Ocular hypotony: A comprehensive review

Faster referral and surgical intervention for rhegmatogenous retinal detachment during COVID-19: a comparison of pre- and during-pandemic cases

To investigate the impact of the COVID-19 pandemic on the incidence and clinical characteristics of rhegmatogenous retinal detachment (RRD) patients referred to a high-volume center, Farabi Eye Hospital, Iran. In a retrospective study, all new RRD patients referred to Farabi Eye Hospital between March 2019 and March 2020 (pre-pandemic, Group 1) and March 2020 and March 2021 (post-pandemic, Group 2) were analyzed. The groups were compared based on demographic and clinical data. A total of 375 patients were included (131 pre-pandemic, 244 post-pandemic, and 34 during lockdowns). The during-pandemic group had a shorter referral time (44.97 vs. 76.76 days, p = 0.031) and surgical wait time (4.64 vs. 8.63 days, p < 0.001). No significant differences were found in pre-operative features (etiology, proliferative vitreoretinopathy, break type), surgical procedures, or initial treatment failure rates between the groups. General anesthesia use was significantly higher in the during-pandemic group (81.6% vs. 71.8%, p = 0.029). The COVID-19 pandemic did not significantly alter the demographic, clinical characteristics, or initial surgical outcomes of RRD patients. However, patients were referred and treated more expeditiously during the pandemic. The increased use of general anesthesia requires further investigation.

Treatment options for chronic hypotony: a scoping review protocol

INTRODUCTION

Chronic ocular hypotony (low intraocular pressure (IOP)) is a potentially sight-threatening condition. Although there is some controversy as to what constitutes non-physiological IOP, generally it is accepted as an IOP of 6.5 mm Hg or less, measured on three separate occasions and lasting for at least 3 months. There is a paucity of data in the literature describing the management of this potentially blinding condition. As such, there is no standardised treatment regime available and no consensus on expected visual prognosis.

METHODS AND ANALYSIS

The protocol for this scoping review will follow best practice as outlined by the JBI Scoping Review Methodology Group. This review will employ the population, concept, and context model for synthesis of the review questions. Databases searched will be Ovid Medline, Ovid Embase, The Cochrane Central Register of Controlled Trials, Web of Science and Scopus databases, as well as reference lists of relevant articles and the grey literature. Key concepts identified for conducting the literature search will be 'Ocular hypotony', 'medication' and 'surgery'. Eligibility criteria include all adults undergoing medical or surgical treatment for chronic ocular hypotony. In order to validate this search strategy, we performed a sample search on Ovid Medline from 1946 to February 2024. Following the selection process, a custom form was developed in Microsoft Excel for data charting. We intend to summarise the data using a narrative model, with the study findings grouped based on similarities in the type of treatment and outcomes assessed.

ETHICS AND DISSEMINATION

Ethical approval was not required, as our review will only include published data. We will publish the review in an open-access, peer-reviewed journal and publicise our findings at international meetings.

Combined sewing machine technique cyclopexy With transscleral diode cyclophotocoagulation for complete posttraumatic cyclodialysis

PURPOSE

To describe an alternative technique used in massive post-traumatic cyclodialysis. Classic techniques such as direct cyclopexy are performed ab externo and entail a higher risk of endophthalmitis or ciliary body hemorrhage. Therefore we present a case report using combined sewing machine technique cyclopexy with transscleral diode cyclophotocoagulation for complete post-traumatic cyclodialysis.

PATIENTS

Our patient is a 43-year-old woman who suffered a blunt trauma 9 months ago from an air-bag blunt in a car accident.

METHODS

Technique report.

RESULTS

Two weeks post-surgery, there has been an elevation in intraocular pressure (IOP), and the cyclodialysis has been resolved. Additionally, signs of macular hypotony, such as optic nerve head edema and vascular tortuosity, have disappeared. As anticipated, the disappearance of chorioretinal folds occurred later but has also been observed. Furthermore, the best corrected visual acuity has been improved and the induced hyperopia has been corrected from +5 (-1.75 × 20°) to +1.5 (-1.75 × 20°).

CONCLUSIONS

Combined sewing machine technique cyclopexy with transscleral diode cyclophotocoagulation for complete post-traumatic cyclodialysis could be an alternative surgical improvement to both direct and indirect cyclopexy. It entails fewer complications, such as endophthalmitis, and offers favorable aesthetic outcomes along with enhanced intraoperative visualization.

Association Between Arch-Shaped Hypo-Autofluorescent Lesions Detected Using Fundus Autofluorescence and Postoperative Hypotony

Background: Chorioretinal folds are observed after vitrectomy due to ocular collapse caused by low intraocular pressure. The purpose of this study is to investigate the relationship between the postoperative hypotony, chorioretinal folds, and the fundus autofluorescence (FAF) findings. Methods: Two-hundred-and-seventy consecutive eyes that had undergone 25- or 27-gauge vitrectomy were examined. The associations between the arch-shaped hypo-autofluorescent lesions in the FAF images and the postoperative hypotony with intraocular pressure (IOP) ≤ 4 mmHg were determined on the day after the surgery. Results: Arch-shaped hypo-autofluorescent lesions were seen in 4 of the 270 eyes (1.5%), and hypo-autofluorescence was observed in 3 of 14 hypotonic eyes (18.5%). This was significantly more frequent than in the non-hypotony group (0.4%, p = 0.0004). Optical coherence tomography showed a loss of the ellipsoid zone and retinal pigment epithelial layer in the region of the arch-shaped lesions. None of the arch-shaped hypo-autofluorescent lesions involved the fovea, and the vision recovered in all cases. The hypo-autofluorescent lesions did not disappear during the 4 to 16 month observation period. Conclusions: The postoperative arch-shaped hypo-autofluorescent lesions were associated with postoperative hypotony and RPE damage due to chorioretinal folds. These findings remained even when the IOP was normalized and chorioretinal folds disappeared.

Risk factors for early and late retinal detachment after boston type I keratoprosthesis surgery

PURPOSE

To determine the differential risk factors for retinal detachment (RD) after Boston Type 1 Keratoprosthesis (B1KPro) during the first year after surgery (early RD; ERD) and afterwards (late RD; LRD).

METHODS

Retrospective cohort study of 94 eyes (90 patients) undergoing B1KPro implantation at Centro de Oftalmología Barraquer from June 2006 to July 2022 with a minimum follow-up of one year.

RESULTS

The incidence of RD in the whole sample after B1KPro implantation was 29% (27/94), occurring in 21% of eyes (ERD; 20/94) the first year, and in 7% afterwards (LRD; 7/94). Hypotony was revealed as a significant risk factor for ERD (16/19 = 84%; OR = 14.5, P < 0.0001), together with aphakia (16/20 = 80%; OR = 5.9, P = 0.004), intraocular lens (IOL) removal (4/8 = 50%; OR = 6.2, P = 0.03), previous choroidal detachment (CD; 7/20 = 35%; OR = 35.5, P = 0.001) and previous pars plana vitrectomy (PPV; 15/20 = 75%; OR = 6.6, P = 0.006). Multivariate analysis included hypotony and PPV at any time as variables significantly associated with ERD occurrence. The occurrence of LRD was significantly related to peripheral retinal changes, detected few days before (4/6 = 66%; OR = 65, P < 0.0001).

