Short-Term Efficacy and Safety of Phacoemulsification Associated With iStent Inject W in Patients With Controlled Open Angle Glaucoma.

PRCIS: The iStent inject W implanted during phacoemulsification effectively reduces IOP. PURPOSE: The purpose of this study was to evaluate the efficacy and safety of iStent inject W combined with phacoemulsification in patients with controlled open angle glaucoma undergoing cataract surgery. PATIENTS AND METHODS: We conducted a retrospective, bicentric study of patients with controlled chronic open angle glaucoma who underwent phacoemulsification combined with the injection of 2 iStent inject Ws. Patient characteristics, including intraocular pressure (IOP) and the number of glaucoma medications, were evaluated preoperatively and 1 week, 1 month, and 6 months postoperatively. The primary end point was IOP reduction, and the secondary end point was the reduction in the number of glaucoma medications. RESULTS: In this study, 85 eyes were included. The majority of patients had primary open angle glaucoma (85% of eyes). Preoperative mean IOP was 16.1±2.0 mm Hg with a mean of 2.3±0.5 glaucoma medications. At 1 week postoperatively, the mean IOP was 16.7±3.1 mm Hg with a mean of 2.0±0.7 hypotensive medications. At 1 and 6 months, the mean IOP was 14.2±2.1 and 13.0±1.5 mm Hg, with a mean of 2.0±0.6 and 1.8±0.5 glaucoma medications, respectively. The percentage IOP reduction at 1 and 6 months was 11.6% ( P =0.001) and 19.3% ( P <0.0001), respectively. Regarding glaucoma medications, at 1 and 6 months, the reduction in the number of medications was 12.9% ( P =0.025) and 22.4% ( P =0.003), respectively. The most frequent significant postoperative adverse events were corneal edema in 7%, IOP spikes in 6%, and hyphema in 6% of eyes, which resolved spontaneously. CONCLUSIONS: The iStent inject W implanted during phacoemulsification effectively reduces IOP and the number of glaucoma medications needed at 6 months of follow-up, with a favorable safety profile in patients with controlled open angle glaucoma.

Safety and Efficacy of the Preserflo® Microshunt in Refractory Glaucoma: A One-Year Study.

Purpose: To evaluate the safety and efficacy of Preserflo® microshunt implantation in eyes with refractory glaucoma. Methods: In this retrospective study, a cohort of patients who underwent Preserflo® microshunt implantation between April 2019 and August 2020 for refractory glaucoma were evaluated. At the time of surgery, all eyes had uncontrolled intraocular pressure (IOP) despite maximally tolerated medical therapy and at least one previous failed glaucoma filtering surgery. The primary outcome was a complete success, defined as postoperative IOP ≤ 21 mm Hg with an IOP reduction ≥ 20% and no repeat filtering surgery. The secondary outcome was qualified success, defined as a complete success with the use of antiglaucoma medications. The rates of needling, bleb repair, and postoperative complications were also recorded. Results: Forty-seven eyes with a mean preoperative IOP of 30.1 ± 7.1 mm Hg and a mean of 3.4 ± 1 glaucoma medications were included. The mean number of previous surgeries prior to microshunt implantation was 2.3 ± 1.3. After 1 year, the mean IOP was significantly reduced to 18.8 ± 4.6 mm Hg, with the mean number of medications significantly reduced to 1.4 ± 1.2. Complete success was achieved in 35% of eyes, and a qualified success in 60% of eyes. A decrease in IOP of at least 30% was found in 55% of eyes. Needling or bleb repair was performed in 49% of eyes. Complications were minimal and transient, except for one eye which presented with tube extrusion, and another eye with a transected tube. A repeat glaucoma surgery had to be performed in 17% of eyes. Conclusions: The Preserflo® Microshunt provided moderate success but a significant reduction in IOP, with a good safety profile after one year of follow-up in eyes at high risk for failure of filtering surgery.

Macular edema in Cogan-Reese syndrome.

