Long-term outcomes and risk factors for failure of glaucoma filtering surgery in eyes with vernal keratoconjunctivitis and steroid-induced glaucoma.

PURPOSE: To report outcomes and assess the risk factors for failure of trabeculectomy (trab), trabeculectomy with mitomycin-C (trabMMC), and combined trabeculectomy with cataract extraction (CT) in vernal keratoconjunctivitis (VKC) eyes with steroid-induced glaucoma (SIG). METHODS: Trab was performed in 45 eyes of 30 subjects, trabMMC in 36 eyes of 25 subjects, and CT in 34 eyes of 27 subjects. Success was complete when intraocular pressure (IOP) was between 6 and 21 mm Hg without anti-glaucoma medications (AGM) and qualified with AGM. RESULTS: Median age (14 vs. 16.3 and 17.4 years) was significantly less in the trab cohort (P = 0.007). Majority (88%-93%) were male (P = 0.78). Preoperatively, median duration of steroid usage was >2 years (P = 0.52), mean IOP (32, 29.4, and 28.4; P = 0.26) and median cup:disc ratio (CDR) (0.9; P = 0.27) were similar in the three groups. Complete success (76%, 71%, and 66% at 5 years; P = 0.91), and qualified success (88%, 97%, and 94% at 5 years; P = 1.0) with trab, trabMMC, and CT, respectively, were similar. Preoperative factors significantly associated with qualified failure (multiple logistic regression) were older children, longer duration of VKC, longer duration and mixed type of steroid use (all P < 0.001) and larger CDR (P < 0.02). At the last follow-up, 38% in trab, 33% in trabMMC, and 50% eyes in CT were blind (visual acuity ≤20/400 and/or visual field ≤10°) due to glaucoma (P = 0.33). CONCLUSION: The surgical success for all three types of surgery was similar at 5-years. Chronic VKC and long-term steroid use were associated with surgical failure. The majority had advanced disease and a significant proportion were blind due to glaucoma.

Topiramate induced bilateral hypopyon uveitis and choroidal detachment: a report of two cases and review of literature.

BACKGROUND: Topiramate (TPM) is a drug commonly used by neurophysicians and psychiatrists for a plethora of indications. Topiramate has been reported to induce acute angle closure glaucoma as an adverse effect. However, there is limited literature on Topiramate causing hypopyon uveitis and intense ocular inflammation. It is imperative for ophthalmologists as well as physicians to be aware of the potential sight threatening ocular adverse effects of Topiramate. We report 2 rare consecutive cases of severe hypopyon uveitis and choroidal detachments after using Topiramate. CASE PRESENTATION: Two patients presented with sudden onset of angle closure, bilateral hypopyon uveitis and choroidal detachments. On reassessing a detailed treatment history, it was found that both patient were taking oral Topiramate which had been started 2 weeks before the onset of ocular symptoms. The bilateral hypopyon and angle closure were considered to be induced by Topiramate and the drug was discontinued. The patients were started on oral and topical steroids which led to resolution of hypopyon uveitis and choroidal detachments. The visual acuity improved and the intraocular pressure also got normalised in both the cases. CONCLUSIONS: Topiramate can lead to a bilateral hypopyon uveitis and severe ocular inflammation. An urgent cessation of topiramate along with topical and systemic steroids is required to prevent serious complications.

Trabeculectomy in pregnancy: Case studies and literature review.

Glaucoma management during pregnancy is a challenge for the patient and doctor. During pregnancy, the intraocular pressure (IOP) decreases. However, some women with preexisting glaucoma have elevated IOP requiring enhanced medical treatment. Glaucoma refractory to medical treatment combined with disease progression may necessitate laser trabeculoplasty or surgical intervention. Surgery during pregnancy has potential risks for both the mother and fetus. The challenges include problems with anesthesia, positioning for surgery, difficulties in the surgical procedure, potential risk with antimetabolites, and concerns with the management of postoperative complications. We report two case scenarios that highlight the challenges associated with trabeculectomy in pregnant women and the modifications that can be adopted to improve safety and the efficacy of glaucoma filtering surgery during pregnancy.

Schiotz Scleral Intraocular Pressure Readings Predict Goldmann Applanation Readings Better Than Rebound Tonometry.

PURPOSE: To study the agreement between scleral intraocular pressure (IOP) measurements using the Schiotz, Icare, and Icare PRO tonometers versus Goldmann applanation tonometer (GAT) in eyes with nonscarred corneas. METHODS: This cross-sectional study included 83 eyes of 55 subjects. The order of IOP estimation was the corneal GAT, followed by ICare, ICare PRO, and Schiotz on the corneal and temporal sclera. The agreement between different tonometers and the 95% limits of agreement (LoA) were assessed using Bland-Altman plots. The repeated measures correlation coefficient was calculated between GAT IOP and scleral Schiotz IOP, and the 95% confidence intervals were calculated by the bootstrap method. The linear mixed effects model was used (adjusted for both eyes of the subjects) to generate an equation to predict GAT IOP from scleral Schiotz IOP. The prediction model was validated with new data from 60 eyes. Statistical analyses were performed using "R" software (version 3.3.2). RESULTS: Comparing the scleral IOP measurements, the mean IOP difference (95% LoA) was the lowest with Schiotz, underestimating by -1.21 mm Hg (7.32, -9.74). Both ICare and ICare PRO significantly overestimated GAT IOP: ICare, 24.6 mm Hg (53.2, -3.97); and ICare PRO, 21.56 mm Hg (52.9, -9.79). The correlation coefficient between scleral Schiotz and GAT IOP was 0.92 (95% bootstrap confidence interval: 0.89, 98). The derived predictive equation was (Equation is included in full-text article.). The mean difference between the predicted GAT IOP and the actual GAT IOP was 0.96 mm Hg with narrow LoA (+1.79, -3.71), validating the prediction model. CONCLUSIONS: Among the tonometers tested, the scleral IOP measurements with Schiotz had the best agreement with the GAT although LoA were wide. The predictive equation may have great potential to predict GAT IOP from scleral IOP readings in eyes with scarred/prosthetic corneas.

