Long-term outcomes after acute primary angle closure: case series from Moorfields Eye Hospital, UK.

BACKGROUND: There is limited data regarding the morbidity and progression to primary angle closure glaucoma in those presenting with acute primary angle closure (APAC) in the UK. We aim to report on the vision and intraocular pressure (IOP) outcomes and treatment required after an APAC episode and to identify any risk factors that could predict worse outcomes. METHODS: A retrospective observational case series review including 117 consecutive patients (121 eyes) attending Moorfields Eye Hospital, at a tertiary referral unit in the UK, with APAC was performed. RESULTS: Most patients (73%) had visual acuities of ≥6/12, meeting the UK driving standard, at the final follow-up. Only 15% (17 eyes) had severe visual impairment, as defined by the WHO, in the affected eye, of which 6.6% (eight eyes) were due to glaucoma. The delayed presentation was linked to a higher need for further medical treatment (OR=2.83, 95% CI 1.09 to 7.40, p=0.03). Patients who underwent phacoemulsification were at lower risk of having blindness in the affected eye (OR 0.18, 95% CI 0.05 to 0.69, p=0.01), having elevated IOP (OR 0.10, 95% CI 0.01 to 0.75, p=0.02) or requiring further medical treatment (OR 0.34, 95% CI 0.12 to 0.99, p=0.04). Older age (OR 1.26, 95% CI 1.08 to 1.48, p<0.01) was associated with worse visual outcomes. CONCLUSIONS: APAC causes low long-term visual and treatment morbidity in this largely Caucasian patient group in the UK. Phacoemulsification as a treatment may enhance visual outcomes and reduce the need for further IOP-lowering treatment.

Reply to Wostyn, P. Targeting the Cerebrospinal Fluid Compartment in Glaucoma: Still the Dark Side of the Moon? Comment on "Passaro et al. Glaucoma as a Tauopathy-Is It the Missing Piece in the Glaucoma Puzzle? J. Clin. Med. 2023, 12, 6900".

We are grateful to the author of the comment [...].

Robotic Ultrasound-Guided Central Pancreatectomy with Main Pancreatic Duct Endoscopy Evaluation for High-Risk, Mixed-Type Intraductal Papillary Mucinous Neoplasm.

BACKGROUND: Central pancreatectomy (CP) is a parenchymal-sparing technique indicated for the resection of selected lesions of the neck or proximal body of the pancreas.1,2 The risk of postoperative complications is theoretically doubled because the surgeon has to manage two cut surfaces of the pancreas. The video shows a fully robotic CP to treat a 62-year-old male patient with a mixed-type intraductal papillary mucinous neoplasm (IPMN) of the pancreatic neck, using ultrasound (US) and Wirsung endoscopic evaluation to guide the pancreatic resection and ensure optimal resection margins. MATERIALS AND METHODS: A US-guided robotic CP was carried out, and an intraoperative endoscopic evaluation of the MPD was performed to determine the distal transection level. A transmesocolic, end-to-side, robot-sewn Wirsung-jejunostomy with internal MPD stenting was then created. The procedure was completed with a side-to-side jejunojejunostomy. RESULTS: The operative time was 290 min, with negligible blood loss. During the postoperative course, the patient experienced bleeding from a branch of the gastroduodenal artery with subsequent fluid collection, which was successfully treated with angioembolization and percutaneous drainage. He was discharged home on postoperative day 22. Final pathology revealed a non-invasive IPMN with low-grade dysplasia and free surgical margins. At 12 months of follow-up, the patient was doing well, with no evidence of local recurrence and endocrine or exocrine pancreatic insufficiency. CONCLUSIONS: The combination of robotic surgery with intraoperative US and Wirsungoscopy may offer distinct technical advantages for challenging pancreatectomies that follow the principles of parenchymal-sparing surgery.

Glaucoma as a Tauopathy-Is It the Missing Piece in the Glaucoma Puzzle?

