Factors associated with blindness three months following treatment for acute primary angle glaucoma.

AIMS: To study the risk factors associated with blindness after treatment of acute primary angle closure (APAC), and to identify the critical time window to decrease rate of blindness. METHODS: In this multicentre retrospective case series, 1030 consecutive subjects (1164 eyes) with APAC in China were recruited. The rates of blindness were analysed up to 3 months after treatment of APAC. A logistic regression was used to identify the risk factors associated with blindness, including age, gender, distance to hospital, rural or urban settings, treatment method, education level, time from symptom to treatment (TST, hours) and presenting intraocular pressure (IOP). The critical time window associated with a blindness rate of ≤1% was calculated based on a cubic function by fitting TST to the rate of blindness at each time point. RESULTS: The rate of blindness after APAC was 12.54% after treatment. In multivariate regression, education level, TST and presenting IOP were risk factors for blindness (p=0.022, 0.004 and 0.001, respectively). The critical time window associated with a blindness rate of ≤1% was 4.6 hours. CONCLUSIONS AND RELEVANCE: Education level, TST and presenting IOP were risk factors for blindness after APAC. Timely medical treatment is key in reducing blindness after APAC.

Neurotrophic keratitis after micropulse transscleral diode laser cyclophotocoagulation.

PURPOSE: To report two cases of neurotrophic keratitis (NK) after micropulse transscleral cyclophotocoagulation (MP-TCP). OBSERVATIONS: Two patients with predisposing factors for decreased corneal sensation developed NK 1 month after MP-TCP. Both patients did not heal with initial treatment with topical antibiotic and preservative free artificial tears. One patient required use of a bandage contact lens and the other patient required tarsorrhaphy. Both eyes experienced recurrence of NK. CONCLUSIONS AND IMPORTANCE: NK can be triggered after MP-TCP in patients with underlying predisposing factors for decreased corneal sensation. This uncommon but vision-threatening complication should be discussed preoperatively with high-risk patients as a possible adverse event after MP-TCP and followed closely postoperatively.

Post-phacoemulsification iris changes in eyes with glaucoma or glaucoma suspect status.

PURPOSE: This prospective study used anterior segment optical coherence tomography (AS-OCT) to determine how phacoemulsification (phaco) changes iris parameters in eyes with glaucoma or glaucoma suspect status. METHODS: Using Visante AS-OCT (Carl Zeiss Meditec AG), the following pre- and post-phaco parameters were measured: IT750 = iris thickness at 750 µm from the scleral spur; IT2000 = iris thickness 2000 µm from the scleral spur; ITCM = the maximum iris thickness at the middle one third of the iris; ICURV = iris curvature; IAREA = iris area; and pupil size = pupil diameter (mm). Only high-quality images with an identifiable scleral spur were included, and only the nasal quadrant was analyzed. A single glaucoma specialist analyzed the parameters according to the Zhongshan Angle Assessment Program (ZAAP, Guangzhou, China). Multivariate analysis was performed using mixed effects regression correcting for age, gender, and ethnicity. RESULTS: 89 subjects and 110 eyes were included in this study. The mean age of subjects was 74.83 {+/-} 8.69 years old. Most common diagnoses were POAG and glaucoma suspect (23% and 52%, respectively), and 16% of subjects had an LPI. In multivariate analysis of AS-OCT parameters, decreases in IT750, IT2000, ITCM, ICURV, and pupil size were statistically significant (p<0.05). CONCLUSIONS: After phacoemulsification, eyes with glaucoma as well as glaucoma suspect eyes have thinner irises and smaller pupils. This may lead to less iris-mediated aqueous outflow obstruction, providing support for early phacoemulsification glaucoma treatment. TRANSLATIONAL RELEVANCE: Our AS-OCT imaging findings may guide clinical practice as iris parameters become increasingly relevant in preoperative phaco planning.

Expert practice patterns and opinions on corneal cross-linking for infectious keratitis.