PURPOSE: Iridocorneo-endothelial (ICE) syndrome is known as a rare spectrum causing glaucoma, corneal and iris damages. Retinal complications are uncommon. OBSERVATIONS: We report the case of a middle-aged woman suffering from a Cogan-Reese Syndrome (CRS) with refractory ocular hypertension (OHT) who presented a cystoid macular edema (CME) during follow up. CONCLUSIONS AND IMPORTANCE: We suspect the CME to be inflammatory linked to the pathophysiological hypotheses of the CRS. The CME was successfully treated with topical nonsteroidal anti-inflammatory drugs (NSAID). No consensus is available on its duration. A recurrence happened when treatment was stopped, its reintroduction was successful.

Driving behaviour and visual compensation in glaucoma patients: Evaluation on a driving simulator.

BACKGROUND: To assess the driving performance and both the visual scanning and driving compensations of glaucoma patients. METHODS: In this case-control pilot study, the driving behaviour and performance of 14 patients with glaucoma and nine healthy age- and sex-similar control subjects were compared in a fixed-base driving simulator. All subjects performed in four scenarios with one to two hazardous situations on urban streets, for a total of five hazards. Measurements taken during the tests included reaction times, longitudinal regulation, lateral control and eye and head movements. RESULTS: Glaucoma patients showed poor driving performance with longer reaction time to hazardous situations than control subjects: pedestrians crossing the road from the left (p < 0.022) or from the right (p = 0.013), and vehicles coming from the left (p = 0.002). Their mean duration of lateral excursion was longer (p = 0.045), and they showed more lane excursions in a wide left curve (p = 0.045). Glaucoma patients also showed a higher standard deviation of time-headway (p = 0.048) with preceding vehicles. Analyses of driving behavioural compensations on curved roads showed that glaucoma patients stayed closer to the centre line in large (p = 0.006) and small (p = 0.025) left curves and on small right curves (p = 0.041). Additionally, on straight roads, as compared to control subjects, glaucoma patients showed longer mean time-headway (p = 0.032) and lower mean speed (p = 0.04). Finally, the glaucoma group exhibited a larger standard deviation of horizontal gaze (p = 0.034) than the control subjects. CONCLUSIONS: In a virtual driving environment, glaucoma patients exhibited unsafe driving behaviours, despite their driving and eye-scanning compensations.

Glare and Mobility Performance in Glaucoma: A Pilot Study.

PRCIS: Glare disability affects patients with moderate and severe glaucoma. Under glare conditions, mobility performances of glaucoma patients are reduced. PURPOSE: The aim of this study was to evaluate glare disability and its impact on mobility and orientation in glaucoma patients. METHODS: Twenty-two glaucoma patients and 12 age-matched control subjects were included. All patients underwent a clinical evaluation of visual function and halo size measurements to determine glare disability with a glare score (GS) of the best eye and worse eye. Mobility was evaluated by 4 mobility courses on an artificial street (StreetLab) under photopic conditions (P) and mesopic conditions with an additional light source in front of the patient to mimic dazzling conditions (M+G). Mobility time, mobility incidents, trajectory segmentation, distance traveled, preferred walking speed on trial (WS) and percentage of preferred walking speed (PPWS) were recorded, and the Nasa task load index (Nasa-TLX) was evaluated. RESULTS: GS of the worse eye and GS of the best eye were significantly higher in glaucoma patients than in the control group (P=0.001 and 0.003). It was significantly different between moderate glaucoma patients and controls (P=0.001 and 0.010, respectively) and between severe glaucoma patients and controls (P=0.049 and 0.016). In locomotion tasks, comparing performance under M+G and P conditions, mobility performance was significantly different concerning mobility time (P=0.010), distance traveled (P=0.008), WS (P=0.007), PPWS (P=0.006), and Nasa-TLX (P=0.017) in the glaucoma group. Under M+G lighting conditions, mobility performance for glaucoma patients was significantly worse than controls with regard to WS (P=0.038), PPWS (P=0.0498), mobility time (P=0.046), and Nasa-TLX (P=0.006). CONCLUSION: Glare disability was observed in patients with moderate and severe glaucoma and had an impact on their mobility performance.

Micropulse transscleral cyclophotocoagulation using a standard protocol in patients with refractory glaucoma naive of cyclodestruction.

