Risk factors for steroid response among cataract patients

Intraocular Pressure Spike Following Stand-Alone Phacoemulsification in the IRIS® Registry (Intelligent Research in Sight)

PURPOSE

To evaluate risk factors for intraocular pressure (IOP) spike after cataract surgery using the IRIS® Registry (Intelligent Research in Sight).

DESIGN

Retrospective clinical cohort study.

PARTICIPANTS

Adults with IRIS Registry data who underwent stand-alone phacoemulsification from January 1, 2013, through September 30, 2019.

METHODS

Intraocular pressure spike was defined as postoperative IOP of > 30 mmHg and > 10 mmHg from the baseline within the first postoperative week. Odds ratios (ORs) for demographic and clinical characteristics were calculated with univariable and multivariable logistic regression analyses.

MAIN OUTCOME MEASURES

Incidence and OR of IOP spike.

RESULTS

We analyzed data from 1 191 034 eyes (patient mean age, 71.3 years; 61.2% female sex; and 24.8% with glaucoma). An IOP spike occurred in 3.7% of all eyes, 5.2% of eyes with glaucoma, and 3.2% of eyes without glaucoma (P < 0.0001). Multivariable analyses of all eyes indicated a greater risk of IOP spike with higher baseline IOP (OR, 1.57 per 3 mmHg), male sex (OR, 1.79), glaucoma (OR, 1.20), Black race (OR, 1.39 vs. Asian and 1.21 vs. Hispanic), older age (OR, 1.07 per 10 years), and complex surgery coding (OR, 1.22; all P < 0.0001). Diabetes (OR, 0.90) and aphakia after surgery (OR, 0.60) seemed to be protective against IOP spike (both P < 0.0001). Compared with glaucoma suspects, ocular hypertension (OR, 1.55), pigmentary glaucoma (OR, 1.56), and pseudoexfoliative glaucoma (OR, 1.52) showed a greater risk of IOP spike and normal-tension glaucoma (OR, 0.55), suspected primary angle closure (PAC; OR, 0.67), and PAC glaucoma (OR, 0.81) showed less risk (all P < 0.0001). Using more baseline glaucoma medications was associated with IOP spike (OR, 1.18 per medication), whereas topical β-blocker use (OR, 0.68) was protective (both P < 0.0001).

CONCLUSIONS

Higher baseline IOP, male sex, glaucoma, Black race, older age, and complex cataract coding were associated with early postoperative IOP spike, whereas diabetes and postoperative aphakia were protective against a spike after stand-alone phacoemulsification. Glaucomatous eyes demonstrated different risk profiles dependent on glaucoma subtype. The findings may help surgeons to stratify and mitigate the risk of IOP spike after cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Triamcinolone Acetonide Subconjunctival Injection as Stand-alone Inflammation Prophylaxis after Phacoemulsification Cataract Surgery

PURPOSE

To compare the effectiveness and safety of a single injection of subconjunctival triamcinolone acetonide (TA) with that of postoperative topical prednisolone acetate (PA) with and without nonsteroidal anti-inflammatory drugs (NSAIDs) for cataract surgery prophylaxis.

DESIGN

Retrospective, comparative effectiveness cohort study.

PARTICIPANTS

Patients at Kaiser Permanente Northern California from 2018 through 2021.

INTERVENTION

Exposure groups included topical PA with or without NSAID and subconjunctival injection of TA (Kenalog; Bristol-Myers-Squibb) 10 mg/ml or 40 mg/ml in a low dose (1.0-3.0 mg) or high dose (3.1-5.0 mg).

MAIN OUTCOME MEASURES

The adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of postoperative macular edema (ME) and iritis diagnoses 15 to 120 days after surgery (effectiveness measures) and a glaucoma-related event (safety measure) between 15 days and 1 year after surgery.

RESULTS

Of 69 832 eligible patient-eyes, postoperative ME, iritis, and a glaucoma-related event occurred on average in 1.3%, 0.8%, and 3.4% of eyes in the topical groups and 0.8%, 0.5%, and 2.8% of eyes in the injection groups, respectively. In multivariable analysis, compared with the PA reference group, the PA plus NSAID group had a lower OR of ME (OR, 0.88; 95% CI, 0.74-1.04; P = 0.135). and all injection groups had even lower odds, with the high-dose TA 10-mg/ml group reaching statistical significance (OR, 0.64; 95% CI, 0.43-0.97; P = 0.033). A trend of lower odds of a postoperative iritis diagnosis was noted in the high-strength (40 mg/ml) groups. For postoperative glaucoma-related events, compared with PA, the TA 10-mg/ml low-dose group showed lower odds (OR, 0.69; 95% CI, 0.55-0.86; P = 0.001), the TA 10-mg/ml high-dose group showed similar odds (OR, 0.90; 95% CI, 0.70-1.15; P = 0.40), and the TA 40-mg/ml low-dose and high-dose groups showed higher odds of an event occurring (OR, 1.46 [95% CI, 0.98-2.18; P = 0.062] and OR, 2.14 [95% CI, 1.36-3.37; P = 0.001], respectively).

CONCLUSIONS

The TA 10-mg/ml high-dose (4 mg) group was associated with a lower risk of postoperative ME and a similar risk of glaucoma-related events compared with the topical groups.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Steroid Response Following Dropless Cataract Surgery Using Subconjunctival Triamcinolone

Purpose

To assess the rates of postoperative steroid response following dropless cataract surgery using a subconjunctival depot of triamcinolone versus conventional cataract surgery using topical prednisolone.

Patients and Methods

We reviewed consecutive cataract surgery cases performed by a single surgeon to determine the likelihood of steroid response, defined as intraocular pressure (IOP) 50% above baseline or IOP > 24 mmHg postoperatively, excluding the first 72 hours. Logistic regression models were performed including baseline characteristics as exposures in the model and steroid response as the outcome. Main outcome measures were the proportion of eyes developing steroid response, risk factors for developing steroid response, and duration of steroid response.

Results

Of the 150 dropless and 218 conventional cases, 26 eyes developed steroid response (15 dropless and 11 conventional cases [10% vs 5%, P=0.096]). Risk factors for steroid response included dropless surgery (OR=2.43, 95% CI=1.03-6.02], P=0.046) and prior diagnosis of glaucoma (OR=7.18, 95% CI=2.66-19.22], P<0.001). Baseline IOP, age, sex, race, and axial length did not increase risk for steroid response. Of the eyes with steroid response, more dropless cases had an IOP elevation ≥30 days (9/15 eyes vs 1/11 eyes; P=0.008), including one patient with refractory IOP elevation in the dropless group who required urgent bilateral trabeculectomy for IOP control.

Conclusion

Dropless cataract surgery increases the risk of prolonged steroid response postoperatively. Patients with glaucoma have an increased risk of steroid response and may not be good candidates for dropless cataract surgery with subconjunctival triamcinolone.

A very early steroid responder after cataract surgery: a case report

BACKGROUND

Increased intraocular pressure (IOP), a side effect of corticosteroid eye drops, typically develops during the first few weeks of administration, and steroid response is not generally considered a cause of increased IOP immediately after cataract surgery.

CASE PRESENTATION

Here, I report a rare case of increased IOP due to steroid eye drops immediately after surgery. A man in his 80s presented with vision loss. Bilateral cataracts and pseudoexfoliation syndrome were confirmed. Postoperative eye drops including steroid eye drops were started immediately after cataract surgery in the right eye. High IOP was observed at the next and subsequent morning visits, but IOP normalized when steroid eye drops were discontinued. After surgery on the left eye, steroids were not administered postoperatively, and no increase in IOP was observed.

CONCLUSION

This case report highlights that a very early steroid response may be potential cause of elevated IOP immediately after cataract surgery.

ALK5 Inhibition of Subconjunctival Scarring From Glaucoma Surgery: Effects of SB-431542 Compared to Mitomycin C in Human Tenon's Capsule Fibroblasts

Purpose

The gold standard for managing postoperative ocular fibrosis in glaucoma surgery is the chemotherapeutic mitomycin C (MMC) despite its association with significant adverse effects. This study compares in vitro the antifibrotic efficacy and cytotoxicity of the small-molecule TGFβ1 inhibitor SB-431542 (SB) to MMC.

Methods

To measure collagen contraction, human Tenon's capsule fibroblasts (HTCFs) embedded in a three-dimensional collagen lattice were exposed to 0.2 mg/mL MMC or 20 µM SB followed by incubation with 2 ng/mL TGFβ1. Total protein extracted from experimentally treated HTCFs underwent immunoblotting for α-smooth muscle actin (α-SMA), matrix metallopeptidase 9 (MMP-9), and EDA splice-variant fibronectin (EDA-FN) expression. Cytotoxicity and cell metabolism were assessed using LIVE/DEAD staining, lactate dehydrogenase (LDH) assay, and methylthiazole tetrazolium (MTT) assay.

