Holló G. Optical Coherence Tomography Angiography to Better understand Glaucoma. J Curr Glaucoma Pract 2017;11(2):35-37.

To compare the effect of 30-gauge vs 27-gauge needle size on intraocular pressure (IOP) rise and patients’ pain experience after intravitreal injection (IVI) of bevacizumab.

Cross-sectional, randomized, double-armed study. Patients were randomized to IVI with 30-gauge or 27-gauge needle. The IOP was measured pre and post IVI. Patients’ pain was graded using the visual analog scale (VAS).

A total of 54 eyes were included. The IVI caused a significant IOP rise in both groups (p < 0.001). In the 30-gauge group, the mean pre- and postinjection IOP was 16.3 ± 3.6 mm Hg and 24.1 ± 9.0 mm Hg. The corresponding figures in the 27-gauge group were 18.0 ± 2.54 (p = 0.26) and 23.1 ± 7.5 mm Hg (p = 0.66). In the 30-gauge group, the mean VAS pain score was 3.2 ± 2.6 compared to 3.0 ± 2.5 in the 27-gauge group (p = 0.78).

The IVI caused a significant rise in IOP after the injection, independently of the needle size used. The 27-gauge needle coursed with lower postinjection IOP without prejudice of the patient comfort.

The IVI with 27-gauge may be considered for glaucomatous eyes (higher risk eyes), for which IOP spikes are not recommended.

Loureiro M, Matos R, Sepulveda P, Meira D. Intravitreal Injections of Bevacizumab: The Impact of Needle Size in Intraocular Pressure and Pain. J Curr Glaucoma Pract 2017;11(2):38-41.

To compare the efficacy and safety of Ex-PRESS glaucoma filtration surgery to trabeculectomy in African origin patients.

A retrospective chart review was performed on 56 African American patients undergoing Ex-PRESS glaucoma shunt (E) or trabeculectomy (T) between 2004 and 2012. Data collected included intraocular pressure (IOP) and glaucoma medication use at baseline and postoperative week 1, Month (M) 1, M3, M6, M12. Postoperative interventions including laser suture lysis (LSL) and 5FU injections were analyzed. Complete and qualified success rate, and eyes failing and requiring more surgery were determined. Means, SD, chi-square, and Student's t-test were performed.

A total of 56 subjects (E 28, T 28) were included in the analysis. There was a statistically significant reduction (p < 0.05) in IOP and number of glaucoma medications at all time points compared to baseline for both groups. Extent of IOP reduction between groups was not statistically significant at any time point, except postoperative week 1. Mean number of glaucoma medications between groups was not significant, except at 3 months (lower in EXP group). The cumulative number of postoperative interventions within 3 months (LSL and 5-FU) was significantly greater for the TRAB than EXP (3.89 ± 2.4 vs 2.36 ± 2.2, p = 0.007). Success rates were comparable between both groups (Table 2).

Our study is unique in patients of African origin showing statistical significance in the requirement of less postoperative 5-FU injections during the first 3 months following surgery in the Ex-PRESS group vs the trabeculectomy group. The Ex-PRESS shunt was as effective as trabeculectomy in reducing IOP and use of glaucoma medications up to 1 year.

The possible benefit of this article is to help guiding ophthalmologists to select the type of glaucoma filtration surgery to undergo in an African American patient with glaucoma.

Bustros YD, Fechtner R, Khouri AS. Outcomes of Ex-PRESS and Trabeculectomy in a Glaucoma Population of African Origin: One Year Results. J Curr Glaucoma Pract 2017;11(2):42-47.

To describe the demographic characteristics, ocular comorbidities, and clinical outcomes of patients with neovascular glaucoma (NVG) and to determine the number of patients who returned for a follow-up eye examination.

We examined the clinical data of patients with NVG, who attended a glaucoma clinic between July 2010 and November 2014. We collected information on the demographic characteristics of the patients to include the level of education, ocular comorbidities, NVG stage, visual acuity, glaucoma medications, intraocular pressure (IOP), and the number of patients who had a follow-up ocular examination at month 1, 3, 6, and 12.

Data from 350 patients (473 eyes) with NVG were collected. We found 91% of the cohort had proliferative diabetic retinopathy (PDR). We found blindness in both or one eye in 14% and 31% of the cohort respectively. Low vision was found in both or one eye in 14% and 32% of the eyes respectively. By 6 months follow-up, only 32% of the patients were seen at our clinic and by 12 months follow-up, this number decreased to 15%. Around 60% of the patients were on no IOP lowering drugs at the first visit. We found 53% of the cohort had an incomplete elementary school education.

