Management of Ocular Surface Disease in Glaucoma: A Survey of Canadian Glaucoma Specialists.

PRéCIS:: Ocular surface disease (OSD) in glaucoma is an area for improvement in the management of patients with glaucoma. This study explores the knowledge of glaucoma subspecialists toward OSD in glaucoma, then provides a suggested treatment algorithm. PURPOSE: To assess the attitudes, knowledge, and level of comfort of Canadian glaucoma specialists with respect to the assessment and management of OSD among patients with glaucoma. METHODS: Ophthalmologist members of the Canadian Glaucoma Society with fellowship training in glaucoma were contacted to participate in this cross-sectional survey study. Responses were recorded to statements regarding attitudes toward OSD in glaucoma, and assessment and management modalities. These were recorded primarily in the form of a Likert scale rated 1 to 7 from "strongly disagree" to "strongly agree." Descriptive statistics were generated, and mean and SD for responses on Likert scales. RESULTS: Thirty-six responses were included. All respondents agreed that comprehensive management of OSD could improve quality of life, 97% agreed it could lead to better glaucoma outcomes, whereas only 22% agreed it is presently being adequately managed in glaucoma practices. Respondents were asked to list all treatment modalities they felt knowledgeable about, ranging from 100% for optimizing topical glaucoma therapies to 31% for serum tears. Nearly all respondents (92%) agreed that a suggested algorithm for the treatment of OSD in glaucoma could improve their approach to management. CONCLUSION: OSD is a common comorbidity of glaucoma. Although respondents overwhelmingly agreed that comprehensive management of OSD may lead to improved quality of life and glaucoma-related outcomes, only a small percentage felt it was presently adequately managed. Increasing knowledge related to the assessment and management of OSD in glaucoma may in the future improve patient care.

An unusual case of acute angle-closure glaucoma following deep anterior lamellar keratoplasty using the "big bubble" technique.

PURPOSE: To report the first case of acute angle closure due to a high-pressure Descemet membrane detachment following deep anterior lamellar keratoplasty (DALK) using the "big bubble" technique. OBSERVATIONS: A 25-year-old man underwent DALK surgery for keratoconus using the "big bubble" technique in which an air bubble is injected in deep stroma to promote dissection of underlying Descemet membrane from stroma. Surgery was uneventful and the patient was discharged home in good conditions. On post-operative day 1, the patient came back with severe periocular pain. Intra-ocular pressure was found to be 38 mmHg. Anterior-segment OCT revealed a "double anterior chamber" created by a high-pressure Descemet detachment that was occluding the pupil and causing secondary acute angle closure glaucoma. The patient was brought back promptly to the operating room where the high-pressure chamber was properly evacuated, allowing Descemet membrane to properly reattach to stroma. CONCLUSIONS AND IMPORTANCE: Inability to recognize stroma from Descemet membrane during the dissection of the "big bubble technique" can result in failure to evacuate the high-pressure Descemet membrane detachment, putting the patient at risk for acute angle closure glaucoma from occlusion of the pupil. Proper dissection of stroma from underlying DM is a challenging and crucial step in the "big bubble" technique. Several methods, such as the injection of small bubbles in the anterior chamber or the use of intra-operative anterior segment OCT could be employed to prevent such a complication.

No Light Perception Outcomes Following Boston Keratoprosthesis Type 1 Surgery.

PURPOSE: To determine the incidence rate, principal causes, and clinical course of eyes developing no light perception (NLP) visual acuity (VA) following Boston Keratoprosthesis (B-KPro) type 1 surgery. Secondary objectives include determining the incidence rate, relative risk (RR), and survival probability with respect to NLP outcomes among eyes with congenital aniridia. DESIGN: Retrospective, interventional case series. SUBJECTS: All patients undergoing B-KPro type 1 surgery between October 2008 and June 2016 by a single surgeon at CHUM - Hôpital Notre-Dame. METHODS: Records of patients having undergone B-KPro implantation were reviewed. Eyes with a final outcome of NLP were further reviewed to determine best recorded postoperative VA, time to NLP onset, clinical course, and principal cause. Descriptive statistics, incidence rates, Kaplan-Meier survival curves, and the RR of NLP outcomes among eyes with aniridia were determined. Statistical significance was defined as P < .05. RESULTS: Records of 119 patients were included, with an average follow-up of 49.1 ± 26.8 months postoperatively. Nineteen eyes had a final outcome of NLP, representing 16.0%. The incidence rate of NLP was 0.04 cases per eye-year of follow-up. The most common principal causes were inoperable retinal detachment (n = 7, 36.8%), terminal glaucoma (n = 6, 31.6%), and carrier graft melt-related complications (n = 5, 26.3%). The RR of developing NLP among eyes with aniridia was 3.04 (P = .01). CONCLUSIONS: No light perception is a devastating but uncommon outcome of B-KPro surgery. Patients with aniridia seem to be at increased risk. In spite of all available medical and surgical interventions, some eyes may still suffer this outcome.