Results

Collagen lattice contraction in TGFβ1-induced HTCFs was significantly lowered by SB and MMC. Pretreatment with SB and MMC significantly lowered protein expression of α-SMA, MMP-9, and EDA-FN in HTCFs relative to TGFβ1 alone. HTCF viability in collagen lattices was significantly reduced with MMC pretreatment but not SB pretreatment. MMC-pretreated HTCFs had a significant increase in LDH release after 3 hours and a decrease in MTT activity after 20 minutes, while SB-pretreated HTCFs showed no significant changes via MTT or LDH assay during the same treatment period.

Conclusions

SB shows comparable efficacy to MMC in reducing expression of fibrosis-promoting proteins in HTCFs and in vitro scarring activity. SB distinguishes itself from MMC by exhibiting less cytotoxicity in both two-dimensional and three-dimensional in vitro assays.

Translational Relevance

This study demonstrates in vitro the potential of SB as a safer alternative ocular antifibrotic agent.

Intraocular Pressure Changes Following Stand-Alone Phacoemulsification: An IRISɌ Registry Analysis

PURPOSE

To describe real-world intraocular pressure (IOP) changes following stand-alone cataract surgery by comparing postoperative IOP to phakic fellow eyes.

DESIGN

Retrospective clinical cohort study.

METHODS

A total of 1,334,868 patients (336,060 with glaucoma and 998,808 without glaucoma) in the IRIS® Registry (Intelligent Research in Sight) underwent stand-alone phacoemulsification from 1 January 2013 to 30 September 2019 with a fellow eye that had subsequent cataract surgery. Postoperative daily mean IOP was compared between surgical and control eyes from postoperative day 1 to 90. A generalized linear model determined when the postoperative daily mean IOP stabilized to calculate a final mean IOP, which was then compared to baseline IOP.

RESULTS

Postoperative daily mean IOP was initially greater for surgical than for control eyes because of an early postoperative IOP spike. By postoperative day 13, postoperative daily mean IOP was significantly lower for surgical than for control eyes every day through postoperative day 90 (P < .001). There was a mean (SD) decrease from baseline to final mean IOP of 1.55 (3.52) mm Hg or 7.79% for all surgical eyes, 1.91 (3.93) mm Hg or 8.89% for surgical eyes with glaucoma, and 1.37 (3.28) mm Hg or 7.24% for surgical eyes without glaucoma, respectively. There was a statistically significant decrease from baseline to the final mean IOP for all surgical eyes, surgical eyes without glaucoma, and all categories of pre-glaucoma and glaucoma (P < .0001 for all, excluding uveitic glaucoma [P = .0016]).

CONCLUSIONS

Eyes both with and without glaucoma that underwent stand-alone phacoemulsification had a significant decrease in IOP through the 90-day postoperative period compared to baseline and phakic fellow eyes.

Steroid Response after Trabeculectomy-A Randomized Controlled Trial Comparing Dexamethasone to Diclofenac Eye Drops

This prospective randomized controlled trial aimed to compare changes in intraocular pressure in three different anti-inflammatory regimens following trabeculectomy. Sixty-nine patients were randomized to receive either postoperative prophylaxis with topical preservative-free dexamethasone (DEX), diclofenac (DICLO), or their combination (DEX+DICLO). Our main outcome measure was an intraocular pressure (IOP) change of a minimum 4 mmHg following the withdrawal of anti-inflammatory prophylaxis 9 weeks after trabeculectomy. We found that the IOP decreased ≥ 4 mmHg in 18.6% of eyes after cessation of the topical steroid DEX (n = 3/22) and DEX+DICLO (n = 5/21), whereas a decrease in IOP was not observed in the DICLO group. In conclusion, IOP decreased in nearly 1/5 of patients after cessation of topical steroidal anti-inflammatory prophylaxis after trabeculectomy. This points toward a steroid-induced increase in IOP even after trabeculectomy. Thus, increased postoperative IOP may be related to steroid use, and the success or failure of a trabeculectomy cannot be fully evaluated before anti-inflammatory prophylaxis with steroids is stopped or changed to non-steroidal eye drops.

Differential effects of acetylsalicylic acid and mitomycin C on cytokine-induced Tenon's capsule myofibroblast transdifferentiation and activity: Implications for glaucoma surgery

Inflammation-driven scarring is a major contributor to surgical failure after subconjunctival bleb forming glaucoma surgery. The current gold standard anti-scarring adjuvant mitomycin C (MMC) has variable effectiveness and is associated with significant risks. Acetylsalicylic acid (ASA), when delivered locally, repurposes the typically pro-inflammatory cyclooxygenase (COX-2) signaling for the resolution of inflammation and mitigating inflammation-mediated fibrosis. The aim of this study is to compare the effects of ASA and MMC in an in vitro model of subconjunctival scarring. Glaucoma patient-derived Tenon's capsule fibroblasts (HTCFs) were treated with TGFβ1 (2 ng/mL) plus or minus ASA (1600 μg/ml), or MMC (0.05, 0.1, 0.2 mg/mL). In vitro collagen contraction, MTT, LDH, immunofluorescence, and Western blot assays were performed. To elucidate the mechanistic effects of ASA in TGFβ1-induced HTCFs, liquid chromatography tandem mass spectrometry (LC-MS/MS) was used to identify and measure pro-inflammatory and pro-resolving lipid mediator secretion. ASA was at least as effective as MMC in reducing TGFβ1-induced HTCF-mediated collagen contraction, metabolic activity, and pro-fibrotic protein expression, with less cytotoxicity. Within cytokine-activated HTCFs, ASA significantly impaired secretion of pro-inflammatory lipid mediators prostaglandin E2 and 6-keto-prostaglandin F1α and significantly increased secretion of the pro-resolving mediators 5-hydroxyeicosatetraenoic acid (HETE), 15-HETE and 18-hydroxyeicosapentaenoic acid (HEPE). ASA reduces cytokine-induced myofibroblast transdifferentiation in HTCFs, being non-inferior to MMC in vitro. ASA's effects are associated with a unique lipid mediator expression profile, suggesting that the ASA-induced resolution of inflammation may be a promising strategy to mitigate inflammation-mediated scarring and could offer a novel alternative as a surgical adjuvant.

Therapeutic Effects of Acer palmatum Thumb. Leaf Extract (KIOM-2015E) on Benzalkonium Chloride-Induced Dry Eye in a Mouse Model

We determined the effects of two extracts from Acer palmatum Thumb. leaves (hot water extract KIOM-2015EW and 25% ethanol extract KIOM-2015EE) in a benzalkonium chloride (BAC)-induced dry eye mouse model. Dry eye was induced by 0.2% BAC for 2 weeks, followed by treatment three times (eye drop) or once (oral administration) daily with KIOM-2015E for 2 weeks. Treatment with both KIOM-2015EE and KIOM-2015EW resulted in a marked increase in tear volume production for the 4 days of treatment. The Lissamine Green staining score, TUNEL-positive cells, and inflammatory index were significantly decreased after 2 weeks. Topical KIOM-2015EE administration exhibited a greater improvement in decreasing the ocular surface staining scores, inflammation, dead cells, and increasing tear production in a dose-dependent manner compared with the other groups. Furthermore, KIOM-2015E significantly reduced the phosphorylation of NF-κB, which was activated in the BAC-treated cornea. Topical administration was much more effective than oral administration for KIOM-2015E and KIOM-2015EE was more effective than KIOM-2015EW. Application of KIOM-2015E resulted in clinical improvement, inhibited the inflammatory response, and alleviated signs of dry eye. These results indicate that KIOM-2015E has potential as a therapeutic agent for the clinical treatment of dry eye.

Prospective, Randomized, Fellow Eye-Controlled Study of Postoperative Pain and Inflammation Control with an Intracanalicular Dexamethasone 0.4 mg Ophthalmic Insert Following Small Incision Lenticule Extraction

PURPOSE

To compare postoperative anterior chamber inflammation, pain, and patient preference following small incision lenticule extraction (SMILE) in eyes treated with a dexamethasone 0.4 mg intracanalicular insert (DEX) or topical prednisolone acetate (PRED).

PATIENTS AND METHODS

In this prospective, randomized, fellow eye-controlled trial, 20 patients underwent same-day, bilateral SMILE. One randomly-selected eye of each patient received DEX placed immediately postoperatively, and the fellow eye received topical PRED tapered over 2 weeks. Postoperative evaluations were performed on day 1, week 1, month 1, and month 3. Primary outcomes included postoperative pain, incidence of anterior chamber cell and flare, and patient preference of steroid therapy.

RESULTS

No eyes in either group had any clinically evident cell or flare at any postoperative time point. Mean pain scores (0-10 by subjective report) and incidence of any pain were statistically similar at all postoperative visits. Uncorrected distance visual acuity improved in all eyes, 91% of which achieved 20/25 or better. No eyes lost any lines of corrected distance visual acuity. Three eyes developed a steroid-related rise in intraocular pressure, all of which resolved with 2 of the 3 eyes requiring topical therapy. At 1 week, 1 month, and 3 months, 70%, 65%, and 53% of patients preferred DEX over PRED therapy, respectively.

CONCLUSION

The DEX insert was preferred by more patients and controlled postoperative inflammation and pain comparably to topical PRED in eyes undergoing SMILE. There were no statistically significant differences in visual outcomes between the two groups.