Profile of childhood glaucoma at a tertiary center in South India.

PURPOSE: To describe the prevalence of various types of childhood glaucomas, their clinical features and treatment methods. METHODS: We prospectively included consecutive children with glaucoma presenting to glaucoma clinic for the first time between March 2013 and May 2014. We classified childhood glaucomas as per the classification proposed by Congenital Glaucoma Research Network. RESULTS: Of the 275 children (449 eyes) with glaucoma during this period, primary glaucomas constituted 56% (n = 252 eyes of 145 children), including 169 eyes (37.64%) of 97 children with primary congenital glaucoma (PCG), 16 eyes (3.56%) of 10 children with infantile glaucoma, and 67 eyes (14.9%) of 38 children with juvenile open angle glaucoma. Among these, 85% (214 eyes of 107 children) had bilateral involvement. Secondary glaucomas constituted 44%; they were glaucoma associated with ocular anomalies 18% (n = 80 eyes), glaucoma associated with acquired conditions (steroid induced and traumatic glaucoma) 14% (n = 61 eyes), glaucoma following congenital cataract surgery 7.6% (n = 34 eyes), and glaucoma associated with systemic or syndromic conditions 5% (n = 22 eyes). In primary glaucomas, boys and girls were equally affected (1:1), and more boys (3.8:1) had acquired glaucomas. Close to 80% PCG eyes were managed surgically with combined trabeculotomy and trabeculectomy (CTT). Majority of secondary glaucomas were managed medically. CONCLUSION: In our cohort, PCG was the most common childhood glaucoma and CTT was the most common surgery performed in these eyes. Steroid-induced and traumatic glaucomas were the most common acquired glaucomas; appropriate measures should be taken to avert these preventable glaucomas in children.

Outcomes of Silicone Ahmed Glaucoma Valve Implantation in Refractory Pediatric Glaucoma.

PURPOSE: The purpose of this study was to report the outcomes of Silicone Ahmed Glaucoma Valve (AGV) implantation in the management of refractory pediatric glaucoma. METHODS: Between 2007 and 2015, 76 eyes of 64 children aged 16 years or younger underwent AGV implantation. We included 65 eyes of 53 children with follow up ≥6 months; 24 eyes had primary congenital glaucoma (PCG) and 41 eyes had secondary pediatric glaucoma (SPG). Success was defined as IOP>5 and ≤21 mm Hg with or without topical antiglaucoma medications; considered failure, when repeat glaucoma surgery was need or loss of light perception. Primary outcome measure was success of AGV in refractory pediatric glaucomas and secondary outcome measure was comparison of outcomes in PCG and SPG. RESULTS: The median age at AGV implantation was 3 years (interquartile range, 2, 12), and median follow up was 27 months (15, 39). The overall cumulative success probability was 88% [95% confidence interval (CI), 76%-94%] at 1 year and was maintained up to 4 years. The success probability in PCG was 91% (80.8%-100%), and SPG was 83% (72%-96%) at 1 year and 4 years (P=0.49). Among the preoperative factors, number of previous intraocular surgeries (hazard ratio of 2.24; 95% CI, 1.14-4.37, was significantly associated with failure; P=0.01). Tube-related complications (16%) were similar in both the groups. One eye in each group had sight-threatening complication. CONCLUSIONS: AGV implantation had good success rate in refractory pediatric glaucoma. The success rates were similar in PCG and SPG as were the complications. Number of prior intraocular surgeries was a risk factor for failure.

Outcomes of Bleb Repair for Delayed Bleb Leaks and Sweating Blebs.

PURPOSE: To report the outcomes of bleb repair for delayed onset leaking blebs and sweating blebs following glaucoma filtering surgery. MATERIALS AND METHODS: Medical records of 76 eyes of 76 subjects that underwent bleb repair for either leaking bleb or sweating bleb between 1990 and 2015 were reviewed. Complete success was resolution of bleb leak and or hypotony with intraocular pressure ≥5 and ≤21 mm Hg with no antiglaucoma medication. RESULTS: There were 45 eyes with leaking bleb and 31 eyes with sweating bleb that underwent bleb repair by either conjunctival autograft or conjunctival advancement (P=0.11). Before bleb repair, complications like blebitis and hypotony maculopathy were significantly higher in sweating bleb group (13/31) compared with bleb leak group (5/45) (P=0.002). Median follow-up after bleb repair was >2 years in both groups (P=0.69). After repair, eyes in leaking bleb group had higher immediate (P=0.01) and long-term intraocular pressure elevation (P=0.06) compared with sweating bleb group. Complete success probability in sweating bleb group was significantly better (88%, 78%, and 71%) compared with leaking bleb group (54%, 45%, and 40%) at 1, 3, and 6 years, respectively (P=0.01). One eye in each group had blebitis, 2 eyes in leaking bleb group and 1 eye in sweating bleb group needed repeat glaucoma intervention. CONCLUSIONS: Higher complication rate before bleb repair in eyes with sweating bleb warrants early bleb repair. Bleb repair helped retain bleb function in majority of the eyes with sweating blebs, strengthening our recommendation.