Glaucoma is a chronic neurodegenerative disorder affecting the visual system which can result in vision loss and blindness. The pathogenetic mechanisms underlying glaucomatous optic neuropathy are ultimately enigmatic, prompting ongoing investigations into its potential shared pathogenesis with other neurodegenerative neurological disorders. Tauopathies represent a subclass of neurodegenerative diseases characterized by the abnormal deposition of tau protein within the brain and consequent microtubule destabilization. The extended spectrum of tauopathies includes conditions such as frontotemporal dementias, progressive supranuclear palsy, chronic traumatic encephalopathy, and Alzheimer's disease. Notably, recent decades have witnessed emerging documentation of tau inclusion among glaucoma patients, providing substantiation that this ocular disease may similarly manifest features of tauopathies. These studies found that: (i) aggregated tau inclusions are present in the somatodendritic compartment of RGCs in glaucoma patients; (ii) the etiology of the disease may affect tau splicing, phosphorylation, oligomerization, and subcellular localization; and (iii) short interfering RNA against tau, administered intraocularly, significantly decreased retinal tau accumulation and enhanced RGC somas and axon survival, demonstrating a crucial role for tau modifications in ocular hypertension-induced neuronal injury. Here, we examine the most recent evidence surrounding the interplay between tau protein dysregulation and glaucomatous neurodegeneration. We explore the novel perspective of glaucoma as a tau-associated disorder and open avenues for cross-disciplinary collaboration and new treatment strategies.

Impact of microbiota-immunity axis in pancreatic cancer management.

The microbiota impact on human diseases is well-known, and a growing body of literature is providing evidence about the complex interplay between microbiota-immune system-human physiology/pathology, including cancers. Together with the defined risk factors (e.g., smoke habits, diet, diabetes, and obesity), the oral, gut, biliary, and intrapancreatic microbiota contribute to pancreatic cancer development through different pathways including the interaction with the immune system. Unfortunately, a great majority of the pancreatic cancer patients received a diagnosis in advanced stages not amenable to be radically treated and potentially cured. Given the poor pancreatic cancer prognosis, complete knowledge of these complicated relationships could help researchers better understand the disease pathogenesis and thus provide early potential non-invasive biomarkers, new therapeutic targets, and tools for risk stratification that might result in greater therapeutic possibilities and eventually in a better and longer patient survival.

Multifocal IOL explantation in patients with opaque lentis after refractive lens exchange.

PURPOSE: We describe the outcomes of intraocular lens (IOL) explantation in a cluster of opaque multifocal Lentis LS-313 following refractive lens exchange (RLE). METHODS: Single-centre, single-surgeon, retrospective case series. RESULTS: The study enrolled 10 eyes of 10 patients, 6 male and 4 female. All patients had uneventful RLE with multifocal IOL implantation. The mean patient age at the time of RLE was 53 years ± 2.52 (SD). Two eyes had YAG laser capsulotomy prior to explantation. The mean interval between the initial RLE and IOL explantation was 5.4 years ± 1.4 (SD). IOL exchange was performed in all eyes in one procedure. Five eyes had in the bag hydrophobic acrylic IOL (3 multifocal and 2 monofocal), three eyes had 3-piece hydrophobic acrylic IOL in the ciliary sulcus and two had an anterior chamber IOL. Intraoperatively one patient had weak zonules and two patients had zonular dehiscence and required anterior vitrectomy. The mean preoperative CDVA was 0.25 ± 0.15 (SD) logMAR and at the final follow-up, improved to 0.00 ± 0.07 (SD) logMAR (p < 0.01). Light microscopy with von Kossa stain confirmed IOL calcification. No postoperative complications were recorded. CONCLUSIONS: IOL exchange appears to be a feasible and safe surgical option for multifocal IOL opacification. However, patients must be warned of additional intraoperative risks including zonular dialysis, vitreous loss, retinal detachment and need for potential scleral or iris fixated IOL or anterior chamber IOL (ACIOL) with its associated sequel of complications. Moreover, YAG laser capsulotomy should be considered carefully as it increases the chances of intraoperative complications and restricts the surgical options of secondary IOL insertion such as in-the-bag IOL exchange with MFIOL.