CONCLUSION

Hypotony emerged as one of the main factors influencing ERD occurrence after B1KPro implantation. Additionally, previous CD, PPV, aphakia, and IOL removal should be considered to estimate the risk of postoperative retinal detachment. In contrast, peripheral retinal changes after B1KPro seem to be significantly related to LRD occurrence. This study reinforces the need for frequent intraocular pressure evaluation, and comprehensive periodic retinal assessment over time.

KEY MESSAGES

What is known Retinal detachment (RD) is a severe complication after Boston Type 1 Keratoprosthesis (B1KPro) implantation, resulting in a permanent reduction of visual acuity in a clinically relevant percentage of eyes. The time of RD occurrence after B1KPro implantation differs in the literature but is reported to be more common within the first year. Previous aphakia, choroidal detachment, or RD repair, intraocular lens removal, vitritis, or history of Nd-YAG laser have been described as risk factors for RD after B1KPro surgery in samples with varying follow-ups.

WHAT IS NEW

Multivariate analysis in the first year after B1KPro surgery showed hypotony and pars plana vitrectomy at any time as significant risk factors for early RD. Late RD cases, occurring after one year following the B1KPro surgery, seem to be significantly related to peripheral retinal changes suffered a few days before loss of visual acuity and RD diagnosis. It is plausible to think that risk factors for RD after B1KPro differ in short and long postoperative times.

Prolonged hypotony maculopathy following uneventful strabismus surgery

Hypotony is a rare postoperative complication of strabismus surgery. Resolution has been reported to occur within 1 month of surgery. Here, we describe the case of a 14-year-old boy with prolonged hypotony maculopathy following uneventful bilateral medial rectus recession. The hypotony resolved without long-term sequela after 7 months of treatment with topical steroids and atropine. Ultrasound biomicroscopy revealed a ciliary body effusion, which we hypothesize was the cause of decreased aqueous humor production and hypotony.

Hypotony Failure Criteria in Glaucoma Surgical Studies and Their Influence on Surgery Success

PURPOSE

Review hypotony failure criteria used in glaucoma surgical outcome studies and evaluate their impact on success rates.

DESIGN

Systematic literature review and application of hypotony failure criteria to 2 retrospective cohorts.

PARTICIPANTS

A total of 934 eyes and 1765 eyes undergoing trabeculectomy and deep sclerectomy (DS) with a median follow-up of 41.4 and 45.4 months, respectively.

METHODS

Literature-based hypotony failure criteria were applied to patient cohorts. Intraocular pressure (IOP)-related success was defined as follows: (A) IOP ≤ 21 mmHg with ≥ 20% IOP reduction; (B) IOP ≤ 18 mmHg with ≥ 20% reduction; (C) IOP ≤ 15 mmHg with ≥ 25% reduction; and (D) IOP ≤ 12 mmHg with ≥ 30% reduction. Failure was defined as IOP exceeding these criteria in 2 consecutive visits > 3 months after surgery, loss of light perception, additional IOP-lowering surgery, or hypotony. Cox regression estimated failure risk for different hypotony criteria, using no hypotony as a reference. Analyses were conducted for each criterion and hypotony type (i.e., numerical [IOP threshold], clinical [clinical manifestations], and mixed [combination of numerical or clinical criteria]).

MAIN OUTCOME MEASURES

Hazard ratio (HR) for failure risk.

RESULTS

Of 2503 studies found, 278 were eligible, with 99 studies (35.6%) lacking hypotony failure criteria. Numerical hypotony was predominant (157 studies [56.5%]). Few studies used clinical hypotony (3 isolated [1.1%]; 19 combined with low IOP [6.8%]). Forty-nine different criteria were found, with IOP < 6 mmHg, IOP < 6 mmHg on ≥ 2 consecutive visits after 3 months, and IOP < 5 mmHg being the most common (41 [14.7%], 38 [13.7%], and 13 [4.7%] studies, respectively). In both cohorts, numerical hypotony posed the highest risk of failure (HR, 1.51-1.21 for criteria A to D; P < 0.001), followed by mixed hypotony (HR, 1.41-1.20 for criteria A to D; P < 0.001), and clinical hypotony (HR, 1.12-1.04; P < 0.001). Failure risk varied greatly with various hypotony definitions, with the HR ranging from 1.02 to 10.79 for trabeculectomy and 1.00 to 8.36 for DS.

CONCLUSIONS

Hypotony failure criteria are highly heterogenous in the glaucoma literature, with few studies focusing on clinical manifestations. Numerical hypotony yields higher failure rates than clinical hypotony and can underestimate glaucoma surgery success rates. Standardizing failure criteria with an emphasis on clinically relevant hypotony manifestations is needed.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Concurrent ciliary body detachment in patients presenting with serous choroidal detachment following glaucoma surgery

PURPOSE

To examine the rate of ciliary body detachment in patients with choroidal detachment following glaucoma surgery and its effect on the clinical course, management, and prognosis.

METHODS

A prospective observational case-series study. Patients with choroidal detachment following glaucoma surgery in 2018-2019 were included. All underwent complete ophthalmological examination and ultrasound biomicroscopy for evaluation of the presence and extent of ciliary body detachment. Follow-up examinations including ultrasound biomicroscopy scans were performed at 1 week, 1 month, 3 months, and 6 months.

RESULTS

Eight patients (8 eyes) were enrolled, 4 male and 4 female, of mean age 72 years (range 60-83). Five patients underwent trabeculectomy with mitomycin C (0.02%), which was combined with phacoemulsification cataract extraction in one; two underwent Ahmed glaucoma valve implantations, and one underwent ab-interno Xen45 gel stent implantation with mitomycin C (0.02%). The mean intraocular pressure was 26.0 ± 7.65 mmHg preoperatively, dropping to 6.9 ± 2.64 mmHg on first postoperative day one. Mean time from surgery to diagnosis of choroidal detachment was 11.6 ± 5.73 days. Ciliary body detachment was identified by ultrasound biomicroscopy in all patients, ranging between one and four quadrants. All patients were treated with topical steroids and cycloplegics; three (37.5%) received oral steroids. No surgical intervention for the choroidal or ciliary body detachments was indicated.

CONCLUSIONS

In this real-world prospective study, concurrent ciliary body detachment was identified in all patients who presented with choroidal detachment following glaucoma surgery. This observation may deepen our understanding of the mechanism underlying the hypotony that is often seen after glaucoma surgery.

Ab Interno Ahmed Glaucoma Valve Plugs In An Eye With Persistent Hypotony

PURPOSE

This case report aims to describe a new method for increasing intraocular pressure (IOP) in patients with acute hypotony resulting from uveitis flare-ups and preexisting glaucoma drainage devices. The temporary glaucoma tube plug method described is effective and safe.