OBJECTIVE: To assess the current opinion and practice patterns from cornea experts regarding the benefit of corneal cross-linking (CXL) for infectious keratitis (IK). METHODS AND ANALYSIS: An international survey was distributed to corneal specialists via an internet survey. The survey data collected were analysed with descriptive statistics. RESULTS: A survey was sent to 190 recipients, and 29 (15%) respondents completed the survey with an average of 7 years' experience using CXL. A majority of respondents (66%) used CXL to treat IK due to bacterial, fungal, protozoan or unknown aetiology. Main indications to use CXL as adjuvant therapy were worsening infiltrate diameter or depth despite therapy (74%), followed by antibiotic resistance (68%), corneal thinning (53%), poor compliance with medication (26%) and other reasons (21%). Most respondents felt CXL would be at least moderately helpful as an adjuvant therapy for bacterial (96%) or fungal (75%) keratitis; about half (46%) thought it would be helpful for acanthamoeba keratitis. As sole therapy, fewer respondents believed CXL would be at least moderately helpful to treat bacterial (75%), fungal (58%) and acanthamoeba (43%) keratitis. CONCLUSION: The survey offered insights into current expert practices and opinions of using CXL as therapy for IK. The results of this survey serve to guide in the design of future clinical studies.

Use of Nd:YAG laser to recanalize occluded Cypass Micro-Stent in the early post-operative period.

PURPOSE: To report the first case of Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser use to recanalize a CyPass occluded with a clot in the early postoperative follow-up. OBSERVATIONS: A 66 year-old woman with primary open angle glaucoma and cataract received combined cataract surgery plus CyPass in the right eye. Surgery was uneventful, however, there was a small amount of hyphema related to bleeding around the site of Cypass insertion. Intraocular pressure (IOP) was between 6 and 7 mmHg in the first week on no glaucoma medications. At the second postoperative week, IOP jumped to 30 mmHg and a clot was observed obstructing the CyPass lumen. We disrupted the clot with a single shot from a Nd:YAG laser. Twenty minutes after the laser, the IOP was 8 mmHg. CyPass was recanalized without complications. IOP was 11 mmHg at 1 month postoperatively with timolol 0.5% twice a day. CONCLUSIONS AND IMPORTANCE: It is important to perform gonioscopy to evaluate for CyPass obstruction in cases of IOP spike. Nd:YAG laser may be a useful approach to recanalize the CyPass in the early postoperative follow-up.

Anterior segment parameters as predictors of intraocular pressure reduction after phacoemulsification in eyes with open-angle glaucoma.

PURPOSE: To evaluate intraocular pressure (IOP) change after cataract surgery in eyes with open-angle glaucoma (OAG) and its relationship to angle and anterior segment parameters measured by anterior segment optical coherence tomography (AS-OCT). SETTING: University of California, San Francisco, California, USA. DESIGN: Prospective case series. METHODS: Eyes were placed into a narrow-angle group or open-angle group based on gonioscopy grading. Biometric parameters were measured using AS-OCT (Visante) preoperatively, and IOP 4 months after surgery was obtained. The IOP change and its relationship to AS-OCT parameters were evaluated. RESULTS: Eighty-one eyes of 69 patients were enrolled. The mean age of the patients was 76.8 years. The preoperative IOP was 15.02 mm Hg on 1.89 glaucoma medications. The average mean deviation of preoperative visual field was -4.58 dB. The mean IOP reduction was 2.1 mm Hg (12.8%) from a preoperative mean of 15.0 mm Hg. The IOP reduction was significantly greater in eyes with narrow angles than in eyes with open angles (20.4% versus 8.0%) (P = .002). In multivariate analysis, preoperative IOP (ß = -0.53, P < .001, R2 = 0.40), angle-opening distance at 500 mm (ß = 5.83, P = .02, R2 = 0.45), angle-opening distance at 750 mm (ß = 5.82, P = .001, R2 = 0.52), and lens vault (ß = -0.002, P = .009, R2 = 0.47) were associated with IOP reduction postoperatively. CONCLUSION: In eyes with OAG, IOP reduction after cataract surgery was greater in eyes with narrower angles. Preoperative IOP, angle-opening distance, and lens vault were predictors for IOP reduction.

Epstein-Barr Virus Neuroretinitis in a Lung Transplant Patient.