The results suggest that advanced NVG is a significant ocular problem for patients referred to our clinic with just over half of the patients presenting as blind. We also found that several socioeconomic factors that had an important role in the development of PDR and NVG, specifically, educational status.

We described the characteristics of a large cohort of patients with very advanced NVG, reflecting the fact that the strict control of the underlying disease must be the main goal of the Mexican national health system.

Lazcano-Gomez G, Soohoo JR, Lynch A, Bonell LN, Martinez K, Turati M, Gonzalez-Salinas R, Jimenez-Roman J, Kahook MY. Neovascular Glaucoma: A Retrospective Review from a Tertiary Eye Care Center in Mexico. J Curr Glaucoma Pract 2017;11(2):48-51.

To evaluate the relationship between retinal nerve fiber layer (RNFL) thickness measured by Cirrus high-definition (HD) optical coherence tomography (OCT) and the axial length and refractive error of the eye.

A total of 100 eyes of 100 healthy subjects (age 20-34 years with M/F ratio of 57/43), comprising 50 eyes with emmetropia [spherical equivalent (SE) 0 D], 25 eyes with moderate myopia (SE between -4 D and -8 D), and 25 eyes with high myopia (SE between -8 D and -12 D) were analyzed in this cross-sectional study. Average and mean clock hour RNFL thicknesses were measured by cirrus HD-OCT and compared between the three groups. Associations between RNFL measurements and axial length and SE were evaluated by linear regression analysis.

The average RNFL measurements were significantly lower in high myopia (78.68 +/- 5.67) and moderate myopia (83.76 +/- 3.44) group compared with emmetropia group (91.26 +/- 2.99), also in the superior and inferior mean clock hours. Significant correlations were evident between RNFL measurements and the SE and axial length. The average RNFL thickness decreased with increasing axial length (r = –0.8115) and negative refractive power (r = 0.8397). Myopia also affected the RNFL thickness distribution. As the axial length increased and the SE decreased, the thickness of the superior, inferior, and nasal peripapillary RNFL decreased.

The axial length/refractive error of the eye affected the average RNFL thickness and the RNFL thickness distribution. Analysis of RNFL thickness in the evaluation of glaucoma should always be interpreted with reference to the refractive status. When interpreting the RNFL thickness of highly myopic patients by OCT, careful attention must be given to the inherently thinner RNFL to avoid a false diagnosis of glaucoma.

Singh D, Mishra SK, Agarwal E, Sharma R, Bhartiya S, Dada T. Assessment of Retinal Nerve Fiber Layer Changes by Cirrus High-definition Optical Coherence Tomography in Myopia. J Curr Glaucoma Pract 2017;11(2):52-57.

To investigate surgical outcomes and success predictors of transconjunctival scleral flap resuturing for the management of hypotony due to overfiltration following trabeculectomy with mitomycin C.

Noncomparative, retrospective, interventional case series in which all glaucoma patients from two glaucoma services undergoing transconjunctival scleral flap resuturing between May 2012 and July 2016 were enrolled. Included eyes had to have hypotony [intraocular pressure (IOP) ≤ 6 mm Hg] and/or hypotony maculopathy caused by excessive filtration following trabeculectomy. Key exclusion criteria were wound/bleb leaking and postoperative ocular trauma or infection. Preoperative and postoperative IOP, best-corrected visual acuity (BCVA), fundus imaging, surgical complications, and any subsequent related events or procedures were recorded. Rates of postsurgical hypotony and/or maculopathy resolution and possible success predictors were investigated.

A total of 22 patients (22 eyes) with a mean age of 56.4 ± 15.2 years were included. Median follow-up was 245 days [interquartilerange (IR); 120–817 days] and mean IOP was increased from 2.9 ± 1.5 mm Hg (1–6 mm Hg) to 8.5 ± 3.1 mm Hg (2–16 mm Hg) at the last follow-up visit (p < 0.01). Approximately 75% of the cases (16 out of 22) had an IOP between 7 and 18 mm Hg at the end of the follow-up period. Median BCVA (log MAR) at last follow-up visit [0.1 (IR; 0.0- 0.3)] was significantly better than preoperative BCVA [0.4 (IR; 0.1-1.0); p < 0.01]. Hypotony resolved in 81% of the cases, while maculopathy resolution was found in 85% of the cases. Time interval between trabeculectomy and flap resuturing was the only factor significantly associated with patient's IOP at last follow-up visit (R² = 0.23; p = 0.036). Success rates (IOP < 6 mm Hg at last follow-up visit) were halved in those left untreated for more than 6 months. No serious adverse event was recorded.