METHODS

This case report presents a 47-year-old female patient with a history of chronic panuveitis and secondary glaucoma, who had 2 previously implanted Ahmed glaucoma valves. The patient developed panuveitis flare-up and persistent hypotony. A novel method of ab interno plugging of the glaucoma tubes using 2-0 prolene suture plugs was performed. Following treatment, the IOP increased successfully and remained within the normal range.

CONCLUSION

The temporary ab interno glaucoma tube plug method effectively increased IOP in a patient with 2 preimplanted Ahmed glaucoma valves with persistent low IOP due to uveitis.

Hypotony in uveitis: an overview of medical and surgical management

Hypotony is a well-recognised, sight-threatening complication of uveitis. It can also be the final common endpoint for a multitude of disease entities. Multiple mechanisms underlie hypotony, and meticulous clinical history alongside ocular phenotyping is necessary for choosing the best intervention and therapeutic management. In this narrative review, a comprehensive overview of medical and surgical treatment options for the management of non-surgically induced hypotony is provided. Management of ocular hypotony relies on the knowledge of the aetiology and mechanisms involved. An understanding of disease trajectory is vital to properly educate patients. Both anatomical and functional outcomes depend on the underlying pathophysiology and choice of treatment.

TREATMENT OF HYPOTONY WITH AN INTRAVITREAL GAS BUBBLE

PURPOSE

To describe a case of successful resolution of severe hypotony and choroidal detachments following nonfiltering glaucoma surgery with an intravitreal injection of C 3 F 8 gas after a poor response to topical steroids and cycloplegia.

METHODS

Retrospective chart review of a case report.

RESULTS

89 year-old male presented with a central retinal vein occlusion, hyphema, vitreous hemorrhage and neovascular glaucoma. After initial intravitreal injection of aflibercept he was treated with pars plana vitrectomy with panretinal photocoagulation and endocyclophotocoagulation to the ciliary body, but he continued to have elevated intraocular pressure. Subsequent external cyclophotocoagulation was performed but severe hypotony with inflammation, choroidal detachments, and corneal edema developed one week later without response to cycloplegic and steroid medications. A therapeutic injection of perfluorpropane (C3F8) gas led to resolution of the hypotony and choroid detachment and long-term maintenance of intraocular pressure.

DISCUSSION/CONCLUSION

An intravitreal gas bubble can be a very useful outpatient procedure to immediately reverse hypotony, resolve choroidal detachment, and decrease associated inflammation. When hypotony does not respond to medical therapy with cycloplegic drops and steroid medications, then an intravitreal gas bubble can rapidly resolve these complications and result in stabilization of intraocular pressure long-term.

A novel predictive model for phthisis bulbi following facial hyaluronic acid cosmetic injection

PURPOSE

To observe long-term prognosis of anterior segment ischemia (ASI) following hyaluronic acid (HA) injection, propose a severity grading system for ASI and a predictive model for phthisis bulbi (PB) based on long-term secretion dysfunction of ciliary process.

METHODS

This is a retrospective case-control study. All enrolled 20 patients were divided into two groups and followed for at least 6 months to observe the formation and transformation characteristics of ASI and long-term prognosis based on the degrees of ciliary function damage.

RESULTS

The severity of ASI following HA injection could be subdivided into 4 grades according to the degrees of ciliary function damage, comprising ASI grades 0, 1, 2 and 3. In 20 patients, ophthalmoplegia at 1-month follow-up, ASI within 1 month, ASI at 1-month follow-up, hypotony within 6 months were all significantly more common in study group than in control group (60% vs. 0%, P = 0.011; 100% vs. 20%, P = 0.001; 100% vs. 0%, P < 0.001; 80% vs. 0%, P = 0.001, respectively). Sensitivity, specificity and the area under the receiver operating characteristic curve (AUC) for predicting subsequent PB at 2-year follow-up through the co-occurrence of ophthalmoplegia at 1-month follow-up and hypotony within 6 months was 100%, 100% and 1.00, respectively.

CONCLUSIONS

The new grading system for ASI and novel predictive model for PB we proposed could predict the long-term prognosis and probability of subsequent PB due to ASI following HA injection through several dynamic assessments within 6 months.

LEVEL OF EVIDENCE

Level IV, observational prognostic study.

Nanofiber-based glaucoma drainage implant improves surgical outcomes by modulating fibroblast behavior

Biomaterials are implanted in millions of individuals worldwide each year. Both naturally derived and synthetic biomaterials induce a foreign body reaction that often culminates in fibrotic encapsulation and reduced functional lifespan. In ophthalmology, glaucoma drainage implants (GDIs) are implanted in the eye to reduce intraocular pressure (IOP) in order to prevent glaucoma progression and vision loss. Despite recent efforts towards miniaturization and surface chemistry modification, clinically available GDIs are susceptible to high rates of fibrosis and surgical failure. Here, we describe the development of synthetic, nanofiber-based GDIs with partially degradable inner cores. We evaluated GDIs with nanofiber or smooth surfaces to investigate the effect of surface topography on implant performance. We observed in vitro that nanofiber surfaces supported fibroblast integration and quiescence, even in the presence of pro-fibrotic signals, compared to smooth surfaces. In rabbit eyes, GDIs with a nanofiber architecture were biocompatible, prevented hypotony, and provided a volumetric aqueous outflow comparable to commercially available GDIs, though with significantly reduced fibrotic encapsulation and expression of key fibrotic markers in the surrounding tissue. We propose that the physical cues provided by the surface of the nanofiber-based GDIs mimic healthy extracellular matrix structure, mitigating fibroblast activation and potentially extending functional GDI lifespan.

Anaesthetic considerations for the surgical management of ocular hypotony in adults

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

Ipilimumab-related uveitis and refractory hypotony with a flat chamber in a trabeculectomized eye with exfoliation glaucoma: A case report

Purpose

Ipilimumab is an immune checkpoint inhibitor that occasionally causes ophthalmic immune-related adverse events (irAEs) such as dry eye, uveitis, and episcleritis. We report a case of ipilimumab-related uveitis and refractory hypotony with a flat anterior chamber (AC) in a trabeculectomized eye with exfoliation glaucoma.

Observation

A 69-year-old man with a history of cataract surgery and trabeculectomy for exfoliation glaucoma in the right eye presented with blurred vision at 2 months after initiation of ipilimumab for metastatic malignant melanoma (day 0). Although no ophthalmic irAEs were observed at the first visit, he developed iritis, vitreous opacity, and choroidal detachment by day 18.As a result of the irAEs, the scheduled course of ipilimumab was canceled and he was instead treated with corticosteroids (eye drops and systemic). The symptoms progressed, and on day 32 visual acuity was light perception, with a flat AC, hypotony maculopathy, and severe choroidal detachment in the right eye. The patient received two AC formations with a viscoelastic substance, but the flat AC and hypotony recurred. Because the effects of the surgeries were temporary, high doses of corticosteroids were administered. AC depth, anterior uveitis, intraocular pressure, and choroidal detachment resolved by day 91.