PURPOSE: To assess the efficacy and safety of a standardized micropulse transscleral diode laser cyclophotocoagulation procedure in refractory glaucoma. METHODS: Retrospective, interventional study in a series of 37 consecutive patients with refractory glaucoma, cyclodestructive procedure-naive, who underwent micropulse transscleral diode laser cyclophotocoagulation from December 2016 to October 2017. A successful laser treatment was defined as (1) intraocular pressure between 6 and 18 mm Hg; (2) 20% of baseline intraocular pressure reduction; (3) no additional glaucoma medications; (4) no decrease in vision due to complications or change in intraocular pressure; and (5) no need for additional glaucoma surgery except micropulse transscleral diode laser cyclophotocoagulation retreatment. RESULTS: Mean age was 60.2 years. Mean follow-up was 9.7 ± 3.9 months. The mean preoperative intraocular pressure (28.7 mm Hg) significantly decreased to 21.0 mm Hg at 1 month, 18.5 mm Hg at 3 months, 18.4 mm Hg at 6 months, and 18.5 mm Hg at 12 months (p < 0.01 at all time points). The mean number of preoperative glaucoma medications (4.7) decreased to 4.0 at 1 month (p = 0.14), 4.5 at 3 months (p < 0.05), 3.9 at 6 months (p < 0.05), and 3.6 at 12 months (p < 0.05). At 1 year, the success rate was 35% with a mean intraocular pressure lowering of 36%. One patient had hypotony and a loss of best-corrected visual acuity. Mild transient postoperative inflammation was observed in 8% of the cases. CONCLUSION: Using a standardized procedure, micropulse transscleral diode laser cyclophotocoagulation allows a mild intraocular pressure decrease with a low rate of complications and thus achieves a relatively good profit risk benefit, mostly for moderately hypertensive refractory glaucoma.

Clinical Features and Diagnosis of Anterior Segment Inflammation Related to Cytomegalovirus in Immunocompetent African, Asian, and Caucasian Patients.

Objective: To report the clinical features and treatment outcomes in immunocompetent patients with anterior segment inflammation (ASI) related to human cytomegalovirus (HCMV) depending on their ethnic origin.Material and Methods: Multicenter retrospective study of 38 patients with at least one test, either HCMV-positive PCR or GWc.Results: Features of Posner-Schlossman syndrome were observed in 50% of the eyes, Fuchs heterochromic iridocyclitis in 13% of the eyes, chronic nonspecific anterior uveitis in 21% of the eyes, and corneal endotheliitis in 18% of the eyes. PCR and GWc were positive for HCMV in 50% and 96.2% of the eyes, respectively. Glaucoma was diagnosed in 50% of eyes. Treatment was oral valganciclovir in about half of the patients. Other treatments were intravenous ganciclovir and/or ganciclovir topical ointment and/or intravitreal ganciclovir.Conclusions: No obvious association of specific clinical features with individual ethnicity could be identified. We found a high rate of glaucoma in all ethnic groups. There was a delay in diagnosis and specific treatment of HCMV in most patients.

The role of Ahmed glaucoma valve in the management of refractory glaucoma: Long-term outcomes and complications.

PURPOSE: To retrospectively evaluate the efficacy and long-term complications of the Ahmed glaucoma valve (AGV) in refractory glaucoma. MATERIALS AND METHODS: Seventy-eight eyes with glaucoma refractory to conventional surgical procedures (filtration surgery and diode laser cyclophotocoagulation) underwent AGV implantation between May 2006 and August 2018. The criteria for success were defined as an intraocular pressure (IOP) less than 18 mmHg and a decrease of at least 20% from the preoperative IOP. The criteria for failure were an IOP greater than 18 mmHg or less than 5 mmHg, an increase in medical treatment, a decrease of less than 20% of the initial IOP, the need for another glaucoma surgery, or a decrease in visual acuity attributable to the valve. RESULTS: IOP decreased from 31.0 ± 9.0 mmHg to 17.2 ± 7.2 mmHg (mean follow-up 32.5 months), for a mean IOP lowering of 44.5% (p < 0.001). Medical treatment was significantly reduced from 5.3 ± 1.5 to 2.8 ± 1.9 (p < 0.0001). The cumulative success rates were 59.4% at 3 years and 45.1% at 5 years. Encapsulation of the filtration bleb was the most common short-term complication (32.1%). Relevant long-term complications were bleb fibrosis with elevated IOP (12.8%) and corneal decompensation (10.2%). CONCLUSION: The AGV is an effective procedure in the long-term for controlling IOP in refractory glaucoma, with limited incidence of complications. These results suggest that the AGV might be considered earlier in the surgical strategy for glaucoma not controlled after one well-performed conventional filtration surgery.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma.