Effect of surgical abstinence on the risk for posterior capsule rupture during cataract surgery.

PURPOSE: To evaluate the impact of surgery restrictions on cataract surgery performance. SETTING: Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom. DESIGN: Retrospective, observational cross-sectional study. METHODS: A single-center, retrospective review of all patients who underwent phacoemulsification surgery at Moorfields Eye Hospital between September 2019 and January 2021 was conducted. The main outcome measure was posterior capsule rupture (PCR) rate before and after COVID-19-imposed restrictions to elective cataract surgery. RESULTS: A total of 15 688 surgeries were performed by 256 different surgeons in the study period. In the prerestriction period (September 2019 to March 2020), the PCR rate was 0.99%, whereas in the 19-week postrestriction period, the PCR rate spiked to 1.62% (odds ratio 1.65; P = .001; CI 1.24 to 2.20; relative risk: 1.64). CONCLUSIONS: The COVID-19 pandemic provided a unique opportunity to assess a large group of surgeons' performances after prolonged surgical abstinence. A 19-week restriction period in surgical activity showed an increased incidence of PCR complications. This is relevant because it can concern any surgeon on the extended time off from work such as sick, sabbatical, research, and parental leave. Supporting strategies should be implemented by associated regulators to minimize this negative impact.

Incidence and complications of retained lens fragment in the anterior chamber after uneventful cataract surgery in a United Kingdom tertiary center.

PURPOSE: To analyze the outcomes of retained lens fragment (RLF) in the anterior chamber after uneventful cataract surgery. SETTING: Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom. DESIGN: Retrospective, observational cross-sectional study. METHODS: A single-center, retrospective review was performed to identify patients who underwent RLF removal after uneventful phacoemulsification surgery between October 2012 and November 2018; 122 eyes from 121 patients were identified. Patient characteristics, clinical findings, visual outcomes, and need for subsequent surgical procedure were recorded. Main outcomes were change in corrected distance visual acuity (CDVA), and number and risk factors associated with additional surgery following RLF removal. RESULTS: One hundred twenty-two RLF over a total of 98 467 uneventful phacoemulsification surgeries were identified, with an incidence of 1 (0.124%) in 807 operations. The mean CDVA improved significantly after RLF removal from 0.32 to 0.26 logMAR (SD 0.26) (P = .001). Six eyes (4.9%) had persistent corneal edema that required endothelial keratoplasty (EK) after a mean of 13 months after RLF removal (SD 12 months; median 8; range 4 to 35). Risk factors for EK include α-receptor blocker use (odds ratio [OR], 6.75; 95% CI, 1.069, 42.63), increased interval (month) between cataract surgery and diagnosis of RLF (OR, 1.29; CI: 1.080, 1.541), increased interval between cataract surgery and RLF washout (OR, 1.28; CI, 1.075, 1.522), and RLF diagnosis on gonioscopy (OR, 10.60; CI, 1.885, 59.59). CONCLUSIONS: RLF is a rare complication of uneventful cataract surgery and appears more frequently in challenging cataract cases and myopic eyes. CDVA improved significantly after RLF removal, but approximately 1 in 20 eyes needed additional surgery-mainly EK for corneal decompensation.

Descemet membrane endothelial keratoplasty in vitrectomized eyes: a case series of outcomes and complications.