Conclusions

Ophthalmologists and oncologists should be aware of the rare but severe irAEs, and careful follow-up is required for ophthalmic irAEs caused by ipilimumab, especially in cases with a history of glaucoma surgery.

A portable feedback-controlled pump for monitoring eye outflow facility in conscious rats

Intraocular pressure (IOP) is heavily influenced by the resistance of trabecular outflow pathways through which most of the aqueous humor produced by the eye continuously drains. The standard method of quantifying outflow resistance and other aspects of ocular fluid dynamics is eye cannulation, which allows for direct measurement and manipulation of IOP and flow in animal models. Since the method is invasive, indirect techniques that are slower and less accurate must be used for chronological studies. A novel technology is introduced that can autonomously measure outflow facility in conscious rats multiple times a day. A smart portable micropump infuses fluid into the eye through a permanently-implanted cannula and dynamically adjusts flow rate using a unique proportional feedback algorithm that sets IOP to a target level, even though IOP fluctuates erratically in awake free-moving animals. Pressure-flow data collected by the system from anesthetized rats were validated against intraocular recordings with commercial pressure and flow sensors. System and sensor estimates of outflow facility were indistinguishable, averaging 23 ± 3 nl·min-1·mmHg-1 across animals (n = 11). Pressure-flow data were then collected round-the-clock for several days from conscious rats, while outflow facility was measured every few hours. A significant diurnal facility rhythm was observed in every animal (n = 4), with mean daytime level of 22 ± 10 nl·min-1·mmHg-1 and mean nighttime level of 15 ± 7 nl·min-1·mmHg-1. The rhythm correlated with diurnal changes in IOP and likely contributed prominently to those changes based on the day-night swing in facility magnitude. Hence, the portable smart pump offers a unique tool for repeated long-term monitoring of outflow facility and other possible parameters of ocular health. It could also be useful in animal glaucoma studies for reversibly inducing acute or chronic ocular hypertension without explicitly damaging trabecular outflow pathways.

Successive trabecular meshwork photocoagulation in the treatment and prevention of refractory hypotony

PURPOSE

To evaluate the effect of successive trabecular meshwork photocoagulation (sTMP) on the elevation of intraocular pressure (IOP) to treat or prevent refractory hypotony.

METHODS

The IOP changes of 15 refractory hypotonic eyes (or estimated to be hypotonic after silicon oil removal) in 15 consecutive patients were retrospectively analysed after sTMP. Fourteen eyes had intraocular silicone oil that was to be removed. Different lasers were used to destroy the trabecular meshwork 1-5 times (2.00±1.20 times on average) via the gonioscope or endoscope. Twelve eyes had a large area of exposed retinal pigment epithelium due to a large area of retinecotomy, one eye had a severe cyclitic scar, and two eyes had both a scar and a retinal defect.

RESULTS

After sTMP (1 to 125 months of follow-up, 22.87 ± 38.88 months), the average IOP in the 15 eyes was 11.70 ± 3.19mmHg (n = 15), significantly higher than the value before sTMP (8.26 ± 1.93 mmHg, P < 0.05). The IOP of the 15 eyes increased by 3.44 ± 2.61 mmHg, Eight eyes with an IOP of less than 10 mmHg before sTMP showed an IOP ≥10 mmHg after sTMP. Following sTMP, the silicone oil was removed from six eyes, and one of these eyes suffered a retinal detachment.

CONCLUSION

sTMP can significantly increase the IOP with a long-lasting effect and provide an opportunity for the removal of silicone oil despite large-area retinal defects or cyclitic scars in selected eyes.

Peripheral Circumferential Retinal Detachment after Pars Plana Vitrectomy: Complications and Management

Purpose: This study aimed to evaluate treatment outcomes and complications of peripheral circumferential retinal detachment (PCD) after successful vitrectomy. Methods: Eyes diagnosed with PCD after pars plana vitrectomy (PPV) were retrospectively reviewed. The patient demographic data, complications, management, and treatment outcomes were collected and analyzed. Results: The mean follow-up duration was 18.0 ± 11.9 months. BCVA ranged from light perception to 0.1 (median: counting fingers at 40 cm). Major complications included rubeosis iridis (seven eyes), vitreous hemorrhage (five eyes), hyphema (five eyes), corneal decompensation (three eyes), hypotony (two eyes), and neovascular glaucoma (two eyes). All eyes underwent peripheral retinectomy to remove the detached retina and release traction. Complete retinal reattachment was achieved in all eyes. The final BCVA ranged from hand motion to 0.1 (median: counting fingers at 30 cm). Conclusion: PCD may be associated with delayed-onset complications, causing severe loss of vision. Proper management, including peripheral retinectomy, may preserve visual function.

Trabeculectomy With Antimetabolite Agents for Normal Tension Glaucoma: A Systematic Review and Meta-Analysis

Background

Evidence regarding the impact on visual field (VF), intraocular pressure (IOP), and antiglaucoma medications from trabeculectomy with antimetabolites for normal tension glaucoma (NTG) is conflicting because of insufficient study sample sizes. The aim of this study is to systematically assess VF progression rate, IOP control and antiglaucoma medication use after trabeculectomy with antimetabolites for progressing NTG.

Methods

We searched published articles on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from database inception to March 21, 2022. We selected studies that reported VF data before and after trabeculectomy with antimetabolite agents for NTG. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. Data were extracted by 2 independent reviewers, and a random-effects model was employed for the meta-analysis. Study outcomes were VF progression rates measured using the pooled mean deviation (MD) slope, changes in antiglaucoma medications, and IOP. Subgroup analyses of the MD slope according to mean age (over or under 65 years), baseline MD (over or under –12 dB), and baseline IOP (over or under 15 mmHg) were performed to determine the results’ robustness.

Results

We included 7 retrospective observational studies (Japan: 6 studies, United States: 1 study) comprising a total of 166 eyes. Mean preoperative VF MD slopes ranged from –0.52 to –1.05 dB/year. The meta-analysis demonstrated significant MD slope improvement after trabeculectomy (pooled mean difference: 0.54 dB/year, 95% CI: 0.40 to 0.67, I² = 9%). Mean age, baseline MD, and baseline IOP subgroup analyses revealed MD slope results were consistent with those of the main analyses. The mean IOP (pooled mean difference: –5.54 mmHg, 95% CI: –6.02 to –5.06, I² = 0%) and mean number of antiglaucoma medications (pooled mean difference: –1.75, 95% CI: –2.97 to –0.53, I² = 98%) significantly decreased after trabeculectomy. The most frequently reported early complications after trabeculectomy were hypotony, hyphema, and shallow anterior chamber.

Conclusion

This systematic review and meta-analysis indicated that trabeculectomy with antimetabolites is beneficial for progressing NTG; it preserves visual function by alleviating the MD slope and reducing antiglaucoma medication use. However, several post-trabeculectomy complications should be monitored.