Epstein-Barr virus (EBV)-associated optic neuropathy is rare with few reported cases, mostly involving immunocompetent patients who developed optic nerve involvement after infectious mononucleosis. We describe a unique case of a patient who developed severe bilateral EBV neuroretinitis after solid organ transplant.

Effect of mitomycin c and 5-flurouracil adjuvant therapy on the outcomes of Ahmed glaucoma valve implantation.

BACKGROUND: To examine the effect of mitomycin c and 5-flurouracil on treatment outcomes following Ahmed glaucoma valve implantation. DESIGN: Retrospective consecutive case series. PARTICIPANTS: Fifty patients who received Ahmed glaucoma valve implantation from 1999 to 2013 in the San Francisco Veterans Administration Hospital. METHODS: The +INJECTION group received intraoperative mitomycin c followed by postoperative mitomycin c and/or 5-flurouracil, whereas the -INJECTION group did not. MAIN OUTCOME MEASURES: Primary outcome was treatment success at 1 year post-implantation. Intraocular pressure, hypertensive phase, and the number of glaucoma medications were also examined. RESULTS: Twenty-six patients/eyes in the +INJECTION group and 24 patients/eyes in the -INJECTION group were included. Treatment success was higher in the +INJECTION compared with the -INJECTION group (86 vs. 58%; P = 0.04). Intraocular pressure was lower in the +INJECTION compared with the -INJECTION group at 1, 3, 6 and 12 months (P ≪ 0.00001, P = 0.00003, 0.0008 and 0.024). Hypertensive phase occurred less often in the +INJECTION compared with the -INJECTION group (3.8 vs. 54%; P = 0.021). The +INJECTION group required fewer medications compared with the -INJECTION group (P = 0.02, 0.002, 0.003 and 0.008 at 1, 3, 6 and 12 months). Complication rates were comparable between groups (46.2 and 54.2%; P = 0.63). CONCLUSIONS: Adjuvant treatment with antifibrotics following Ahmed glaucoma valve implantation decreased the hypertensive phase and improved surgical outcomes without impacting complication rates at 1 year. This study postulates a role for antifibrotics in the postoperative management of Ahmed glaucoma valves.

Early Reoperation Rate, Complication, and Outcomes in Resident-performed Glaucoma Surgery.

PURPOSE OF THE STUDY: The purpose of the study was to examine reoperation rate and complications of resident-performed glaucoma surgeries within the first 90 postoperative days. MATERIALS AND METHODS: A retrospective study of resident-performed glaucoma filtering surgeries at the San Francisco Veterans Affairs Medical Center between 2002 and 2014 was performed. Patients requiring reoperation within 90 days of the initial surgery were included in our study. Combined surgeries were excluded. Complications and the rates of reoperation within the first 90 days were evaluated. Clinical outcomes for those who needed reoperations were evaluated at the 1-year follow-up. RESULTS: Total of 180 cases were reviewed [34 trabeculectomy, 85 Ex-PRESS shunt, and 61 Ahmed glaucoma valve (AGV)]. One hundred and four eyes developed complications, most commonly choroidal effusion (65.3%), followed by hypotony (45.2%) and wound leak (32.7%). Complications were comparable among the 3 groups, except that filtering surgery had significantly more wound leak than AGV (P<0.001). Seven (3.9%) cases required reoperation within first 90 days. There was no reoperation for trabeculectomy group. Reoperation rate was 4.7% for Ex-PRESS and 4.9% for AGV (P=0.74). Indications for reoperation were persistent wound leak (4 cases) and tube occlusion/revision (3 cases). For the 7 patients who required reoperations, their intraocular pressure at 1-year postreoperation was significantly decreased compared with intraocular pressure before the initial glaucoma surgery (P<0.001) with similar number of glaucoma medications and stable visual acuity. CONCLUSIONS: Glaucoma incisional surgeries performed by third-year ophthalmology residents had acceptable and comparable reoperation rates and complication rates for patients with trabeculectomy, Ex-PRESS, and AGV. Clinical outcomes for the patients requiring reoperation were favorable.