BACKGROUND: The aim of this study was to evaluate the clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) in vitrectomized eyes. METHODS: A multi-surgeon, retrospective case series of previously vitrectomized eyes that underwent DMEK between 2013 and 2018 at Moorfields Eye Hospital. Patients' demographics, preoperative, intraoperative and postoperative data were collected. RESULTS: In total, 14 eyes of 13 patients, aged 63 ± 14.6 years were included. Three eyes had intraoperative posterior dislocation of the DMEK graft into the vitreous cavity, two of these were aphakic and one had an unstable PCIOL. Postoperatively, one graft had a total detachment and required repeat keratoplasty for primary failure, two grafts had visually significant partial detachment and needed rebubbling. Three patients developed high intraocular pressure (IOP) and one required an urgent glaucoma drainage device 1-month post-DMEK. The mean corrected distance visual acuity was 0.81 ± 0.42 logMAR preoperatively, and postoperatively was 0.6 ± 0.51 at 3 months (p = 0.414); 0.69 ± 0.81 at 6 months (p = 0.684); and 0.7 ± 0.8 at 12 months (p = 0.658). CONCLUSIONS: DMEK in vitrectomized eyes has unique challenges that necessitate careful preoperative planning. We observed a significant proportion of dislocated grafts in vitrectomized eyes with either unstable IOL or aphakic. Moreover, vitrectomized eyes with secondary glaucoma may be particularly vulnerable to uncontrolled IOP postoperatively and close monitoring is essential to prevent worsening of visual acuity. We recommend that DMEK may not be a feasible option in eyes that are prone to collapse, in particular aphakic vitrectomized eyes, as opposed to DSAEK or penetrating keratoplasty.

Cataract surgery in eyes with congenital ocular coloboma.

PURPOSE: To assess the safety, efficacy, and complication rate of phacoemulsification and intraocular lens (IOL) implantation in patients with congenital uveal coloboma and to evaluate the role of pupilloplasty. METHODS: A retrospective review of 41 eyes (31 patients) with congenital coloboma that underwent phacoemulsification and IOL implantation between September 2012 and September 2018. Preoperative, intraoperative, and postoperative data were collected for analysis. RESULTS: The mean patient age at surgery was 53.9 years (range 15-82). The primary indication for surgery was cataract removal for visual improvement, and lens subluxation was additionally present in two eyes (5%) preoperatively. The mean preoperative corrected distance visual acuity (CDVA) was 0.90 LogMAR. Phacoemulsification surgery was performed in all cases and nine eyes (22%) had pupilloplasty for pupil reconstitution at the time of the procedure. Surgeon grade varied from trainee surgeon under supervision to consultant. Eight patients (19.5%) had posterior capsular rupture (PCR) with or without vitreous loss requiring anterior vitrectomy. Of these, 2 cases (5%) had dropped nuclear fragments requiring subsequent pars plana vitrectomy and lens fragment removal. The mean postoperative CDVA was 0.62 LogMAR (p = 0.0003). CONCLUSION: Patients with iridolenticular choroidal coloboma appear to be more at risk of complications, as were cases performed by non-consultant surgeons. Contrary, patients with phakodonesis, preoperative anterior chamber vitreous, dense cataracts, and cases were iris hooks used had no significant difference at PCR rate. The risk of postoperative glare and pupilloplasty needs to be considered in cases with good visual potential to avoid a possible second procedure.

Comparative analysis of 2 swept-source optical coherence tomography biometers.

PURPOSE: To report the level of agreement, repeatability, and correlation of axial length (AL), mean keratometry, central corneal thickness, anterior chamber depth, lens thickness, and corneal diameter measurements of 2 swept-source optical coherence tomography (SS-OCT) biometers, the IOLMaster 700 (reference biometer) and the Argos (new biometer). SETTING: Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom. DESIGN: Retrospective case series. METHODS: Each patient had SS-OCT biometry with the reference biometer and new biometer. In addition to reporting the statistical results derived from both eyes, this study included a subgroup analysis of right eyes and left eyes. The level of agreement between the biometers was represented with the Bland-Altman method. Power vector analysis of the J0 (Jackson cross-cylinder, axes at 0 degrees and 90 degrees) and J45 (Jackson cross-cylinder, axes at 45 degrees and 135 degrees) vectorial components of astigmatism was performed. Internal consistency was assessed with the Cronbach α coefficient of reliability. The dispersion of probability distribution was computed with the coefficient of variation. The intraoperator repeatability was calculated using the intraclass correlation coefficient (ICC). RESULTS: The study comprised 112 patients (218 eyes). There was a statistically significant difference between the 2 biometers in all measurements (P < .05) except AL. The level of correlation between the reference biometer and the new biometer was very high for all the parameters except corneal diameter, and the agreement was high. The ICC and internal consistency were excellent with both biometers. CONCLUSION: The new biometer provided good agreement and repeatability compared with the reference biometer.