Biomarkers as Predictive Factors of Anti-VEGF Response

Age-related macular degeneration is the main cause of irreversible vision in developed countries, and intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections are the current gold standard treatment today. Although anti-VEGF treatment results in important improvements in the course of this disease, there is a considerable number of patients not responding to the standardized protocols. The knowledge of how a patient will respond or how frequently retreatment might be required would be vital in planning treatment schedules, saving both resource utilization and financial costs, but today, there is not an ideal biomarker to use as a predictive response to ranibizumab therapy. Whole blood and blood mononuclear cells are the samples most studied; however, few reports are available on other important biofluid samples for studying this disease, such as aqueous humor. Moreover, the great majority of studies carried out to date were focused on the search for SNPs in genes related to AMD risk factors, but miRNAs, proteomic and metabolomics studies have rarely been conducted in anti-VEGF-treated samples. Here, we propose that genomic, proteomic and/or metabolomic markers could be used not alone but in combination with other methods, such as specific clinic characteristics, to identify patients with a poor response to anti-VEGF treatment to establish patient-specific treatment plans.

Management of cyclodialysis cleft with transscleral cryotherapy

A cyclodialysis cleft is a rare disease that is produced as a result of a separation of the longitudinal fibers of the ciliary body muscle from the scleral spur. A stepwise approach is the best course of action to treat cyclodialysis, starting with medical therapy and continuing with more invasive surgical options. We report a case of ocular hypotony due a traumatic cyclodialysis successfully resolved with transscleral cryotherapy.

Effect of Different Preoperative Intraocular Pressures on the Prognosis of Traumatic Cyclodialysis Cleft Associated with Lens Subluxation

Purpose

To evaluate the prognosis of patients with blunt trauma-mediated cyclodialysis cleft and lens subluxation treated by dual capsular tension rings (CTRs) with different preoperative intraocular pressures (IOPs).

Methods

Twenty-five patients with cyclodialysis cleft and lens subluxation after blunt trauma were recruited in this study. They were categorized into the low IOP group (IOP < 10 mmHg) and normal IOP group (between 10 mm and 21 mmHg). A modified CTR (MCTR) or CTR was sutured into the ciliary sulcus, and another MCTR or CTR was implanted in the capsular bag. The prognosis outcome measurements, including BCVA (LogMAR), IOP, UBM, and macular character on OCT, were collected during the regular outpatient follow-up after surgery until the recovery of cyclodialysis cleft was found. Measures of cyclodialysis cleft recovery included successful IOP control (defined as an IOP within 10–21 mmHg), confirmation of cleft closure on UBM, and confirmation of IOL centration under slit-lamp examination. Follow-up period or recovery time was regarded as the duration between discharge from the hospital after the operation and the recovery of cyclodialysis cleft. The longest follow-up period was 1 year.

Results

Cyclodialysis cleft was successfully treated in 21/25 eyes, whereas lens subluxation was treated effectively in all 25 eyes. CTRs and IOLs were stable in all eyes. BCVA (P < 0.001) and IOP (P < 0.001) were significantly improved after surgery. The primary surgical complication included reversible IOP spike in seven eyes. Postoperative BCVA was found to have correlation with the preoperative IOP (P = 0.016), maculopathy (P = 0.002,), and trauma duration (P = 0.046). Worse BCVA (P = 0.037) and more severe grade of maculopathy (P = 0.030) were observed in the low IOP group (14 eyes). In contrast, a better prognosis and greater probability of IOP spike (P = 0.021) were observed in the normal IOP group (11 eyes).

Conclusion

Timely and proper intervention for traumatic cyclodialysis cleft associated with lens subluxation is essential. Lower preoperative IOP is associated with worse prognosis and prolonged recovery time, while caution should be taken in IOP spike monitoring in patients with normal preoperative IOP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00468-0.

Risk Factors for Corneal Striae in Eyes After Glaucoma Surgery

PRCIS

Eyes with corneal striae had steeper cornea, induced astigmatism, and higher corneal hysteresis (CH), which implies a relationship between striae, corneal shape, and the cornea's resistance to deformation at low intraocular pressures (IOPs).

BACKGROUND

Anterior corneal striae (ACS) are associated with low IOP. However, the clinical significance of ACS is unclear. Here, we aim to evaluate differences in eyes with striae compared with eyes without striae.

METHODS

Adults with ACS (cases) and without ACS (controls) ≥8 weeks after glaucoma surgery with an IOP ≤10 mm Hg were enrolled. Optical coherence tomography and optical biometry were performed. CH, defined as the difference in pressure between corneal indentation and reformation in response to an air jet, was obtained by the ocular response analyzer. Hypotony maculopathy (HM) was defined as optic disc swelling, vascular tortuosity attributed to hypotony, or clinical presence of chorioretinal folds confirmed on OCT.

RESULTS

One hundred sixteen eyes (76 cases, 40 controls) were included. Cases had a lower IOP compared with controls (6.5±2.3 vs. 8.5±1, P<0.0001). A 1 mm Hg increase in CH increased ACS odds [odds ratio (OR)=1.51, P=0.01]. A 1 D increase in the flattest presurgical and postsurgical corneal power increased ACS odds by 1.83 (P=0.01) and 1.41 (P=0.02), respectively. Astigmatism increased in eyes with ACS by 1.11 D (P<0.001). ACS odds were increased with every 1 minute increase in mitomycin-C duration (OR=1.58, P=0.047) and decreased with the use of topical glaucoma medication (OR=0.62, P=0.03). Visual acuity decreased from logarithm of the minimal angle of resolution 0.22 (20/33 Snellen) presurgery to 0.28 (20/38) postsurgery (P=0.008), independent of ACS. HM occurred in 19% of cases (P=0.05). A higher postsurgical CH increased HM odds (OR=1.8, P=0.003). HM predicted a 0.41 mm decrease in axial length (P<0.0001), independent of IOP.

CONCLUSION

ACS were associated with a steeper cornea, induced astigmatism, and higher CH, suggesting a relationship between striae, corneal shape, and the cornea's ability to resist deformations at lower IOP. CH, HM, and axial length shortening were associated independently of IOP.

Corneal epithelial defects following vitreoretinal surgery: incidence and outcomes from the DISCOVER study

AIM

To investigate the incidence, risk factors, clinical course, and outcomes of corneal epithelial defects (CED) following vitreoretinal surgery in a prospective study setting.

METHODS

This was a post-hoc analysis of all participants in DISCOVER intraoperative optical coherence tomography study. Subjects with CED 1d after surgery without intraoperative corneal debridement was defined as the postoperative CED group. Subjects who underwent intraoperative debridement were defined as intraoperative debridement group. Eyes were matched 2:1 with controls (eyes without postoperative CED) for comparative assessment. The primary outcomes were the incidence of CED on postoperative day one and the incidence of required intraoperative debridement. Secondary outcomes included time to defect closure, delayed healing (>2wk), visual acuity (VA) and presence of scarring at one year and cornea consult.

RESULTS

This study included 856 eyes that underwent vitreoretinal surgery. Intraoperative corneal debridement was performed to 61 (7.1%) subjects and postoperative CED developed spontaneously in 94 (11.0%) subjects. Significant factors associated with postoperative CED included prolonged surgical duration (P=0.003), diabetes mellitus (P=0.04), postoperative ocular hypotension (P<0.001). Prolonged surgical duration was associated with intraoperative debridement. Delayed defect closure time (>2wk) was associated with corneal scar formation at the end of the 1y in all epithelial defect subjects (P<0.001). The overall rate of corneal scarring for all eyes undergoing vitrectomy was 1.8%.