PURPOSE: Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion. METHODS: A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures. RESULTS: Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term. CONCLUSION: Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

Correlations Between Subjective Evaluation of Quality of Life, Visual Field Loss, and Performance in Simulated Activities of Daily Living in Glaucoma Patients.

PRECIS: Glaucoma patients displayed alterations in their quality of life (QoL) and their ability to perform activities of daily living. The visual field (VF) of the worse eye might serve as a good marker for QoL evaluation. PURPOSE: The purpose of this study was to explore the correlations between VF defects, performance in simulated activities of daily living, and subjective evaluation of QoL in glaucoma patients. METHODS: Thirty-two patients with glaucoma and 10 age-matched control subjects were included. All participants answered a QoL questionnaire and underwent an assessment of visual function including monocular and binocular best-corrected visual acuity, binocular contrast sensitivity test (LogCS), and monocular and binocular VF. All subjects also carried out a series of simulated activities of daily living in a controlled environment. RESULTS: Glaucoma patients had lower QoL scores compared with controls for the composite score, near and distance activities, social functioning, mental health, role difficulties, dependency, and color vision. With regard to performance in the simulated mobility task, the number of mobility incidents was higher for glaucoma patients than for control subjects. For the reaching and grasping tasks, the overall movement duration for small objects was significantly longer in glaucoma patients compared with controls. The VF mean deviation of the worse eye was correlated with most of the QoL subscores. Mobility incidents as well as the reaching and grasping task parameters were not significantly correlated with QoL scores. CONCLUSIONS: Glaucoma patients showed an alteration of performance in simulated daily living activities, associated with a decreased QoL. There was no clear correlation between alterations in QoL and ability to perform activities of daily living. The QoL related to vision was mostly correlated to the visual function of the worse eye.

Cataract and glaucoma combined surgery: XEN® gel stent versus nonpenetrating deep sclerectomy, a pilot study.

BACKGROUND: To compare the efficacy of phacoemulsification (PKE) combined with nonpenetrating deep sclerectomy (NPDS) with mitomycin C (MMC) versus XEN® gel stent with MMC. METHODS: In this nonrandomized, retrospective, comparative, single-center pilot study, 105 consecutive eyes of 75 patients with uncontrolled primary open-angle glaucoma (POAG) and cataract who underwent PKE combined with either XEN implantation (n = 47) or NPDS (n = 58) between May 2013 and November 2018 were included. The primary outcome was complete success at 9 months, which was defined as intraocular pressure (IOP) ≤18, 15 or 12 mmHg without treatment; qualified success was IOP ≤18, 15 or 12 mmHg with antiglaucoma medications. Secondary outcome measures included the number of antiglaucoma medications, visual acuity (VA), and postoperative adverse events. RESULTS: Using the 18 mmHg threshold, complete or qualified success was achieved in 69.6 and 89.1% in the PKE + XEN group, and 63.8 and 89.7% in the PKE + NPDS group (p = .54 and p = .93), respectively, at 9 months. The mean IOP decreased from 20.8 ± 6.8 mmHg to 16.2 ± 2.8 mmHg in the PKE + XEN group (p < .001, 18.9% mean drop), and from 21.5 ± 8.9 mmHg to 14.9 ± 3.9 mmHg in the PKE + NPDS group (p < .001, 25.6% mean drop). Best-corrected VA significantly improved (p < .001) in both groups. The mean number of antiglaucoma medications was significantly reduced from 2.66 ± 1.1 to 0.49 ± 1.0 in the PKE + XEN group (p < .001) and from 2.93 ± 0.9 to 0.69 ± 1.2 in the PKE + NPDS group (p < .001). CONCLUSIONS: The XEN stent combined with PKE seemed to be as effective and safe as PKE + NPDS at 9 months in this pilot study.