Our findings support the use of transconjunctival scleral flap resuturing as an effective and safe alternative for hypotony management due to overflitration following trabeculectomy. As time interval seems to influence the odds of hypotony resolution, early intervention is recommended.

Scoralick ALB, Almeida I, Ushida M, Dias DT, Dorairaj S, Prata TS, Kanadani FN, Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017;11(2):58-62.

The current treatment for posterior capsular opacification (PCO), neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy, may lead to increased intraocular pressure (IOP). Our aim was to survey routines in the management of IOP spikes and to identify the rate of IOP spikes following prophylactic apraclonidine treatment.

A survey questionnaire among ophthalmologists and a retrospective registry review was used. Patients were administered apraclonidine 0.5% prior to capsulotomy. The IOP was measured before and 1 hour postprocedure.

A total of 71% of responders (n = 45) routinely prescribe topical IOP-lowering medication and 82% routinely measure IOP before or after capsulotomy. The registry analysis included 87 eyes of 75 patients. Mean IOP decreased by 0.9 ± 3.3 mm Hg (p = 0.01, range: −6 to 10) following capsulotomy. No patient reached IOP values above 21 mm Hg following the procedure, with 3.4 and 1.1% of patients demonstrating an IOP elevation of more than 3 and 5 mm Hg respectively. No association was found between number of laser shots, mean laser power, or comorbid conditions, such as diabetes, hypertension, or glaucoma status with posttreatment IOP.

Most ophthalmologists surveyed routinely prescribe prophylactic IOP-lowering medication and measure IOP before or after capsulotomy. Mean IOP remained clinically stable following capsulotomy with prophylactic apraclonidine instillation, and no patient reached IOP values above 21 mm Hg. Differences in laser delivery or comorbid conditions were not associated with posttreatment IOP. Considering that no patient demonstrated a clinically significant IOP spike following prophylactic apraclonidine instillation, perhaps routine measurement of IOP following primary Nd:YAG laser may be reserved for high-risk patients only.

In this work, we showed the prophylactic effect of apraclonidine 0.5% and suggest that measuring IOP after the procedure is necessary only in certain high-risk cases, possibly helping to reduce workload and patient waiting time and improving quality of service.

Achiron A. Intraocular Pressure Spikes following Neodymium-doped Yttrium Aluminum Garnet Laser Capsulotomy: Current Prevalence and Management in Israel. J Curr Glaucoma Pract 2017;11(2):63-66.

Phulke S, Kaushik S, Kaur S, Pandav SS. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. J Curr Glaucoma Pract 2017;11(2):67-72.

To describe the surgical management of glaucoma in a patient with severe scleromalacia, and secondary angle closure.

The management of glaucoma with coexisting scleromalacia plus secondary angle closure is challenging as most commonly performed incisional glaucoma surgery as well as minimally invasive glaucoma surgery (MIGS), which targets the drainage angle are all contraindicated.

Medically refractory glaucoma in a 60-year-old male with a 30-year history of granulomatosis with polyangiitis resulting in extensive severe scleromalacia, cicatricial lower lid retraction with significant conjunctival exposure, and widespread synechial angle closure from chronic anterior uveitis was managed with combined phacoemulsification cataract surgery, and endoscopic cyclophotocoagulation (ECP). Careful postoperative management with intensive immunosuppression was used to successfully prevent complications related to the surgery, which resulted in improved visual acuity, and control of intraocular pressure (IOP).

The ECP is a minimally invasive procedure that targets inflow of aqueous, and can be safely and successfully used to control IOP in challenging patients with complex secondary glaucoma, where the use of traditional incisional surgery, and other MIGS procedures are all contraindicated.

The choice of surgical treatment for medically refractory glaucoma needs to be selected based on the circumstances of individual patients, and take into consideration the condition of the sclera, conjunctiva and drainage angle, against the safety and efficacy of possible treatments.

Rodrigues IAS, Lindfield D, Stanford MR, Goyal S. Glaucoma Surgery in Scleromalacia: Using Endoscopic Cyclophotocoagulation where Conventional Filtration Surgery or Angle Procedures are contraindicated. J Curr Glaucoma Pract 2017;11(2):73-75.