CONCLUSION

Prolonged duration of surgery is the strongest factor associated with both intraoperative debridement and spontaneous postoperative CED. Delayed defect closure is associated with a greater risk of corneal scarring at one year. The overall rate of corneal scarring following vitrectomy is low at <2%.

Unilateral Isolated Paucisymptomatic Optic Disc Edema

BACKGROUND

Unilateral isolated optic disc edema (UIODE) represents a challenging clinical presentation that frequently precipitates an extensive diagnostic work-up. Patients without an apparent diagnosis despite appropriate investigations are often categorized as having "papillophlebitis," an entity that is poorly defined in the existing literature. Our aim was to describe the characteristics of a series of patients with paucisymptomatic UIODE, determine the optimal diagnostic approach to such cases, and clarify the clinical features of presumed papillophlebitis.

METHODS

We retrospectively identified 29 patients with UIODE who were seen by neuro-ophthalmologists at a single center between 2005 and 2019. Each patient presented with isolated, unilateral disc edema that was either entirely asymptomatic or associated with minimal visual symptoms. Patients underwent a comprehensive neuro-ophthalmic evaluation and several ophthalmic and systemic investigations. Data from the initial visit and all subsequent clinical visits were collected, including patient demographics, examination findings, and details of the diagnostic work-up.

RESULTS

Our 29 patients with UIODE were found to have a variety of underlying diagnoses including unilateral papilledema due to idiopathic intracranial hypertension (10 patients), optic nerve sheath meningioma (5), incipient nonarteritic anterior ischemic neuropathy (4), vitreopapillary traction (3), orbital masses (2), a peripapillary choroidal neovascular membrane (1), and presumed papillophlebitis (4). The duration of disc edema varied considerably based on the etiology, but most patients had favorable visual outcomes.

CONCLUSIONS

A systematic approach to the evaluation of UIODE, combined with long-term follow-up, led to a definite diagnosis in a majority of patients, with only 4 patients presumed to have papillophlebitis, a diagnosis the actual existence of which remains controversial.

Descemet Membrane Endothelial Keratoplasty in Eyes With Chronic Ocular Hypotony Following Glaucoma Surgery

PURPOSE

To assess the outcomes of Descemet membrane endothelial keratoplasty (DMEK) in patients with ocular hypotony after glaucoma surgery.

DESIGN

retrospective case series.

METHODS

Setting: Multicenter retrospective case series.

PATIENTS/INTERVENTION

Hypotonic eyes with prior glaucoma surgery that underwent DMEK between January 2013 and July 2019 in Israel (2 centers) and Canada (1 center).

MAIN OUTCOME MEASURES

Pre/postoperative corrected distance visual acuity, complications, 3- to 6-month endothelial cell loss, and intraocular pressure (IOP).

RESULTS

The study included 11 DMEK procedures performed in 10 eyes of 4 males and 6 females aged 65-84 years. Indications for DMEK included 7 cases of pseudophakic bullous keratopathy, 2 cases of failed DMEK, and 1 case of failed Descemet stripping automated endothelial keratoplasty. All patients had at least 1 previous trabeculectomy operation. One patient had 2 trabeculectomy procedures and 1 tube placement procedure. Two patients had 1 previous trabeculectomy and 1 tube placement procedure. The corrected distance visual acuity improved significantly from 1.52 ± 0.68 logarithm of minimal angle of resolution preoperatively to 0.49 ± 0.32 logarithm of minimal angle of resolution 3 months postoperatively (P < .001). Rebubbling occurred in 3 of 11 procedures (27%). Endothelial cell loss 6-12 months postoperatively was 60% ± 16% (range, 41%-89%). At the last follow-up visit, 6 of 11 (54%) of the grafts were clear. The remaining 5 grafts failed at 1-4 years postoperatively. The preoperative IOP was 5.1 ± 1.6 mm Hg (range, 1-7 mm Hg). In all but one patient, the postoperative IOP did not increase to more than 13 mm Hg. In 2 cases, the IOP decreased from 5 and 7 mm Hg preoperatively to 1 mm Hg 1 year postoperatively.

CONCLUSION

DMEK is a valid procedure for the treatment of corneal edema in hypotonic eyes after glaucoma procedures. These eyes benefit from improvement in vision after DMEK.

Hypotony Following Intravitreal Silicone Oil Removal in a Patient With a Complex Retinal Detachment With Giant Retinal Tear

Postoperative ocular hypotony after silicone oil removal in complex cases of retinal detachment is a complication that can occur in about 20% of cases and can prevent the successful management of retinal detachments. Thus, it is critical to understand the mechanisms of hypotony and the potential interventions that can be done in order to avoid irreversible tissue damage. We present a case of a 35-year-old man who underwent intraocular surgery for removal of silicone oil tamponade following a combined scleral buckling and pars plana vitrectomy (PPV) surgery for a rhegmatogenous retinal detachment associated with a giant retinal tear. On Day 1 after the operation, the patient was found to have hypotony with optic disc edema, chorioretinal folds, and visual acuity of ‘hand movement’ perception. Two weeks postop, the patient’s condition stabilized, with a visual acuity of 0.38 logMAR, an intraocular pressure (IOP) of 12 mmHg, and the absence of macular edema.

Globe Subluxation After Proning in a Coronavirus Disease 2019 Patient

A 79-year-old male was hospitalized for respiratory failure secondary to coronavirus disease 2019 pneumonia. Approximately 6 hours after initiating proning, left globe subluxation with darkening of the superior sclera consistent with tache noir was noted. The left globe was thought to be hypotonus secondary to ciliary body shut down after a prolonged period of high intraocular pressure. The globe was reduced in the supine position with gentle traction of the eyelids. Over the next 24 hours, the left intraocular pressure improved to 10 mm Hg, and the tache-noir de la sclérotique resolved. The authors report the first known case of globe subluxation secondary to proning.

Lymphatics in Eye Fluid Homeostasis: Minor Contributors or Significant Actors?

Lymphatic vessels exert major effects on the maintenance of interstitial fluid homeostasis, immune cell trafficking, lipid absorption, tumor progression and metastasis. Recently, novel functional roles for the lymphatic vasculature have emerged, which can be associated with pathological situations. Among them, lymphatics have been proposed to participate in eye aqueous humor drainage, with potential consequences on intraocular pressure, a main risk factor for progression of glaucoma disease. In this review, after the description of eye fluid dynamics, we provide an update on the data concerning the distribution of ocular lymphatics. Particular attention is given to the results of investigations allowing the three dimensional visualization of the ocular surface vasculature, and to the molecular mechanisms that have been characterized to regulate ocular lymphatic vessel development. The studies concerning the potential role of lymphatics in aqueous humor outflow are reported and discussed. We also considered the novel studies mentioning the existence of an ocular glymphatic system which may have, in connection with lymphatics, important repercussions in retinal clearance and in diseases affecting the eye posterior segment. Some remaining unsolved questions and new directions to explore are proposed to improve the knowledge about both lymphatic and glymphatic system interactions with eye fluid homeostasis.