Optical Coherence Tomography Angiography Evaluation of Conjunctival Vessels During Filtering Surgery.

PURPOSE: To evaluate the changes in conjunctival vascularization with optical coherence tomography angiography (OCT-A) before and after filtering surgery and to correlate these results with filtering surgery success. METHODS: We evaluated 20 blebs of 20 patients after a first-time trabeculectomy. Conjunctival vascularization was quantified using ImageJ software. Eyes were classified into two groups according to the preoperative conjunctival vessel density: hypovascularized conjunctiva (HypoV; 10 eyes) and hypervascularized conjunctiva (HyperV; 10 eyes). The density of intraepithelial microcysts (0 to 3) was also analyzed. RESULTS: There were significantly more needling procedures in the HyperV group, with 70% of the eyes undergoing needling during follow-up compared to 20% in the HypoV group (P = 0.012). In the HyperV group, 50% of the eyes required IOP-lowering eyedrops after surgery, compared to 10% in the HypoV group (P = 0.029). HypoV showed significantly more intraepithelial microcysts than did HyperV at 1 week (1.1 vs. 0.4, P = 0.0215), 1 month (2.2 vs. 0.4, P = 0.0003), and 6 months postoperatively (2.0 vs. 0.7, P = 0.0068). A statistically significant correlation was found between preoperative conjunctival vascular density and mean IOP at 1 week (r = 0.483, P = 0.038), 1 month (r = 0.714, P = 0.001), and 6 months postoperatively (r = 0.471, P = 0.043). There was no statistically significant correlation between the preoperative conjunctival vascularization density and the eyedrop-year rate (r = 0.036, P = 0.8704) or the preservative-year rate (r = 0.1444, P = 0.5107). CONCLUSIONS: Poor conjunctival vascularization was associated with lower IOP and a higher number of intraepithelial microcysts evaluated with OCT-A. OCT-A provides a simple, noninvasive, and reproducible method to analyze and quantify bleb vessels before and after filtering surgery. TRANSLATIONAL RELEVANCE: Several studies have demonstrated that highly vascularized blebs might be associated with a higher risk of failure. OCT-A may provide a dye-free, noncontact method for monitoring conjunctival vascularization after filtering surgery.

Influence of Treating Ocular Surface Disease on Intraocular Pressure in Glaucoma Patients Intolerant to Their Topical Treatments: A Report of 10 Cases.

PURPOSE: The purpose of this study was to evaluate the effect of treating ocular surface disease (OSD) in patients with medically uncontrolled primary open-angle glaucoma (POAG) associated with OSD. METHODS: We compiled a retrospective observational case series of 10 patients with POAG that remained uncontrolled with topical treatments and who were referred for filtering glaucoma surgery. All patients underwent a complete assessment of their glaucoma and ocular surface for both eyes. The main treatments were change of topical antiglaucoma medications to preservative-free equivalents, removal of allergenic treatments or those identified as causing side effects, switch to another therapeutic class with the same efficacy but with a better safety profile and treatment of OSD. RESULTS: After a minimum follow-up of 6 months, we observed improved ocular surface in all patients, associated with an intraocular pressure (IOP) decrease or stabilization even if some antiglaucoma medications were removed. The mean IOP significantly decreased from 23.75±9.98 mm Hg to 15.15±4.75 mm Hg (-36.2%; P=0.0001). The mean number of IOP-lowering medications was 3.7±1.06 at presentation and 2.8±0.63 after treatment (P=0.01). The Oxford score also decreased from a mean 1.7±0.67 to 0.4±0.51 (-76.5%; P<0.001). For 2 patients, IOP was not sufficiently reduced after treatment and they finally underwent filtering surgery. CONCLUSIONS: The prevalence of OSD in POAG patients is very high, particularly in patients with uncontrolled glaucoma with multiple topical medications. Careful management of the ocular surface associated with a reduction of the toxicity of eyedrops may result in improvement of ocular surface health and better IOP control.