Review of Loteprednol Etabonate 0.5%/Tobramycin 0.3% in the Treatment of Blepharokeratoconjunctivitis

Use of a combination corticosteroid and antibiotic in a single formulation is common in the treatment of ocular inflammatory conditions for which corticosteroid therapy is indicated and there exists a risk of superficial bacterial infection. Loteprednol etabonate (LE) is a corticosteroid engineered to maintain potent anti-inflammatory activity while minimizing the risk of undesirable class effects of corticosteroids, such as elevated intraocular pressure and cataract. Tobramycin is a broad-spectrum aminoglycoside antibiotic that is considered generally safe and well tolerated. An ophthalmic suspension combining LE 0.5% and tobramycin 0.3% (LE/T) is approved in the US and several other countries. Use of a combination therapy increases convenience, which may promote patient adherence. A systematic literature review was conducted to examine the efficacy and safety of LE/T for ocular inflammatory conditions within the scope of its labeled indications. Results of published studies indicate that LE/T is effective in the treatment of blepharokeratoconjunctivitis in adults, with similar efficacy as dexamethasone 0.1%/tobramycin 0.3%, but is associated with a lower risk of clinically significant increases in intraocular pressure as demonstrated in both efficacy and safety studies and studies with healthy volunteers. Furthermore, studies in children with blepharitis or blepharoconjunctivitis indicate LE/T was well tolerated in this population, although efficacy vs vehicle was not demonstrated, potentially due to improvements in all groups overall and/or limited sample size. Separately, tobramycin demonstrated potent in vitro activity against most bacterial species associated with blepharitis. In conclusion, published data demonstrate the utility of LE/T for the treatment of the various clinical manifestations of blepharokeratoconjunctivitis in adults.

Incidence and risk factors for postoperative intraocular pressure response to topical prednisolone eye drops in patients undergoing phacoemulsification

AIM/PURPOSE

To report the incidence, risk factors, and magnitude of steroid response in individuals receiving topical 1% prednisolone acetate eye drops following phacoemulsification surgery MATERIALS AND METHODS: Postoperative IOP of 1118 consecutive patients who had uneventful cataract surgery and used 1% topical prednisolone acetate were studied. Baseline ocular parameters like best-corrected visual acuity, IOP, and slit-lamp examination findings were noted preoperatively and at postoperative day 30. Incidence of postoperative intraocular pressure response to steroid was analyzed and graded as mild, moderate, or severe and risk factors studied.

RESULTS

The mean age of our study cohort was 59.49 ± 7.25 years. The overall incidence of steroid response was 3.2%, (2.8% being moderate responders, and 0.4% high responders). Mean preoperative IOP was 14.67 ± 2.2 mm Hg in the study cohort (n = 1118). Mean postoperative IOP was 21.33 ± 7.97 mm Hg in the steroid responder (SR) and 14.66 ± 2.8 mm Hg in the non-responder (NR), with a statistically significant difference from the baseline IOP in the SR group (p < 0.001) and no difference in the NR. Univariate analysis revealed younger age and high axial length as risk factors but on multiple regression analysis, only younger age < 50 years was found to be a significant risk factor for steroid response.

CONCLUSION

The overall steroid response in this population post-cataract surgery was low with most being moderate responders. Younger age and higher axial length were identified as risk factors for steroid response, and hence this warrants the judicious use of steroids in such individuals.

A Randomized, Controlled, Prospective Study of the Effectiveness and Safety of an Intracanalicular Dexamethasone Ophthalmic Insert (0.4 Mg) for the Treatment of Post-Operative Inflammation in Patients Undergoing Refractive Lens Exchange (RLE)

Purpose

To determine patient preference and treatment outcomes with an intracanalicular dexamethasone (0.4 mg) insert compared to standard steroid drop regimen in the contralateral eye following bilateral RLE surgery.

Methods

This is a prospective, open-label, interventional, randomized, controlled study in 20 subjects who underwent bilateral RLE. Each patient served as their own control with one eye randomized to the intracanalicular insert (Group A) placed at the time of surgery and the contralateral randomized to topical corticosteroid drops (Group B). All eyes received intracameral moxifloxacin at the time of surgery, and post-operatively, topical moxifloxacin QID for one week and topical NSAID daily for four weeks. Post-operative evaluations were performed on Day 1, Week 1, and Week 4–8.

Results

Twenty patients participated. At 4–8 weeks post-operation, 90% of patients evaluated with the COMTOL questionnaire preferred the intracanalicular insert while 10% preferred the topical steroid. Comparative analysis using the visual analog scale showed no difference in pain between the study and control group. No statistical difference was shown in post-operative corneal staining, anterior chamber cell count, anterior chamber flare or intraocular pressure. Mean LogMAR UCVA at 4–8 weeks post-operation was 0.06 (± 0.230) in the study group and 0.065 (± 0.241) in the control group, which was not statistically or clinically different (p > 0.05).

Conclusion

Patients undergoing bilateral RLE expressed a strong preference towards the use of an intracanalicular insert over a topical steroid for post-operative steroid treatment. There was no clinically or statistically significant difference in outcomes, including rate of cystoid macular edema, visual acuity and elevation of intraocular pressure.

National Clinical Trial Number

04549935.

Incidence of steroid response in microinvasive glaucoma surgery with trabecular microbypass stent and ab interno trabeculectomy

OBJECTIVE

To determine the incidence and risk factors for steroid response in patients undergoing combined phacoemulsification cataract extraction (PCE) and microinvasive glaucoma surgery with either trabecular microbypass stent implantation (iStent) or ab interno trabeculectomy (Trabectome).

DESIGN

Retrospective, noncomparative, single-institutional observational chart review.

PARTICIPANTS

Consecutive patients with open-angle glaucoma who underwent PCE with iStent or Trabectome with 3 months of follow-up.

METHODS

Data were collected from patient charts, including pre- and postoperative intraocular pressure (IOP) following application of topical corticosteroid on postoperative visits for at least 3 months. A steroid response was defined as an IOP rise of greater than 5 mm Hg beginning at least 3 days after surgery with no other obvious explanation and with IOP < 20 mm Hg following rapid tapering or withdrawal of the steroid.

RESULTS

A total of 118 eyes from 89 patients, average age of 71.4 ±12.1 years, were included. Overall, a steroid response was seen in 12.7% of eyes (n = 15), and no difference was noted between Trabectome (11.8%) and iStent (13.6%, p = 0.782) eyes. Axial length (AL; p = 0.01), younger age (p = 0.009), traumatic glaucoma (p = 0.004), and normal-tension glaucoma (NTG; p = 0.0048) were significant predictors of steroid response in a multivariate analysis. In eyes with AL ≥ 25 mm, the steroid response rate was 40%, in contrast to eyes with AL < 25 mm, where it was 10.2%.

CONCLUSION

A steroid response develops in approximately 1 in 8 patients undergoing PCE with Trabectome or iStent. Young age, AL > 25 mm, traumatic glaucoma, and NTG were found to be significant predictors of steroid response.

Surgical and Perioperative Considerations for the Treatment of Cataract in Eyes with Glaucoma: A Literature Review

Cataract surgery in the presence of glaucoma poses certain challenges that need to be addressed to offer the maximum benefit without complications. In this paper, we are reviewing the preoperative assessment, surgical options, the planning, and postoperative care. Cataract surgery can help reduce the intraocular pressure alone or combined with MIGS. When performed in patients with glaucoma, it can transiently increase the intraocular pressure and later on decrease the IOP to levels lower than the postoperative. The preoperative IOP and biometric characteristics are the main predictors of the postoperative course of IOP. The combination of cataract surgery with trabeculectomy remains controversial, in terms of best timing of each operation.

Risk factors for open-angle glaucoma and recommendations for glaucoma screening

Open-angle glaucomas are a group of chronic progressive optic nerve neuropathies with a gonioscopic open anterior chamber angle. They are one of the main causes of visual impairment and blindness in industrialized countries. The aim of this article is to discuss and evaluate the epidemiology and risk factors for the development of open-angle glaucoma and to present the screening procedure for open-angle glaucoma according to the recently published S2e guidelines of the Association of the Scientific Medical Societies in Germany (AWMF).

Incidence of and Risk Factors for Steroid Response After Cataract Surgery in Patients With and Without Glaucoma

PRECIS

Steroid response after cataract surgery was more frequent in glaucoma patients than nonglaucoma patients. Longer axial length and more preoperative medications were risk factors for steroid response in glaucoma patients.

PURPOSE

The aim was to evaluate incidence and risk factors for topical steroid response after uneventful cataract surgery in patients with and without glaucoma.

SETTING

Academic glaucoma clinics.

DESIGN

This was a retrospective review.

PARTICIPANTS

Consecutive patients with and without glaucoma and no prior incisional glaucoma surgery undergoing cataract surgery between March 2007 and September 2016. All patients routinely received topical prednisolone acetate 1% postoperatively.

METHODS

Pertinent clinical information was recorded. Steroid response was defined as intraocular pressure >50% above the baseline intraocular pressure measurement, occurring at or after the second postoperative week.