Boston Keratoprosthesis Type 1: A Randomized Controlled Trial of Fresh versus Frozen Corneal Donor Carriers with Long-Term Follow-up.

PURPOSE: To compare the long-term clinical outcomes of fresh versus frozen corneal graft carriers for the Boston Keratoprosthesis type 1 (B-KPro). DESIGN: Prospective, single-center, nonblinded, randomized controlled trial. All participants were followed through the initial study protocol of 24 months and were approached to enter an extension phase, with continuing follow-up visits to 60 months. PARTICIPANTS: All patients undergoing B-KPro surgery between October 2008 and December 2009 by a single experienced surgeon at the Centre Hospitalier de l'Université de Montréal using an allograft carrier were considered. Patients were excluded if they had previously undergone B-KPro implantation. METHODS: Participants were randomized individually to receive a B-KPro using a frozen or a fresh corneal graft carrier on the basis of tissue availability on the day of surgery, as determined by the local eye bank. MAIN OUTCOME MEASURES: The primary outcome measure was device retention at 24 and 60 months. Secondary outcome measures included surgical feasibility, visual acuity (VA), and complications. RESULTS: Thirty-seven eyes of 37 patients were enrolled in the initial study protocol, with 19 eyes randomized to fresh and 18 to frozen carrier grafts. Thirty-six eyes were followed through to 24 months, with 1 lost to follow-up. Of these, 26 were enrolled in the extension (11 eyes with a frozen and 15 eyes with a fresh carrier graft). There were no differences in the baseline characteristics of patients enrolled in the extension phase versus those who were not. At 60 months, median corrected distance VA) in the fresh group had improved to 20/150 from a baseline of counting fingers, whereas the frozen group improved to 20/400 from a baseline of hand motions. Device retention was 100% at 24 months and 96% at 60 months. There were no significant differences in the rate of complications between groups. CONCLUSIONS: Fresh and frozen corneal donors offer similar clinical outcomes when used as carriers for the B-KPro, with no significant differences in device retention, visual rehabilitation, or rates of complications at 24 or 60 months.

Chinook wind barosinusitis: an anatomic evaluation.

BACKGROUND: Chinook, or föhn, is a weather phenomenon characterized by a rapid influx of warm, high-pressured winds into a specific location. Pressure changes associated with chinook winds induce facial pain similar to acute sinusitis. The purpose of this study was to determine the relationship between sinonasal anatomy and chinook headaches. METHODS: Retrospective computed tomography (CT) sinonasal anatomy analysis of 38 patients with chinook headaches and 27 controls (no chinook headaches). The chinook headache status was blinded from the CT reviewer. Forty-one sinonasal anatomy variants, Lund-Mackay status, and sinus size (cm(3)) were recorded. RESULTS: There were three statistically significant sinonasal anatomy differences between patients with and without chinook headaches. The presence of a concha bullosa and sphenoethmoidal cell (Onodi cell) appeared to predispose to chinook headaches (p = 0.004). Chinook headache patients had larger maxillary sinus size (right, p = 0.015, and left, p = 0.002). The Lund-Mackay score was higher in the control patients (p = 0.003) indicating that chronic sinusitis does not play a role in chinook headaches. CONCLUSION: Chinook winds are a common source of facial pain and pressure. This is the first study to show that sinonasal anatomic variations may be a predisposing factor. Anatomic variants may induce facial pain by blocking the natural sinus ostia, thus preventing adequate pressure equilibrium.