Correlation Between Visual Function and Performance of Simulated Daily Living Activities in Glaucomatous Patients.

PURPOSE: To analyze the correlations between functional clinical tests and the performance of glaucoma patients in simulated daily living activities. PATIENTS AND METHODS: Thirty-two patients with chronic glaucoma, followed at the Quinze-Vingts National Ophthalmology Hospital, were included. All patients had a clinical evaluation of visual function including best-corrected visual acuity, contrast sensitivity, and monocular and binocular visual field (VF) tests. Four different simulated activities of daily living were evaluated in standardized artificial platforms (StreetLab and HomeLab): "mobility" and an obstacle avoidance task in an artificial street, "reaching and grasping" large and small objects on a kitchen work surface, "localization of people" and "face orientation recognition." Patient performance in the different tasks was correlated with VF evaluation including integrated binocular visual field (IVF), VF mean deviation (MD) of the better and the worse eye, Esterman binocular VF, best-corrected visual acuity, and contrast sensitivity. RESULTS: The IVF score was significantly correlated with "localization of people" time (r=0.49; P=0.003), "face orientation recognition" time (r=0.50; P=0.002), and "movement onset" for reaching and grasping small objects (r=0.38; P=0.029). The MD of the better eye appeared significantly correlated with "face orientation recognition" time (r=-0.44; P=0.009) and "localization of people" time (r=-0.46; P=0.005). The Esterman score appeared significantly correlated with "mobility time" (r=-0.40; P=0.018), "localization of people" (r=-0.37; P=0.030), "face orientation recognition" times (r=-0.39; P=0.024), and "movement onset" for reaching and grasping large objects (r=-0.43; P=0.015). CONCLUSIONS: The IVF score and the MD of the better eye appeared to better evaluate "reaching and grasping," "face orientation recognition," and "localization of people" simulated tasks, whereas for the "mobility" task, the Esterman VF seemed more useful. The precise evaluation of the glaucoma patient's ability to perform everyday life tasks is complex and may require both monocular and binocular VF tests.

The Efficacy of Deep Sclerectomy on Posture-induced Intraocular Pressure Changes.

PURPOSE: The purpose of this study was to evaluate the efficacy of nonpenetrating deep sclerectomy (NPDS) on posture-induced intraocular pressure (IOP) changes in open-angle glaucoma (OAG). MATERIALS AND METHODS: Twenty-five eyes of 25 patients with OAG that underwent NPDS were included in this study. IOP was measured with the IcarePro (ICP) tonometer in the sitting, supine, dependent lateral decubitus position (DLDP), and nondependent lateral decubitus position (NDLDP) before surgery, and at 1 and 3 months after surgery. RESULTS: The mean baseline IOP measured in the sitting position was 20.5±8.4 mm Hg with Goldmann applanation tonometry and 19.6±6.5 mm Hg with ICP. At 1 and 3 months after NPDS, mean IOP decreased significantly in each position (P<0.001). At each time point, mean IOP was higher in all lying positions than in the sitting position (P<0.001) and higher in the DLDP than in the supine and NDLDP positions (P<0.001 and P=0.001). Posture-induced IOP changes between the sitting and supine position, DLDP, and NDLDP, respectively, were significantly reduced by 77% (P=0.009), 60% (P=0.001), and 82% (P=0.01) at 1 month and by 79% (P=0.004), 70% (P<0.001), and 79% (P<0.001) at 3 months after surgery. The IOP fluctuation reduction was significantly inferior when considering sitting-DLDP than other postural changes. CONCLUSIONS: NPDS is effective in lowering the mean IOP in all body positions and also the postural IOP fluctuations. The mean IOP in the DLDP remained higher than in the other body positions. This posture should be avoided in patients with asymmetric OAG.

Effect of Surgical Intraocular Pressure Lowering on Peripapillary and Macular Vessel Density in Glaucoma Patients: An Optical Coherence Tomography Angiography Study.