RESULTS

We included 472 eyes of 472 nonglaucoma patients and 191 eyes of 191 glaucoma patients. Ten (2.1%) nonglaucoma eyes and 16 (8.4%) glaucoma eyes were diagnosed as steroid responders (relative risk=3.72; 95% confidence interval: 1.71-8.07; P<0.001). Logistic regression showed that for nonglaucoma, longer axial length (AL) and younger age were associated with a higher incidence of steroid response (P≤0.003), while for glaucoma patients, longer AL and more preoperative medications were associated with steroid response (P≤0.030). An AL ≥26 mm was associated with steroid response for both groups (P≤0.024).

CONCLUSION

Although glaucoma patients were 3.72 times more likely to have steroid response after uneventful cataract surgery, the incidence of steroid response with prednisolone acetate 1% was relatively low after phacoemulsification in both nonglaucoma and glaucoma eyes. Steroid response was associated with longer AL in both groups and with more preoperative medications in glaucoma patients.

Do Levels of Stress Markers Influence the Retinal Nerve Fiber Layer Thickness in Young Adults?

PRECIS

Although mental or emotional stress may result raise in intraocular pressure (IOP) we found weak associations between endogenous stress markers concentrations and retinal nerve fiber layer (RNFL) thickness, thus limited evidence that stress affects retinal ganglion cells integrity.

PURPOSE

Increased exposure to glucocorticoids is linked to elevated IOP, which is a risk factor for glaucoma. We explored the RNFL thickness for changes that may mimic preclinical glaucomatous changes, in relation to the hormonal stress response.

MATERIALS AND METHODS

Young healthy adults (n=863) underwent a Trier Social Stress Test. Endogenous plasma adrenocorticotropic hormone (ACTH) and cortisol were measured for those who provided biological samples, and adrenal sensitivity was calculated. On the basis of cortisol levels before and after the Trier Social Stress Test, participants were categorized into one of 3 stress response types: anticipatory-responders, reactive-responders, and nonresponders. Participants underwent an eye examination that included spectral-domain optical coherence tomography to measure peripapillary RNFL thickness.

RESULTS

Higher levels of ACTH were associated with thinner RNFL globally (P=0.009), and at the inferotemporal (P=0.015), superotemporal (P=0.044), and temporal sectors (P=0.046). Lower adrenal sensitivity was associated with thinner RNFL inferotemporally (P<0.001) and temporally (P=0.037). However, these effect sizes were small; for example, a 10 pg/mL increase in baseline ACTH was associated with only a 3 µm thinner RNFL. RNFL thickness was not associated with plasma cortisol levels and or significantly different between groups of acute stress response patterns.

CONCLUSIONS

Although there was a link between ACTH or adrenal sensitivity and RNFL thickness, this association was weak and its clinical significance is unclear. Despite the close associations between levels of endogenous stress markers and IOP, we found limited evidence of a link to RNFL integrity.

[Risk factors for open-angle glaucoma and recommendations for glaucoma screening]

Open-angle glaucomas are a group of chronic progressive optic nerve neuropathies with a gonioscopic open anterior chamber angle. They are one of the main causes of visual impairment and blindness in industrialized countries. The aim of this article is to discuss and evaluate the epidemiology and risk factors for the development of open-angle glaucoma and to present the screening procedure for open-angle glaucoma according to the recently published S2e guidelines of the Association of the Scientific Medical Societies in Germany (AWMF).

Comparison of 12-Month Outcomes of Kahook Dual Blade Excisional Goniotomy Performed by Attending versus Resident Surgeons

Objective Kahook Dual Blade goniotomy (KDB) has proven effective in lowering intraocular pressure (IOP) and reducing the medication burden in patients with glaucoma. This study compares outcomes up to 12 months postoperatively after KDB combined with phacoemulsification (phaco-KDB) between an ophthalmology attending and residents.

Methods A retrospective analysis was performed on 160 eyes of 113 patients who received a phaco-KDB performed by either an ophthalmology attending or a resident under direct guidance of the attending. Data for each patient was collected preoperatively and at 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively. The primary outcome measure was surgical success, defined as 20% IOP reduction or at least 1 medication reduction at 12 months. The secondary outcome measures included mean IOP and medication reduction at each postoperative time point, adverse events, operating time, and survival time, defined as time to failure to meet the criteria for surgical success or requiring a secondary IOP-lowering procedure.

Results Preoperative mean IOP was comparable between the two groups (p = 0.585), while baseline medications were higher in the attending group (p = 0.040). Rate of successful outcomes was similar in both groups at 12 months (73.3% attending vs. 87.5% residents, p = 0.708). Mean IOP reduction (1.7 vs. 4.3%, p = 0.278) and medication reduction (0.7 vs. 0.6, p = 0.537) also did not differ at 12 months. Presence of adverse events was similar between the groups (21.6 vs. 27.3%, p = 0.938). The survival time was significantly longer in the attending group (356.3 ± 20.2 days vs. 247.1 ± 26.8 days, p = 0.003). Resident cases took ∼10 minutes longer compared with attending cases (p < 0.001).

Conclusion IOP lowering outcomes and rate of adverse events of KDB were similar whether the primary surgeon was an attending or a resident surgeon. The survival time was significantly longer in the attending group, but overall success rate was 77.5% for both groups. This suggests phaco-KDB is an effective procedure that can be safely performed by a trainee under direct supervision of an experienced surgeon.

Risk factors for ocular hypertension after intravitreal dexamethasone implantation in diabetic macular edema

We designed a retrospective observational study to identify factors associated with ocular hypertension [OHTN, defined as intraocular pressure (IOP) > 25 mmHg] after intravitreal dexamethasone (IVD) implantation in diabetic macular edema (DME) patients. We measured IOP monthly after placement of an IVD implant, and identified the trend of IOP, incidence of OHTN, and its associated systemic or ocular factors. On average, IOP was highest at 2 months after IVD implantation. Of 84 DME patients who received an IVD implant, 3 (3.57%) presented with an IOP ≥ 25 mmHg at 1 month after implantation, 6 (7.14%) at 2 months, and 2 (2.38%) at 3 months. Compared with the non-OHTN group, the OHTN group had significantly shorter axial lengths and were younger. Logistic regression analysis revealed that axial length < 23.00 mm and age < 57 years were associated with OHTN occurrence. Patients whose IOP was elevated > 30% or ≥ 20 mmHg at 1 month post-implantation, subsequently developed OHTN with statistical significance. In conclusion, shorter axial length and younger age were associated with OHTN occurrence after IVD implantation. Additionally, identifying levels or trends in IOP at 1 month after the IVD procedure may be helpful in predicting subsequent OHTN occurrence.

Risk factors predicting steroid-induced ocular hypertension after photorefractive keratectomy

PURPOSE

To assess the risk factors contributing to steroid-induced ocular hypertension after photorefractive keratectomy (PRK).

SETTING

Care Laser Centers, Tel Aviv, Israel.

DESIGN

Retrospective case series.

METHODS

Patients having PRK between January 2000 and December 2015 were followed for at least 3 months. Intraocular pressure (IOP) was measured using the Goldmann applanation tonometer after 1 week and after 1, 3, and 6 months. Ocular hypertension was defined as an IOP elevation of 25% while on topical steroid treatment (minimum 28 mm Hg) followed by an IOP drop of 25% when steroid treatment was discontinued.

RESULTS

The study comprised 1783 patients (3566 eyes). The mean age of the patients was 26.95 years ± 7.56 (SD), and 54.85% were men. A total of 106 eyes (2.97%) were steroid responders. The responder group had a higher proportion of men than the nonresponder group (70.75% versus 29.25%; P < .001), higher central corneal thickness (CCT) (531.9 ± 40.2 μm versus 521.2 ± 40.9 μm; P = .008), lower mean keratometry (K) power (43.39 ± 1.84 diopters [D] versus 44.08 ± 1.88 D; P < .001), higher proportion of high myopia (>6.0 D) (31.13% versus 22.18%; P = .03), and higher rate of postoperative corneal haze (16.98% versus 4.25%; P < .001) and were treated postoperatively with more potent steroids. All factors remained significant in the multivariate analysis.

CONCLUSION

Significant factors associated with post-PRK ocular hypertension were male sex, high CCT, a low mean K reading, high myopia, corneal haze, and treatment with stronger steroids such as dexamethasone.

[Pharmacological treatment strategies and surgical options for uveitis]

BACKGROUND

Modern treatment of uveitis aims at a complete control of inflammatory activity, preservation of visual function and the prevention of secondary organ damage as a consequence of the underlying inflammatory disease and its treatment.

OBJECTIVE

This article gives an update about the strategies of pharmacological and surgical options for uveitis.

MATERIAL AND METHODS

The outcomes reported here are based on a PubMed search using the terms <"uveitis" AND "therapy"> and <"uveitis" AND "surgery" OR "surgical treatment">. All prospective studies and case series with more than 20 cases as well as review articles from the last 5 years along with cited cross-references were evaluated.