Indapamide-induced bilateral choroidal effusion in pseudophakic patient.

We describe a case of indapamide-induced bilateral choroidal effusion, first time reported in pseudophakic patient, associated with no change in visual acuity and stable refraction.A 70-year-old man was referred for ophthalmic assessment, with binasal visual field defect for 2 days. He had been started on treatment with indapamide 3 weeks earlier. His ophthalmic history included bilateral cataract surgery and intraocular lens implant. Fundal examination revealed bilateral choroidal effusions; B-scan ultrasonography was used to measure the extent of the choroidal detachment and the anterior chamber depth. Discontinuation of indapamide resulted in spontaneous resolution of choroidal effusion after 3 days. Our case is the first in the literature that describes bilateral choroidal effusion induced by indapamide in a pseudophakic patient. The lack of myopic shift likely resulted in a later presentation, enhancing the theory that lens thickening and/or accommodative spasm may play a crucial role in pathophysiology.

Acute Glaucoma Following Cyanoacrylate Glue Patch for Corneal Perforation.

PURPOSE: To describe a case of acute glaucoma after cyanoacrylate gluing for a nontraumatic central corneal perforation. METHODS: A 55-year-old woman with history of rheumatoid arthritis and severe dry eye presented to emergency with a right central corneal perforation. She was treated successfully with the use cyanoacrylate glue patch but iridocorneal adhesions remained. The next day she presented with ocular pain, headaches, and vomiting. On examination she had shallow anterior chamber (AC) with no aqueous leakage but her intraocular pressure (IOP) was 56 mm Hg measured with rebound tonometry. An anterior segment optical coherence tomography scan showed a 360 degrees central iris adhesion with shallow AC. Topical and oral treatment for acute glaucoma was given that decreased her IOP. She then underwent urgent surgery to release the iridocorneal adhesions and restore aqueous flow that was achieved without replacing the glue patch. RESULTS: One day postoperatively her right eye was comfortable and her IOP measurement remained within normal limits. The AC was deep with no iridocorneal adhesions. CONCLUSIONS: Close monitoring of the IOP is recommendable in central corneal perforations with iris adhesions managed with cyanoacrylate glue due to the potential developing of aqueous blockage.

Vertical implantable collamer lens (ICL) rotation for the management of high vault due to lens oversizing.

PURPOSE: To describe the good outcome of implantable collamer lens (ICL) rotation to reduce post-operative vault. METHODS: Retrospective analysis of case report. A 43-year-old woman had V4c EVO + myopic non-toric ICL implantation and post-operatively she presented with anisocoria and high vault. She underwent surgery to rotate the ICL 90 degrees to a vertical orientation. RESULTS: We achieved a reduction in the vault from 1020 to 486 µm after vertical ICL rotation. Satisfactory refractive outcome and optimal vault were achieved and maintained during the period of follow-up. CONCLUSION: Optimal ICL sizing is important as too high vault/clearance is associated with problems such as angle closure glaucoma, pupil dilatation and anisocoria and too low vault/clearance to increased risk of cataract formation. Non-toric ICL rotation can be a simple surgical technique to deal with oversized lenses thus avoiding ICL exchange.