PURPOSE: To measure the influence of surgically induced intraocular pressure lowering on peripapillary and macular vessel density in glaucoma patients using optical coherence tomography angiography. METHODS: Twenty-one eyes of 21 patients with open-angle glaucoma scheduled for filtering surgery were enrolled prospectively. Using optical coherence tomography angiography, vessel density was quantified within the peripapillary and macular regions, before and 1 month after filtering surgery. Change in vessel density was calculated for all analyzed areas. RESULTS: One month after surgery, the mean intraocular pressure reduction was 44.2%±4.8% (range, 15.2% to 77.1%). The mean change in vessel density for the whole peripapillary area was 0.065±0.88% (P=0.788). In the macular region, the mean change in vessel density was -0.022%±0.691% (P=0.405) with significant changes only within the inferotemporal area of patients with predominantly superior visual field defects (-1.86%±1.43%, P=0.024). CONCLUSIONS: Optical coherence tomography angiography allowed very limited measurement of intraocular pressure lowering-induced changes on the vessel density of the peripapillary and macular regions in glaucoma patients.

Evaluation of Blebs After Filtering Surgery With En-Face Anterior-Segment Optical Coherence Tomography: A Pilot Study.

PURPOSE: To compare characteristics of functioning blebs (FBs) and nonfunctioning blebs (NFBs) with en-face spectral-domain optical coherence tomography (OCT). METHODS: We evaluated 41 blebs of 38 patients after a first-time trabeculectomy. Eyes were classified into 2 groups: FBs (22 eyes) and NFBs (19 eyes). En-face OCT images were analyzed semiquantitatively for the density of intraepithelial microcysts (0 to 3), internal fluid-filled cavity (0 to 3), and bleb vascularization (0 to 2). Presence of conjunctival fibrosis and visualization of the scleral flap were also analyzed. RESULTS: FBs showed significantly more intraepithelial microcysts than did NFBs: the mean grading of microcyst density was 1.86 for FBs and 0.11 for NFBs (P<0.0001). None of the FBs were rated 0 and none of the NFBs were rated 2 or 3 for the density of intraepithelial microcysts. NFBs presented more conjunctival fibrosis than FBs (63% vs. 32%, P<0.05). There was no significant difference between FBs and NFBs for bleb vascularization, visualization of the scleral flap, and presence of subepithelial fluid-filled cavities. There was a direct correlation between postoperative intraocular pressure and intraepithelial microcyst density (r=-0.7655, P<0.0001). The long-term administration of preserved eyedrops before surgery was associated with fewer intraepithelial microcysts (r=-0.5436; P=0.0006). CONCLUSIONS: FBs were associated with a higher number of intraepithelial microcysts evaluated with en-face OCT. A higher density of microcysts was associated with a lower intraocular pressure and a shorter duration of preserved topical treatment before surgery. En-face OCT provides a simple, noninvasive, and reproducible method to analyze blebs after filtering surgery.

Monochromatic Pupillometry in Unilateral Glaucoma Discloses no Adaptive Changes Subserved by the ipRGCs.

PURPOSE: To detect signs of a possible adaptive mechanism of the intrinsically photosensitive ganglion cells in unilateral glaucoma. METHOD: Eleven patients with unilateral glaucoma, classified by automated perimetry (glaucoma: mean deviation <0), were studied by monochromatic pupillometry, employing red (660 nm) or blue (470 nm) light, and by optical coherence tomography of the peripapillary retinal nerve fiber layer. The main outcome measure in pupillometry, the area under the curve (AUC), i.e., the product of pupillary contraction amplitude and time, was determined during and after light exposure in glaucomatous and unafflicted fellow eyes and compared to the AUCs of a healthy, age-matched control group. RESULTS: The AUC to stimulation with blue light was significantly reduced in glaucomatous eyes, both during and after stimulus, compared with that of fellow, unafflicted eyes (p ≤ 0.014). The AUC to red light stimulation was reduced during (p = 0.035), but not after (p ≥ 0.072), exposure in glaucomatous eyes. In the unafflicted fellow eyes, the pupillary response to blue light did not differ from that of healthy controls. CONCLUSION: The pupillary response to blue light was decreased in the glaucomatous eyes of unilateral glaucoma. No difference was detected between the pupillary light response of the unafflicted fellow eyes and that of a healthy, age-matched control group. Thus no sign of an adaptive mechanism was detected, neither in the glaucomatous nor in the unafflicted fellow eyes, and consequently glaucoma appears to differ from non-arteritic anterior ischemic optic neuropathy.