RESULTS

Local and systemic corticosteroids form the foundation of treatment after exclusion of an infectious etiology. If uveitis activity is not controlled within 6 weeks or if the daily corticosteroid dosage is unacceptably high, a treatment escalation using immunomodulatory drugs is required. If a complete control of inflammatory activity is not achieved, in a third phase treatment is supplemented by antibody-based treatment or cytokines, so-called biologics, with the aim of complete long-term freedom from disease without local or systemic steroid treatment. This target is achieved in 65-80% and guarantees long-term functional stability and anatomical integrity. Early treatment escalation in cases of persisting or recurrent activity as a rule prevents new secondary organ damage. Surgical options are utilized for diagnostic purposes, the administration of intravitreal drugs and for treatment of secondary complications.

CONCLUSION

Just like the majority of immunological diseases, uveitis is a chronic disease requiring long-term and possibly lifelong treatment and remission (absence of inflammation without treatment) is achieved in only <20%. Surgical interventions can be performed with a good prognosis, if the optic nerve head and macula are not involved. They have a substantially lower complication rate when freedom from symptoms exists preoperatively for at least 3 months.

Transzonular Triamcinolone-Moxifloxacin Versus Topical Drops for the Prophylaxis of Postoperative Inflammation After Cataract Surgery

Purpose: To compare the safety and efficacy of an intraoperative transzonular injection of triamcinolone-moxifloxacin (Imprimis' Tri-Moxi 15 mg/1 mg/mL) to topical drops in patients undergoing cataract surgery. Methods: Between January 2017 and October 2017, patients undergoing phacoemulsification cataract surgery by a single surgeon at the Penn State Eye Center were offered a single intraoperative injection of transzonular triamcinolone-moxifloxacin in lieu of perioperative drops. Between November 2017 and July 2018, the transzonular injection was not offered, and all patients who underwent surgery by the same surgeon received a drop regimen consisting of polymyxin b/trimethoprim and prednisolone acetate 1%. Patients were seen 1 day, 1 week, and 6-9 weeks postoperatively. Outcome measures included incidence of intraoperative complications, postoperative breakthrough inflammation, cystoid macular edema, and infectious sequela. Results: Of the 198 eyes, 99 from 73 patients received the injection and 99 from 82 patients received topical drops. One (1%) intraoperative posterior capsule tear occurred in each group. Eleven (11.1%) eyes in the injection group and 3 (3%) in the drop group experienced symptomatic breakthrough inflammation necessitating treatment (P = 0.0488). One (1%) eye in the injection group and zero (0%) in the drop group developed clinically significant macular edema (P = 1.0). No instances of elevated intraocular pressure or infectious sequela occurred in either group (P = 1.0). Conclusions: Transzonular injection of triamcinolone-moxifloxacin may be associated with an increased incidence of breakthrough inflammation compared to topical drops.

Outcome of phacoemulsification combined with excisional goniotomy using the Kahook Dual Blade in severe glaucoma patients at 6 months

Purpose

The aim of this study was to describe 6-month rates of achieving target IOP without requiring additional glaucoma surgery after excisional goniotomy using the Kahook Dual Blade combined with phacoemulsification (phaco-KDB) in patients with severe-stage glaucoma.

Methods

Retrospective review of 42 eyes from 36 patients with severe glaucoma who received phaco-KDB. Primary and secondary open-angle and combined-mechanism glaucoma were included. Preoperative, intraoperative, and postoperative data were collected through the 6-month follow-up period. The primary outcome was proportion of patients achieving IOP ≤15 mmHg without additional glaucoma procedures. Secondary outcomes were mean change in IOP, reduction of glaucoma medications, additional glaucoma procedures needed, and adverse events.

Results

Preoperative baseline mean IOP was 17.1±4.8 mmHg (mean ± SD) and number of medications was 2.4±1.3. At 6 months, 64.3% (27/42) of eyes had achieved IOP ≤15 mmHg without additional glaucoma procedures, 45.2% (19/42) reached this target IOP on fewer medications, and 31.0% (13/42) on no medications. Mean IOP reduction was 2.1±4.67 mmHg (P=0.022) and mean medication reduction was 1.2±1.4 (P≤0.001). Visually significant complications were experienced by 7.1% (3/42) of eyes, and 7.1% (3/42) required additional IOP-lowering procedures within 6 months of surgery.

Conclusion

Patients with severe-stage open-angle glaucoma achieved significant IOP and medication reductions following phaco-KDB. Notably, about two-thirds of eyes achieved an IOP of ≤15 mmHg at 6 months without additional glaucoma procedures. Complications and need for additional procedures were rare. Phaco-KDB may be an effective and safe alternative to more invasive filtering surgery in many patients with severe glaucoma.

Differential effects of dexamethasone and indomethacin on Tenon's capsule fibroblasts: Implications for glaucoma surgery

Dysregulated wound healing and subsequent fibrosis represents the most common cause of failure in glaucoma filtration surgery. Primary means to prevent this outcome are the anti-metabolite surgical adjuvants, however, topical corticosteroids are commonly used postoperatively to permit further control of wound healing and development of the filtration bleb. Unfortunately, they carry important side effects such as raised intraocular pressure, cataract and increased infection risk. Non-steroidal anti-inflammatory drugs (NSAIDs) show promising results in clinical trials as an alternative wound modulatory drug. NSAIDs exhibit non-inferiority to steroids in terms of post-operative intraocular pressure control and secondary IOP lowering interventions, however there is little known about the differing effects these drugs exert on human Tenon's capsule fibroblast (HTCF) mediated wound healing. The purpose of this study was to assess the individual effects of dexamethasone and indomethacin on the extracellular matrix modifying actions of HTCFs in vitro. To this end, HTCFs were cultured in 3D collagen matrices as well as in 2D monolayers and exposed to clinically relevant concentrations of dexamethasone or indomethacin for up to seven days. HTCF-mediated wound healing functions were assayed through collagen matrix contraction, extracellular matrix morphology, estimation of HCTF proliferation and differentiation into myofibroblasts within the collagen matrices, as well as western blot. Both drugs significantly reduced HTCF-mediated collagen contraction relative to control however there was a significant trend towards greater inhibition with indomethacin exposure compared to dexamethasone. Indomethacin exposure significantly reduced HTCF-mediated collagen remodelling activity compared vehicle control, whereas dexamethasone was unable to reduce remodelling activity at any of the studied exposures. Both drugs reduced myofibroblast differentiation, however indomethacin alone demonstrated an inhibitory effect on final cell number relative to control whereas dexamethasone had no significant effect at any studied exposure. These findings demonstrate that both steroidal and NSAID treatment can mitigate HTCF-mediated collagen contraction and αSMA expression. However, NSAIDs may function to better impede HTCF proliferation and remodelling activity. Taken in the context of previous glaucoma surgical trials, NSAIDs appear to be a viable alternative to steroids for post-operative wound modulation.

Early postoperative intraocular pressure elevation following cataract surgery

PURPOSE OF REVIEW

The aim of this review was to assess the risk factors and course of postoperative intraocular pressure (IOP) increase in order to determine the optimal the treatment.

RECENT FINDINGS

Early postoperative IOP elevation following cataract surgery is a frequent adverse event, and might represent 88% early postoperative complications. The risk factors for IOP elevation following phacoemulsification cataract surgery include residual viscoelastic material, resident performed surgery, glaucoma, pseudoexfoliation syndrome, axial length over 25 mm, tamsulosin intake, topical steroid application in steroid responders. A day-1 postoperative follow-up might be questioned, even in glaucoma patients, as in IOP spikes the topmost IOP elevation occurs 3-4 h postoperatively.

SUMMARY

Several IOP-lowering agents have been evaluated, but none has completely prevented the occurrence of IOP spikes. We recommend applying a combination of dorzolamide/timolol and brinzolamide topically in high-risk patients, particularly with preexisting optic nerve damage. Corticosteroid cessation usually results in a reduction of the IOP to normal levels in steroid responders. Additional studies are required to assess the optimal treatment, especially in glaucoma patients.

Comparison between Betamethasone, Fluorometholone and Loteprednol Etabonate on intraocular pressure in patients after keratorefractive surgery

Purpose

The aim of this study was to compare the ocular hypertensive effect of the commercially available Betamethasone, Fluorometholone in Iran and Loteprednol Etabonate in patients undergoing keratorefractive surgery.

Methods

In this prospective randomized clinical trial, 300 eyes of 150 patients were included, and patients were randomly assigned to 3 groups and used one of the 3 steroid drops (Betamethasone 0.1%, Fluorometholone 0.1%, and Loteprednol Etabonate 0.5%) after myopic photorefractive keratectomy (PRK). Intraocular pressure (IOP) was measured 2, 4, and 6 weeks post-surgery. Twenty-two mmHg was set as the threshold IOP for starting anti-glaucoma medication and tapering steroid drops.

Results

Of 300 eyes from 150 patients over the first 6 postoperative weeks, 2 eyes in Fluorometholone group (2%), 12 eyes in Betamethasone group (12%), and 16 eyes in Loteprednol group (16%) had IOP equal or more than 22 mmHg. Analysis of variance (ANOVA) test showed that the rise in IOP was significantly different between groups in the 2nd and 4th (P ≤ 0.001) postoperative weeks but not at 6th week (P = 0.230). An IOP rise equal or more than 10 mmHg was detected in 13 and 15 eyes in Betamethasone and Loteprednol groups, respectively. None of the eyes in Fluorometholone group had such an IOP rise.