Optic Disc Edema and Posterior Globe Flattening Secondary to Ocular Hypotony: Case Report and Discussion Regarding Pathophysiology and Clinical Findings

ABSTRACT

We describe a case of a young female patient presenting with ocular hypotension (4 mm Hg) secondary to cyclodialysis, and optic disc edema (ODE) after a blunt trauma in the right eye (right eye). MRI showed posterior globe flattening of the right eye, drawing our attention to the pathophysiology behind these findings. The combination of ODE and posterior globe flattening, as observed in the present case of ocular hypotony, is known from other conditions such as intracranial hypertension and space-flight neuro-ocular syndrome, pointing to a common pathophysiological mechanism, possibly resulting from axoplasmic stasis at the level of the lamina cribrosa due to a high translaminar pressure difference.

COMPARING VITRECTOMY, SILICONE OIL ENDOTAMPONADE WITH/WITHOUT CYCLOPEXY TO TREAT CYCLODIALYSIS CLEFTS WITH SEVERE OCULAR TRAUMA

PURPOSE

Comparing the anatomical and functional outcomes of vitrectomy, silicone oil endotamponade without cyclopexy (VEWOC) and with cyclopexy (VEWC) in patients with traumatic cyclodialysis clefts and severe ocular comorbidities.

METHODS

A total of 55 patients (55 eyes) with traumatic cyclodialysis clefts were divided into VEWOC and VEWC groups according to the surgery undergone. Besides the cyclodialysis clefts, all study eyes had one or more additional conditions caused by severe ocular trauma: cataract, lens dislocation, vitreous hemorrhage, retinal detachment, choroidal detachment, maculopathy, suprachoroidal hemorrhage, subretinal hemorrhage, or proliferative vitreoretinopathy. The minimum postoperative follow-up period for all patients was six months. The main measures of outcome were rate of successful anatomical repair, intraocular pressure, and best-corrected visual acuity.

RESULTS

Both the VEWOC group (33 eyes) and the VEWC group (22 eyes) showed significant improvement in postoperative best-corrected visual acuity and intraocular pressure at the final follow-up. The groups had no significant differences in terms of anatomical success rates (VEWOC 29/33 vs. VEWC 20/22, P = 1.000), final best-corrected visual acuity (VEWOC 1.60 ± 0.76 [median Snellen acuity: counting fingers, range: light perception to 20/20] vs. VEWC 1.46 ± 0.66 [median Snellen acuity: 20/800, range: light perception to 20/32], P = 0.485), and final intraocular pressure (VEWOC 13.40 [8.20-17.80] vs. VEWC 11.40 [6.65-14.00] mmHg, P = 0.311). However, the intraocular pressure on postoperative Day 1 was significantly different between the groups (VEWOC 10.40 [6.40-14.60] vs. VEWC 6.40 [4.70-7.98] mmHg, P = 0.002).

CONCLUSION

This study showed that both surgical approaches were equally effective in treating cyclodialysis clefts secondary to severe ocular trauma. Therefore, it may be unnecessary to perform cyclopexy in addition to the vitrectomy procedure in such cases.

Ocular Hypotension and Epiretinal Membrane as Risk Factors for Visual Deterioration Following Glaucoma Filtering Surgery

PRECIS

Postsurgical hypotension at 1 week and the presence of an epiretinal membrane (ERM) were significant risk factors for the deterioration of postsurgical visual acuity (VA) at 3 and 12 months, respectively.

PURPOSE

The purpose of this study was to assess the effects of an ERM and postsurgical hypotension <6 mm Hg at 1 week on postsurgical VA loss.

PATIENTS AND METHODS

A total of 69 patients (69 eyes) who underwent trabeculectomy with adjunctive mitomycin C between 2017 and 2019 (mean follow-up period: 22.8 mo) were enrolled, and 14 parameters that could be associated with the deterioration of VA at 3 and 12 months were studied.

RESULTS

There was a significant association between VA loss at 3 months and postsurgical intraocular pressure at 1 week (P=0.006 by multiple regression) and hypotony maculopathy (P=0.024 by Fisher exact test). However, this association was lost at 12 months. Instead of postsurgical hypotension, the presence of an ERM was significantly associated with VA loss at 12 months (P=0.035 by Fisher exact test, and P=0.023 by logistic regression).

CONCLUSIONS

Postsurgical hypotension at 1 week was significantly associated with mid-term, but not long-term, postsurgical VA loss. The presence of an ERM, which was not a risk factor for mid-term acuity loss, was a significant risk factor for VA loss at 12 months.

Management of cyclodialysis cleft with transscleral cryotherapy

A cyclodialysis cleft is a rare disease that is produced as a result of a separation of the longitudinal fibers of the ciliary body muscle from the scleral spur. A stepwise approach is the best course of action to treat cyclodialysis, starting with medical therapy and continuing with more invasive surgical options. We report a case of ocular hypotony due a traumatic cyclodialysis successfully resolved with transscleral cryotherapy.

Novel Drug Delivery Systems Fighting Glaucoma: Formulation Obstacles and Solutions

Glaucoma is considered to be one of the biggest health problems in the world. It is the main cause of preventable blindness due to its asymptomatic nature in the early stages on the one hand and patients' non-adherence on the other. There are several approaches in glaucoma treatment, whereby this has to be individually designed for each patient. The first-line treatment is medication therapy. However, taking into account numerous disadvantages of conventional ophthalmic dosage forms, intensive work has been carried out on the development of novel drug delivery systems for glaucoma. This review aims to provide an overview of formulation solutions and strategies in the development of in situ gel systems, nanosystems, ocular inserts, contact lenses, collagen corneal shields, ocular implants, microneedles, and iontophoretic devices. The results of studies confirming the effectiveness of the aforementioned drug delivery systems were also briefly presented.

Acute Bilateral Uveitis, Hypotony, and Cataracts Associated with Ipilimumab and Nivolumab Therapy: Optical Coherence Tomography Angiography Findings

Immune checkpoint inhibitors are increasingly being used for the treatment of several malignancies. In rare cases, patients develop disabling ophthalmic side effects such as dry eyes, episcleritis, keratitis, uveitis, inflammatory orbitopathy, myasthenia gravis, macular edema, and serous retinal detachment. We present a case of acute bilateral anterior uveitis, prolonged hypotony, and cataracts following the use of dual therapy ipilimumab and nivolumab. Physicians should be aware of these immune-mediated ocular adverse events and should have a management plan to deal with these side effects that range from mild to vision threatening.

