained for measurements unadjusted for age. Measurements obtained under the two conditions correlated well in normal (r = 0.92-0.97, p < 0.001) and in glaucomatous eyes (r = 0.84-0.98, p < 0.001). Bland-Altman analyses showed good agreements between them in both groups of eyes, with mean difference ranges of 0.43-2.86 and 0.39-3.08 µm between pre- and post-dilation measurements in normal and glaucomatous eyes, respectively. Subfoveal and average choroidal thickness decreased significantly by 2 µm/year. Each millimeter increase in axial length decreased subfoveal choroidal thickness by 16.5 µm and average thickness by 14.1 µm. Macular choroidal thicknesses measured before and after pupil dilation are comparable and may be used interchangeably without significant discrepancies both in normal and glaucomatous eyes.

Evidenced-based comparison of aqueous shunts.

PURPOSE OF REVIEW: This review provides an evidence-based comparison of aqueous shunts in common use. RECENT FINDINGS: Aqueous shunts are being used with increasing frequency in the surgical management of glaucoma. Recent retrospective studies and prospective clinical trials have compared the outcomes of different shunt designs. Larger end-plate size is associated with greater intraocular pressure (IOP) reduction, but there may be an upper limit beyond which a further increase in plate surface area does not contribute beneficially to pressure control. The biocompatibility of plate material may also influence shunt efficacy. The flow restrictor of the Ahmed glaucoma valve provides an added level of safety by reducing the risk of postoperative hypotony, but this implant also appears to have a higher incidence of bleb encapsulation. SUMMARY: Several aqueous shunts are commercially available, and all have been shown to be safe and effective in lowering IOP. Studies comparing aqueous shunts have provided valuable information to assist in surgical decision-making in similar patient groups.

Angle closure after Boston keratoprosthesis.

PURPOSE: To evaluate changes in the anterior chamber angle after Boston keratoprosthesis (KPro) placement. PATIENTS/METHODS: Ten patients were serially imaged with anterior segment optical coherence tomography after Boston KPro surgery. Angles were judged to be open or closed in the horizontal axis. RESULTS: Seven of 10 patients had open angles before KPro placement. Within 4 months, 4 of 7 patients developed angle closure. Contact between the iris and the backplate was seen in 3 of these patients. Two of the 4 eyes demonstrated progressive angle closure. Intraocular pressure was elevated in 3 patients postoperatively due to the obstruction of a glaucoma drainage device tube (1 eye) and angle closure (2 eyes). CONCLUSIONS: After Boston KPro surgery, patients must be carefully monitored for the onset or progression of glaucoma. Progressive angle closure can occur after placement of a Boston KPro and may be seen in conjunction with irido-backplate touch.

Scleral fistula closure at the time of glaucoma drainage device tube repositioning: a novel technique.

Repositioning a glaucoma drainage device tube from the anterior chamber to the ciliary sulcus or pars plana can be a challenging procedure owing to the difficulty in obtaining tight closure of the original limbal fistula. Failure to achieve watertight and airtight closure of the fistula can result in substantial difficulty in completing other key portions of the surgery and may lead to postoperative hypotony and associated complications. A novel technique using a Tutoplast scleral plug, polyglactin sutures, and, in certain cases, fibrin tissue sealant to close a limbal fistula at the time of glaucoma drainage device tube repositioning is described. This technique can be replicated with ease and provides a tight seal so that other concurrent surgical procedures can safely be completed and postoperative hypotony is avoided.