Conclusions

Loteprednol and Fluorometholone were associated with the most and least increase in IOP, respectively. The highest pressures were detected 4 weeks after surgery in the Betamethasone and Loteprednol groups and 6 weeks after surgery in the Fluorometholone group. Fluorometholone was the safest among the three examined steroid drops in terms of IOP rise.

Secondary surgical intervention after primary glaucoma filtration surgery: an Ontario population-based study

OBJECTIVE

To identify factors associated with secondary surgical intervention after glaucoma filtration surgery.

DESIGN

Population-based retrospective cohort.

METHODS

Patient records with billing claims for a primary glaucoma filtration surgery occurring between April 2003 and March 2015 were identified. Each identified record was examined for instances of secondary glaucoma surgeries within the patient's first postoperative year. Baseline characteristics of patients who required secondary surgical intervention were compared with those who did not. A multivariable Cox proportional hazards model was used to calculate hazard ratios.

RESULTS

Within a cohort of 10,097 patients, 349 (3.46%) underwent a secondary surgical intervention within the first postoperative year. Interventions were less frequent after surgeries that included an indwelling drainage device (HR=0.58 95% CI, 0.37-0.89), phacoemulsification (HR=0.33, 0.21-0.52), or both (HR=0.09, 0.03-0.31). Patients with preoperative aminoglycoside and mydriatic exposure had significantly increased risk of secondary surgical intervention (HR=3.19, 1.89-5.36) and (HR=2.32, 1.49-3.61). Patients who underwent surgery on their contralateral eye experienced secondary surgical interventions more frequently: 7.44 per 10,000 person-days (versus 1.18 per 10,000 person-days, p < 0.0001). No significant differences in the rates of secondary surgical intervention were observed for patients taking different classes of glaucoma medications or those exposed to higher amounts of benzalkonium chloride.

CONCLUSIONS

In Ontario, the overall rates of secondary surgical interventions in the first postoperative year are low but significantly higher in certain patient populations. Further work is required to address the higher rate of secondary surgical intervention in patients with a history of certain perioperative eye drop medications and those who require sequential-bilateral procedures.

Injectable drug depot engineered to release multiple ophthalmic therapeutic agents with precise time profiles for postoperative treatment following ocular surgery

A multi-drug delivery platform is developed to address current shortcomings of post-operative ocular drug delivery. The sustained biodegradable drug release system is composed of biodegradable polymeric microparticles (MPs) incorporated into a bulk biodegradable hydrogel made from triblock copolymers with poly(ethylene glycol) (PEG) center blocks and hydrophobic biodegradable polyester blocks such as poly(lactide-co-glycolide) (PLGA), Poly(lactic acid) (PLA), or Poly(lactide-co-caprolactone) (PLCL) blocks. This system is engineered to flow as a liquid solution at room temperature for facile injection into the eye and then quickly gel as it warms to physiological body temperatures (approximately 37 °C). The hydrogel acts as an ocular depot that can release three different drug molecules at programmed rates and times to provide optimal release of each species. In this manuscript, the hydrogel is configured to release a broad-spectrum antibiotic, a potent corticosteroid, and an ocular hypotensive, three ophthalmic therapeutic agents that are essential for post-operative management after ocular surgery, each drug released at its own timescale. The delivery platform is designed to mimic current topical application of postoperative ocular formulations, releasing the antibiotic for up to a week, and the corticosteroid and the ocular hypotensive agents for at least a month. Hydrophobic blocks, such as PLCL, were utilized to prolong the release duration of the biomolecules. This system also enables customization by being able to vary the initial drug loading to linearly tune the drug dose released, while maintaining a constant drug release profile over time. This minimally invasive biodegradable multi-drug delivery system is capable of replacing a complex ocular treatment regimen with a simple injection. Such a depot system has the potential to increase patient medication compliance and reduce both the immediate and late term complications following ophthalmic surgery.

STATEMENT OF SIGNIFICANCE

After ocular surgery, patients routinely receive multiple medications including antibiotics, steroids and ocular hypotensives to ensure optimal surgical outcomes. The current standard of care for postoperative treatment after ocular surgery involves using eye drops daily, which has limited effectiveness mainly due to poor patient adherence. To improve patient experience and outcomes, this article presents the first thermoresponsive hydrogel able to release multiple drug molecules for the application of post-operative treatment following ocular surgery. By varying the parameters such as hydrogel type and polymer hydrophobicity, the drug release profile, duration and dosage can finely be tuned. The approach presented in this article can readily be applied to other applications by simply changing the drug loaded in the drug delivery system.

EFFECT OF AN INTRAVITREAL DEXAMETHASONE IMPLANT ON DIABETIC MACULAR EDEMA AFTER CATARACT SURGERY

PURPOSE

To analyze the effects of a dexamethasone intravitreal implant (DEX; Ozurdex 700 μg; Allergan) administered immediately after cataract surgery in diabetic patients.

METHODS

This prospective, single-arm, open label study (NCT01748487 at ClinicalTrials.gov) involved Type 2 diabetic patients with at least mild diabetic retinopathy (DR) who underwent cataract surgery and DEX insertion after phacoemulsification, and intraocular lens implantation were enrolled. Best-corrected visual acuity and central retinal thickness (CRT) measured by spectral-domain optical coherence tomography were recorded at 1 week preoperatively, and 1 week, 1 month, and 3 months after surgery. Adverse events were also recorded.

RESULTS

Twenty-four eyes of 24 patients (17 [70.8%] men; mean age 63.7 ± 8.7 years) with mild nonproliferative DR (41.7%), moderate nonproliferative DR (33.3%), severe nonproliferative DR (16.7%), or treated proliferative DR (8.3%) were selected. After DEX treatment, mean CRT changed from 241.1 μm (95% confidence interval, 227.5-254.6 μm) at baseline to 236.9 μm (95% confidence interval, 223.9-249.9 μm) at 1 week (P = 0.09), 238.9 μm (95% confidence interval, 225.5-252.3 μm) at 1 month (P = 0.44), and 248 μm (95% confidence interval, 232.4-260.8 μm) at 3 months (P = 0.15). No eyes showed a postoperative increase >50 μm in the CRT at any visit. A 10% increase in CRT was found in 8.3% of eyes. Mean best-corrected visual acuity significantly improved from 0.37 (20/50) at baseline to 0.19 (20/30) at 1 week, 0.12 (20/25) at 1 month, and 0.12 (20/25) at 3 months (P < 0.001 for each comparison). Mean intraocular pressure before surgery was 13.8 mmHg, and none of the patients developed an intraocular pressure ≥22 mmHg at any visit. None of the patients developed any serious adverse events during the follow-up.

CONCLUSION

These short-term results suggest that a single DEX injection intraoperatively after phacoemulsification could avoid an increase in CRT after cataract surgery in diabetic patients.

Clinical Applications of Dexamethasone for Aged Eyes

The risk of severe eye problems has been found to increase significantly with age, particularly between the fifth and sixth decades of life. Cataracts, dry eye, neovascular age-related macular degeneration, diabetic retinopathy and retinal vein occlusion (RVO) are very common and very different age-related ocular diseases that reduce the patient's quality of life. The rationale for using corticosteroids to treat anterior and posterior ocular segment diseases is driven by inflammation. Dexamethasone, one of the most powerful corticosteroids available, is widely used for topical or intravitreal administration. Topical dexamethasone has proven efficacy for the management of postoperative inflammation in the anterior segment after cataract surgery and symptom relief in dry-eye disease. A new sustained-release 700 µg dexamethasone intravitreal implant (DEX) was recently approved for the treatment of macular edema following RVO, diabetic macular edema, or non-infectious uveitis, and its use is increasing, especially when other therapeutic agents have failed. The most common side effects are increased intraocular pressure and cataract formation. The potency of DEX, alone or in combination with other agents, makes DEX a promising option for treating several retinal diseases.

Etiology and Management of Raised Intraocular Pressure following Posterior Chamber Phakic Intraocular Lens Implantation in Myopic Eyes

AIM

To evaluate the etiology and management of elevated intraocular pressure (IOP) following posterior chamber phakic implantable collamer lens (ICL) surgery.

METHODS

Between 2009 and 2015, 638 eyes of 359 subjects with refractive myopia, underwent V4b and V4c (CentraFLOW) model ICL implantation. Ocular hypertension (OHT) was defined as IOP of ≥ 22 mm Hg on two separate occasions and elevated IOP with corresponding optic disc or visual field damage was defined as glaucoma.