Infantile esotropia: risk factors associated with reoperation.

The aim of this study was to identify clinical and demographic factors associated with misalignment after first surgery performed on children affected by infantile esotropia to evaluate the reoperation rate. A retrospective study was carried out, analyzing data from 525 children who underwent bilateral medial recti recession, bilateral lateral recti resection, and inferior oblique recession and anteroposition by the same surgeon (AM). Postoperative evaluation included assessment of motor alignment at approximately 3 months, 6 months, 1 year, and 5 years. Statistical analysis was performed with a logistical regression model in which the dependent variable was the presence/absence of reoperation. We found that late surgery (after 3 years of age) and a family history of strabismus are associated with a higher risk of reoperation, while some clinical factors, including some classically associated with worst motor outcome as preoperative angle, dissociated vertical deviation, and amblyopia, did not influence the incidence of reoperation in infantile esotropia. Male patients and patients with hyperopia in preoperative examinations have a significantly decreased reoperation rate.

Essential infantile esotropia: postoperative motor outcomes and inferential analysis of strabismus surgery.

BACKGROUND: The aim of this retrospective study is a long-term evaluation of postoperative motor outcomes and the inferential analysis of strabismus surgery in infant eyes with essential infantile esotropia. METHODS: 576 patients were compatible with the criteria: confirmed EIE diagnosis, angle ≥ 30 pD, absence of associated ocular anomalies, onset by 6 months of age, absence of hyperopia > 3 Diopters, operation before age 4. Preoperative deviation classes (30-40 pD, 41-59 pD, ≥ 60 pD) were established, different types of surgery were performed. Follow-up was conducted for 5 years after surgery. Longitudinal data were analyzed using general linear mixed models stratified according to the class of pre-operative deviation. A random intercept and a random slope with time (in months) was assumed with an unstructured within subject correlation structure for repeated measurements. RESULTS: In patients with preoperative angle ≤ 40 pD, a significant interaction effect for intervention by time (F5,155.9 = 3.56, p = 0.004) and a significant intervention effect (F5,226.1 = 6.41, p < 0.001) on residual deviation were observed; only the intervention 5 showed a residual deviation inside the limits of a partial success. In Class 41-59, a significant interaction effect for intervention by time (F4,166.7 = 5.16, p = 0.001), intervention (F4,178.1 = 2.48, p = 0.046) and time (F1,174.6 = 9.99, p = 0.002) on residual deviation were observed; intervention 7 had the highest degree of stability showing an outcome within the range of a partial success. In Class ≥ 60 pD no significant effect for intervention (F4,213.9 = 0.74, p = 0.567), time (F1,169.5 = 0.33, p = 0.569) or intervention by time (F4,160.9 = 1.08, p = 0.368) on residual deviation was observed; intervention 3,6 and 7 resulted in a residual deviation within the range of a partial success. CONCLUSIONS: We suggest, where possible, a two-horizontal muscles approach in small angle EIE, while a multiple muscles surgery in large angle EIE.

Orbital lymphoma mimicking lacrimal gland pleomorphic adenoma.

PURPOSE: To describe the case of a patient affected by orbital lymphoma mimicking pleomorphic adenoma of the lacrimal gland. METHODS: This was a retrospective case report. RESULTS: We present the case of a patient with 15-year history of slowly progressive left proptosis and inferomedial bulbar dislocation who had the presumptive diagnosis of lacrimal gland pleomorphic adenoma based on clinical and radiological features. The patient underwent lateral orbitotomy and lacrimal gland excision. Postoperative histological features were consistent with low-grade B-cell non-Hodgkin lymphoma. CONCLUSION: The accepted clinico-radiological criteria used for the diagnosis of lacrimal gland fossa lesions might have a certain false-positive rate, even in recent years. The initial surgical approach with the appropriate choice between fine-needle aspiration biopsies, intraoperative biopsies and lacrimal gland excisions might be a challenge.