Modifications in corneal biomechanics and intraocular pressure after deep sclerectomy.

PURPOSE: To compare preoperative and postoperative measurements of corneal biomechanical properties and intraocular pressure (IOP) using Goldmann applanation tonometry (GAT) and the ocular response analyzer (ORA) in eyes undergoing deep sclerectomy with collagen implant (DSCI). PATIENTS AND METHODS: Thirty eyes of 30 glaucomatous patients undergoing deep sclerectomy with collagen implant and 30 eyes of 30 normal subjects were included. Goldmann applanation IOP, central corneal thickness (CCT), and ORA measurements [corneal compensated IOP (IOPcc), Goldmann-correlated IOP (IOPg), corneal resistance factor (CRF), and corneal hysteresis (CH)] were taken the day before deep sclerectomy with collagen implant and on days 1, 8, and 30 after surgery. Preoperative CH values were correlated to the number of preoperative medications and to the CCT. Also, the ORA measurements of normal subjects were compared with the preoperative measurements of the glaucomatous patients. RESULTS: The 30 glaucomatous eyes showed a statistically significant difference between preoperative and day 1 postoperative GAT IOP, ORA IOPcc, IOPg, CRF, and CH measurements. No statistically significant difference was noted when comparing the GAT IOP, ORA IOPcc, IOPg, and CRF measurements between days 1, 8, and 30 after DSCI.On the contrary, CH values were statistically different when comparing days 1, 8, and 30 after DSCI. The 30 normal eyes showed no statistical difference when compared with the preoperative IOPg parameter in the 30 glaucomatous eyes; the mean CRF and the mean CH values were statistically significantly higher than the preoperative values of the glaucomatous group. CONCLUSIONS: CH statistically increased between preoperative and postoperative day 1 DSCI. On days 8 and 30, the change in CH values was statistically significant.

Filtering blebs and aqueous pathway an immunocytological and in vivo confocal microscopy study.

OBJECTIVE: To characterize and understand, at the cellular level, the aqueous humor pathways after filtering surgery, using in vivo confocal microscopy and impression cytology (IC). DESIGN: Observational case series. PARTICIPANTS: Thirty-two blebs of 29 patients after trabeculectomy were retrospectively evaluated. METHODS: In vivo confocal microscopy and immunofluorescence staining of IC samples taken on and around the bleb area were performed. Impression cytology samples were examined under confocal microscopy after goblet cell and inflammatory cell immunostaining with anti-MUC5AC and antivimentin antibodies, respectively. Eyes were classified into 3 groups: (1) functioning blebs (11 eyes), (2) nonfunctioning blebs (10 eyes), and (3) functioning blebs after mitomycin C application (12 eyes). Impression cytology specimens and in vivo confocal microscopy images were analyzed and compared in a masked manner. MAIN OUTCOME MEASURES: Conjunctival epithelium changes of each type of bleb were analyzed using both impression cytology specimens and in vivo confocal microscopy and correlated to clinical outcomes. RESULTS: In all IC specimens, numerous MUC5AC-positive cells were observed outside the edges of the blebs. Few MUC5AC-positive cells were observed at the surface of nonfunctioning blebs. Numerous goblet cells with immunostaining that was weak or limited to the membrane were clearly visible morphologically at the surface of functioning blebs (with and without adjunctive mitomycin C). Using in vivo confocal microscopy, all functioning blebs showed numerous intraepithelial optically empty microcysts, whereas nonfunctioning blebs had none or only a few. All blebs contained dendritiform inflammatory cells, especially after mitomycin C application. CONCLUSION: Impression cytology and in vivo confocal microscopy provide a new approach to filtering blebs. Microcysts observed at the surface of functioning blebs seemed to correspond to goblet cells, mostly containing aqueous humor instead of highly hydrophilic gel-forming mucins. Although this hypothesis requires further confirmation, the transcellular pathway of the aqueous humor could be hypothesized to occur at the level of goblet cells toward the ocular surface.