RESULTS

Elevated IOP ≥ 22 mm Hg was noted in 33 eyes of 30 subjects (33/638; 5.17%). Median age of subjects with raised IOP was 26 years (Inter quartile range (IQR):22, 29) and median refarctive error was -16 diopters (-19.5, -13). The median follow up was 7.8 months (IQR:0.3, 17.6) and median time for postoperative IOP rise was 12 days, (IQR:2, 24). The various etiologies for elevated IOP were steroid response in 21 eyes (64%; 10 eyes with V4b, 11 eyes with V4c), retained viscoelastic in 5 eyes (15%) (3 with V4b, 2 with V4c), pupillary block in four eyes (12%; 3 with V4b, 1 with V4c), malignant glaucoma in one eye (3%, V4b), and missed pre-existing Juvenile open angle glaucoma (JOAG) in two eyes (6% with V4b). Elevated IOP in 31 eyes resolved with conservative management. One eye (centraFLOW design) with central aquaport block by viscoelastic, needed AC wash and one eye with malignant glaucoma needed parsplana vitrectomy and hyaloidotomy. Ten eyes required longterm (>2 months) antiglaucoma medications (AGM) for IOP control. Except the two eyes with JOAG, none had disc and field damage.

CONCLUSION

In our series, OHT was seen in 4.85% and glaucoma in 0.3% eyes that underwent V4b and V4c model ICL implantation. Multiple etiologies were noted and steroid induced ocular hypertension was the most common cause of elevated IOP followed by retained viscoelastic and pupillary block. One third of these eyes required longterm AGM for IOP control.

Sustained-release dexamethasone for the treatment of ocular inflammation and pain after cataract surgery

PURPOSE

To evaluate the safety and efficacy of dexamethasone as a sustained-release drug depot when placed in the canaliculus for the treatment of ocular inflammation and pain in cataract surgery patients.

SETTING

Four private practice sites in the United States.

DESIGN

Multicenter randomized double-masked clinical trial.

METHODS

Patients were randomized (1:1) to receive either the sustained-release dexamethasone or a placebo vehicle punctum plug inserted into the inferior distal canaliculus of the operated eye intraoperatively during cataract surgery. The primary endpoints were the proportions of patients with absence of cells or pain in the anterior chamber at 8 days. Secondary endpoints included cells, flare, pain, and the presence of the device at various timepoints through 30 days.

RESULTS

Approximately one fifth (20.7%) of patients in the sustained-release dexamethasone group had an absence of anterior chamber cells at 8 days compared with 10.0% in the placebo group (P = .1495). A higher proportion of patients in the sustained-release dexamethasone group (79.3%) than in the placebo group (30.0%) had an absence of ocular pain at 8 days (P < .0001) and at all other timepoints (P < .0002). There were significantly higher proportions of patients in the sustained-release dexamethasone group than in the placebo group with an absence of anterior chamber cells, anterior chamber flare, and pain at several timepoints through 30 days (P ≤ .0251).

CONCLUSION

Sustained-release dexamethasone provided elution of drug for up to 1 month after cataract surgery, providing clinically significant reductions in inflammation and pain.

FINANCIAL DISCLOSURE

Dr. Masket is a consultant to and shareholder in Ocular Therapeutix, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Initial Clinical Experience With the CyPass Micro-Stent: Safety and Surgical Outcomes of a Novel Supraciliary Microstent

PURPOSE

To evaluate safety and clinical outcomes of a novel supraciliary device, the CyPass Micro-Stent, for surgical treatment of open-angle glaucoma when implanted in conjunction with cataract surgery.

PATIENTS AND METHODS

Subjects (n=142) with open-angle glaucoma and cataract underwent combined phacoemulsification, with intraocular lens insertion, and microstent implantation into the supraciliary space of study eyes (n=167). Two analysis cohorts were prespecified based upon medicated baseline intraocular pressure (IOP): ≥21 mm Hg (cohort 1, n=65) or <21 mm Hg (cohort 2, n=102). Glaucoma medications were discontinued or tapered at surgery, and restarted at investigator discretion. The main postoperative outcome measures were adverse events, IOP changes, and number of IOP-lowering medications.

RESULTS

Mean±SD follow-up was 294±121 days. No major intraoperative or postoperative complications occurred. Preoperative baseline mean IOP was 20.2±6.0 mm Hg and mean number of IOP-lowering medications was 2.0±1.1. Cohort 1 showed a 35% decrease in mean IOP and a 49% reduction in mean glaucoma medication usage; cohort 2 demonstrated a 75% reduction in mean medication usage while maintaining mean IOP<21 mm Hg. For all eyes, mean IOP at 12 months was 15.9±3.1 mm Hg (14% reduction from baseline). Early and late postoperative IOP elevation occurred in 1.2% and 1.8% of eyes, respectively. Two subjects developed mild transient hyphema, and none exhibited prolonged inflammation, persistent hypotony, or hypotony maculopathy.

CONCLUSIONS

CyPass Micro-Stent implantation, combined with cataract surgery, resulted in minimal complications and reduced IOP and IOP-lowering medication use at 12 months postoperatively.

Impact of the Topical Ophthalmic Corticosteroid Loteprednol Etabonate on Intraocular Pressure

Corticosteroids are a mainstay therapeutic option for the treatment of ocular inflammation. However, safety remains a concern for clinicians, particularly with long-term use. Though highly effective at suppressing inflammatory and allergic responses, topical ophthalmic corticosteroids carry an inherent risk of side effects, including elevated intraocular pressure (IOP), a risk factor for the development of glaucoma. The corticosteroid loteprednol etabonate (LE) contains an ester rather than a ketone at the C-20 position, minimizing the potential for side effects, including IOP elevation. In early pivotal clinical trials of LE ophthalmic suspension for conjunctivitis (allergic, giant papillary), anterior uveitis, and post-operative inflammation, LE had minimal impact on IOP over short-term (<28 days) and long-term (≥28 days) use. Since then, new LE formulations—including a gel, an ointment, and a suspension of LE in combination with tobramycin—have become commercially available. Multiple studies evaluating the safety and efficacy of LE for inflammatory conditions have been reported, including those requiring longer-term treatment such as photorefractive keratectomy, corneal transplantation, and dry eye disease. We review the available published data on the effect of LE on IOP and report on the cumulative incidence of clinically significant IOP elevations (≥10 mm Hg from baseline) with short-term and long-term LE use. In all studies, LE consistently demonstrated a low propensity to elevate IOP, regardless of formulation, dosage regimen, or treatment duration, including in known steroid responders. The cumulative proportion of patients exhibiting clinically significant IOP increases was 0.8% (14/1725 subjects) in studies evaluating short-term LE treatment and 1.5% (21/1386 subjects) in long-term studies. Furthermore, use of LE was associated with significantly lower rates of IOP elevation ≥10 mm Hg as compared to prednisolone acetate or dexamethasone (when used in combination with tobramycin). The cumulative data to date substantiates a favorable IOP-safety profile for LE with both short-term and long-term use.

Loteprednol Etabonate 0.5%/Tobramycin 0.3% Compared with Dexamethasone 0.1%/Tobramycin 0.3% for the Treatment of Blepharitis

PURPOSE

To compare the efficacy of loteprednol etabonate 0.5%/tobramycin 0.3% (LE/T) and dexamethasone 0.1%/tobramycin 0.3% (DM/T) ophthalmic suspensions in reducing select signs of blepharitis.

METHODS

Data were pooled from two studies (one from the USA; one from China) of adults (n = 627) with blepharokeratoconjunctivitis treated with LE/T or DM/T four times daily for 2 weeks (safety population). Efficacy analyses included 495 eyes (247 LE/T, 248 DM/T) with any baseline sign of blepharitis.

RESULTS

At Day 15, the least squares mean change from baseline in composite blepharitis severity was similar between LE/T (-2.86) and DM/T (-2.99) (90% CI for mean treatment difference: -0.35, 0.11). Intraocular pressure (IOP) increases ≥10 mmHg over baseline were reported for 1 US patient (DM/T group) and 19 Chinese patients (6 LE/T; 13 DM/T).

CONCLUSIONS

LE/T was similarly effective in reducing the signs of blepharitis compared with DM/T, but demonstrated a better safety profile with respect to changes in IOP.

Treatment options for advanced keratoconus: A review

Traditionally, the mainstay of treatment for advanced keratoconus (KC) has been either penetrating or deep anterior lamellar keratoplasty (PK or DALK, respectively). The success of both operations, however, has been somewhat tempered by potential difficulties and complications, both intraoperatively and postoperatively. These include suture and wound-healing problems, progression of disease in the recipient rim, allograft reaction, and persistent irregular astigmatism. Taken together, these have been the inspiration for an ongoing search for less troublesome therapeutic alternatives. These include ultraviolet crosslinking and intracorneal ring segments, both of which were originally constrained in their indication exclusively to eyes with mild to moderate disease. More recently, Bowman layer transplantation has been introduced for reversing corneal ectasia in eyes with advanced KC, re-enabling comfortable contact lens wear and permitting PK and DALK to be postponed or avoided entirely. We offer a summary of the current and emerging treatment options for advanced KC, aiming to provide the corneal specialist useful information in selecting the optimal therapy for individual patients.

Perioperative pharmacological management in patients with glaucoma

REVIEẂS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery.

PROPOSED PROTOCOLS

In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery.

CONCLUSIONS

this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.

Reasons for Early Ocular Hypertension after Uneventful Cataract Surgery

Purpose

To discuss the reasons for and measurements of early ocular hypertension after uneventful phacoemulsification and intraocular lens (IOL) implantation.

Methods

This was a retrospective review of patients who had early ocular hypertension after cataract surgery from a single-surgeon practice that medications failed to control or required additional surgery from September 2011 to January 2013.

Results

Of the 1270 eyes that had cataract surgery by one surgeon in our department in 16 months, 12 (9.4‰) eyes of 12 patients met the inclusion criteria. The mean postoperative intraocular pressure (IOP) peak was 41 (range 32-62) mm Hg. The median time of initial onset after cataract surgery was 3.5 days (range 1-60 days). Six eyes had antiglaucoma surgery history. Ahmed valve implantation with mitomycin C (MMC) was applied to 4 eyes. Two eyes underwent 5-fluorouracil needling revision with MMC. The IOP dropped in 3 eyes only in the case that the conventional topical corticosteroid agent was stopped, diagnosed as steroid responders. One eye of a patient with diabetes mellitus (DM) developed pseudophakic pupillary block angle-closure glaucoma due to the plasma glucose fluctuations. The IOP was controlled after Nd:YAG laser iridotomies. Residual cortex caused ocular hypertension in 2 eyes and surgical aspirations were performed. Following monitoring of IOP for 6 to 24 months, all eyes were within the normal range.

Conclusions

Patients with history of glaucoma surgery; high myopia, especially in young age; and DM merit particular observation and treatment for possible IOP elevation following cataract surgery.

Loteprednol etabonate ophthalmic gel 0.5% following cataract surgery: integrated analysis of two clinical studies

INTRODUCTION

We aimed to evaluate the safety and efficacy of loteprednol etabonate (LE) gel 0.5% compared with vehicle in the treatment of postoperative inflammation and pain following cataract surgery, using the integrated analysis of data from two identical, prospective, multicenter, randomized, double-masked, parallel-group, vehicle-controlled trials.

METHODS

Patients with anterior chamber cell (ACC) inflammation ≥ grade 2 (6-15 cells) 1 day post-surgery were randomized to receive 1 or 2 drops of LE gel 0.5% or vehicle 4 times per day instilled in the study eye for 14 days. Primary outcome measures included the proportion of patients with complete resolution of ACC and grade 0 (no) pain on postoperative Day 8. Safety endpoints included adverse events (AEs), changes from baseline in intraocular pressure (IOP) and visual acuity (VA), biomicroscopy, and funduscopy findings. Gel comfort was graded by patients according to drop sensation.

RESULTS

The intent-to-treat population included 813 patients (409 LE gel 0.5% and 404 vehicle). At postoperative Day 8, 30.8% and 15.1% of patients randomized to LE gel 0.5% or vehicle, respectively, had complete resolution of ACC, while 74.3% and 43.8% of patients, respectively, had grade 0 pain (P < 0.001 for both). Tolerability assessments for ocular itching, photophobia, and tearing favored LE gel 0.5% compared with vehicle at different time points beginning at Day 3. Two patients in the LE gel 0.5% group and 1 patient in the vehicle group exhibited a transient treatment-emergent increase in IOP ≥ 10 mmHg. Treatment-related AEs were generally mild to moderate and occurred less frequently with LE gel 0.5% than with vehicle. Reports of treatment-related blurred vision were rare (n = 2, vehicle).

CONCLUSION

LE gel 0.5% was efficacious and well tolerated in the treatment of postoperative pain and inflammation following ocular surgery, with minimal risk of IOP elevation.

De novo ocular hypertension after Descemet stripping endothelial keratoplasty: comparative 3-year incidence, risk factors, and outcomes

OBJECTIVE

To compare the 3-year incidence of de novo ocular hypertension (OHT) after Descemet stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK). For DSAEK, to evaluate predictors for OHT and 2-year outcomes after OHT development.

METHODS

This was a review of the prospective Singapore Corneal Transplant Study at a single tertiary referral center. Consecutive DSAEKs and PKs for Fuchs' endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK) in eyes without pre-existing glaucoma were analyzed. OHT incidence after DSAEK and PK were compared using Kaplan-Meier survival analysis, and OHT risk factors identified using Cox proportional regression. OHT was defined: intraocular pressure (IOP) ≥ 24 mmHg or ≥ 10 mmHg from baseline. Secondary outcomes 2 years after OHT development in DSAEK were rates of glaucoma medical therapy failure, IOP success, graft failure and rejection, and best-spectacle corrected visual acuity (BSCVA).

RESULTS

There were 108 (96.4%) DSAEKs and 216 (96%) PKs. The 1-, 2- and 3-year de novo OHT incidence was not significantly different between DSAEK (36.1%, 47.2%, 47.2%, respectively) and PK (35.7%, 44.9%, 45.8%, respectively; P = 0.914). OHT incidence did not differ in subgroup analyses of multiple clinical variables (P > 0.1). OHT predictors after DSAEK were: fellow eye glaucoma (hazard ratio [HR] 3.20, P = 0.004), age <60 years (HR 2.41, P = 0.016), concurrent goniosynechiolysis (HR 3.29, P = 0.021), post-graft complications or procedures (HR 2.85, P = 0.006). Two years after OHT onset, 29.7% of DSAEKs failed glaucoma medical therapy requiring trabeculectomy. Complete and qualified IOP success was achieved in 23.5% and 76.5%, respectively. Graft failure developed in 9.8% and graft rejection in 5.9%. At 6 months, 1, and 2 years from OHT onset, 86.3%, 88.3%, and 92.1% achieved BSCVA 20/40, respectively.

CONCLUSION

DSAEK and PK have comparable OHT risks. A significant 30% of DSAEK eyes with OHT require filtration surgery. Effective IOP control and good graft and visual outcomes are achieved with treatment.

Intraocular pressure effects of common topical steroids for post-cataract inflammation: are they all the same?

The efficacy of topical corticosteroids as ocular anti-inflammatory agents following cataract surgery is well-documented. They also help to prevent a number of complications associated with post-operative ocular inflammation, including corneal edema and cystoid macular edema. However, topical corticosteroids are associated with side effects, such as increased intraocular pressure (IOP). Indeed, corticosteroid-induced ocular hypertension and the potential for steroid-induced glaucoma remain the leading drawbacks of topical corticosteroid therapy. Some individuals are known to experience a high degree of IOP elevation with low doses or short durations of treatment with topical corticosteroids. Careful monitoring of IOP in such individuals is essential. Few randomized, controlled studies are available on the comparative safety and efficacy of common topical corticosteroids in the treatment of post-operative ocular inflammation. Furthermore, the lack of consistent reporting criteria for clinically significant IOP increases across clinical studies makes meaningful comparisons among corticosteroids difficult. This review aims to examine data from available published studies, including studies in steroid responders, to determine whether topical corticosteroids are the same in terms of their effect on IOP. Early generation corticosteroids, such as dexamethasone and prednisolone, are more likely to result in clinically significant increases in IOP. Newer corticosteroids, such as rimexolone and the retro-metabolically designed corticosteroid, loteprednol etabonate, offer similar anti-inflammatory efficacy to older corticosteroids with less effect on IOP. However, randomized controlled trials of newer corticosteroids are needed. The proportion of patients exhibiting an increase of ≥10 mmHg IOP in clinical studies has emerged as the most clinically relevant parameter for ophthalmologists to consider when deciding on which topical corticosteroid to use.

Iris-fixated phakic intraocular lens implantation after retinal detachment surgery: long-term clinical results

PURPOSE

To assess the efficacy and safety of iris-fixated phakic intraocular lens (pIOL) implantation to correct myopia in eyes with previous retinal detachment (RD) surgery.

SETTING

Department of Ophthalmology, Soonchunhyang University College of Medicine, Seoul, South Korea.

DESIGN

Retrospective case series.

METHODS

Patients having pIOL implantation in both eyes were enrolled. Eyes that had scleral buckling or encircling (RD group) and healthy fellow eyes (non-RD group) were evaluated over a 6-year follow-up. The corrected distance visual acuity (CDVA), endothelial cell density (ECD), intraoperative complications, and long-term complications were safety outcomes. Uncorrected distance visual acuity (UDVA), predictability, and stability of refraction were efficacy outcomes.

RESULTS

The study comprised 34 eyes (17 patients). The mean postoperative CDVA and ECD were not significantly different between groups, and no patient lost CDVA. The rate of transient intraocular pressure spike was significantly higher in the RD group (P=.043). After 3 years and 6 years, the mean postoperative UDVA was 0.06 logMAR ± 0.09 (SD) and 0.08 ± 0.10 logMAR, respectively, in the RD group and 0.04 ± 0.08 logMAR and 0.04 ± 0.09 logMAR, respectively, in the non-RD group (P=.518 and P=.478, respectively). The rate of eyes within ±0.50 diopter of the desired refraction and the postoperative refraction was not significantly different between groups. No eye had vitreoretinal changes requiring secondary surgical intervention.

CONCLUSION

Iris-fixated pIOL implantation corrected the myopic refractive error in patients who had scleral buckling or encircling surgery for RD with a high degree of efficacy, safety, and long-term stability.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.