Aqueous humour outflow imaging: seeing is believing

Elevated intraocular pressure (IOP) is the primary risk factor for blindness in glaucoma. IOP is determined by many factors including aqueous humour production and aqueous humour outflow (AHO), where AHO disturbance represents the primary cause of increased IOP. With the recent development of new IOP lowering drugs and Minimally Invasive Glaucoma Surgeries (MIGS), renewed interest has arisen in shedding light on not only how but where AHO is occurring for the trabecular/conventional, uveoscleral/unconventional, and subconjunctival outflow pathways. Historical studies critical to understanding outflow anatomy will be presented, leading to the development of modern imaging methods. New biological behaviours uncovered by modern imaging methods will be discussed with relevance to glaucoma therapies emphasized.

Vitrectomy with Air Endotamponade for Traumatic Cyclodialysis

Background

Various techniques have been described for repairing cyclodialysis clefts, but there is no consensus regarding the optimal treatment. This study investigated the clinical efficacy of a novel surgical approach that is used to manage traumatic cyclodialysis.

Methods

We prospectively enrolled 7 patients (7 eyes) with traumatic cyclodialysis of the concomitant lens and other vitreous diseases. Ultrasound biomicroscopy was used to diagnose cyclodialysis, and all eyes underwent pars plana vitrectomy with air endotamponade. The main outcome measures were postoperative anatomical success rates, best-corrected visual acuity (BCVA), and intraocular pressure (IOP).

Results

All patients were male, and their age ranged from 46 to 64 years (mean: 54.3 years). After the surgical intervention, the extent of the cyclodialysis cleft ranged from 1 to 4 clock hours (mean: 2.3 clock hours) and the detached ciliary body of all cases was completely restored; the anatomical success rate was 100%. The BCVA significantly increased from 1.40 ± 0.49 to 0.42 ± 0.31 (P = 0.002). The IOP increased from 8.91 ± 1.77 to 14.67 ± 6.38, but the difference was not significant (P = 0.056). The postoperative IOP of most patients was temporarily elevated or lowered after surgery. At the last follow-up, there were still two abnormal cases, including one with ocular hypertension and one with hypotony.

Conclusions

This study revealed that vitrectomy with air endotamponade is an effective and minimally invasive alternative surgical approach for small traumatic cyclodialysis clefts.

Conjunctival flap advancement with or without scleral graft for hypotony maculopathy after trabeculectomy

AIM

To investigate the outcomes of adaptive conjunctival flap advancement surgical techniques with or without scleral graft for patients undergoing revision surgery after trabeculectomy.

METHODS

This retrospective study included 28 eyes of 28 subjects from December 2015 to April 2018. A group of 15 eyes underwent conjunctival advancement only while the other 13 eyes did conjunctival advancement with partial thickness scleral graft. In both study groups, we considered the intraocular pressure (IOP) as our primary outcome and visual acuity (VA) as our secondary outcome. Both were assessed pre- and post-operatively till the last follow-up possible point. Additionally, we classified the patients according to complete and qualified success criteria.

RESULTS

The mean age of the conjunctival advancement group was 36.87±19.25y, while it was 44.08±18.04 in the other group. In both study groups, the mean IOP significantly increased after revision surgery at 1, 2, 3mo and the last follow-up visit when compared to prior the surgery (P<0.001). Moreover, VA was significantly improved (P=0.03) in the final follow-up for both surgical techniques. When we compared the change from baseline in both groups, there was no significant difference between IOP improvement in 1mo (P=0.263), while the difference was significant in 2mo (P=0.03), 3mo (P=0.02) and in the final follow-up visit postoperatively. However, this difference was not significant regarding VA (P=0.5).

CONCLUSION

The both adaptive techniques of conjunctival advancement and conjunctival advancement with scleral graft are effective for treating patients with late-onset hypotony. Yet, more prospective studies are needed to assert upon these results.

Corneal Opacification and Spontaneous Recovery following Injection of Healon5 into the Corneal Stroma during Intervention for Postoperative Hypotony

We report the self-limited nature of corneal opacification after accidental injection of Healon5 into the corneal stroma. A 52-year-old male with a new diagnosis of severe stage, primary open-angle glaucoma underwent successful trabeculectomy OS, which was complicated by ocular hypotony and shallow anterior chamber (AC) on postoperative day 1. Healon5, a hyaluronic acid-containing viscoelastic device, was accidentally introduced into the corneal stroma during attempted injection into the AC. The cornea hydrodissected and opacified, leading to precipitous loss of best-corrected visual acuity (BCVA). The corneal opacification spontaneously resolved over a 7-month period without specific intervention. During this period, the patient also underwent cataract extraction with posterior chamber intraocular lens placement and YAG capsulotomy, after which his BCVA returned to approximately baseline. Though intrastromal injection of sodium hyaluronate-containing material has been reported elsewhere, this complication with Healon5 use specifically has yet to be described in the literature and may occur in any procedure involving Healon5 in the AC. This case report is important, since the precipitous loss of BCVA can be alarming to the ophthalmologist and the patient. The affected patient may be counseled that the opacification should improve with time.

Ab interno suture tube occlusion of the Baerveldt glaucoma implant for management of postoperative hypotony: A case series

Purpose

Delayed hypotony can be a vision threatening complication following aqueous shunt surgery in patients with glaucoma. Multiple medical and surgical management strategies have been utilized, but results have been inconsistent. The present case series describes management of delayed hypotony associated with the Baerveldt glaucoma implant (BGI) by surgically introducing 4-0 polypropylene suture into the tube lumen.

Observations

The cases of four patients who presented with hypotony following BGI surgery were reviewed. Following BGI tube lumen occlusion with suture, sustained intraocular pressure increase (mean 7.25 mmHg, range 4–14) was noted in all patients and visual acuity improved in three cases.

Conclusions and importance

This is the first report of ab interno suture occlusion of the BGI for management of post-operative hypotony. Further studies are required to determine the utility of this procedure, but our results suggest that in select patients, ab interno suture occlusion be advantageous in managing delayed hypotony refractive to medical therapy.

A relatively higher intraocular pressure set at the end of vitrectomy is associated with a more stable and rapid visual recovery for patients with vitreous haemorrhage

PURPOSE

To compare structural and functional improvements in patients with vitreous haemorrhage (VH) with different IOPs re-established at the end of pars plana vitrectomy (PPV).

METHODS

It is a prospective, randomized, comparative, interventional study. Ninety-five patients with nonclearing VH were randomized to receive PPV with normalized IOPs of 15 mmHg (Group I: 32 eyes), 25 mmHg (Group II: 32 eyes) and 35 mmHg (Group III: 31 eyes) at the end of surgery. The grade of vitreous opacity and best-corrected visual acuity (BCVA) on postoperative day 1, week 1, month 1 and month 3 were compared with a mixed model for repeated measures analysis.

RESULTS

All 3 groups achieved significant improvement on postoperatively in BCVA (p < 0.01) and vitreous opacity (p < 0.01) compared with the baseline. The group difference was significant at the end of week 1 and showed a trend of higher IOP set at the end of PPV with better anatomical (p < 0.01) and visual recovery (p < 0.01). However, at postoperative month 1 and month 3, equivalent anatomical (month 1: p = 0.56; month 3: p = 0.36) and visual outcomes (month 1: p = 0.16; month 3: p = 0.88) were obtained in the 3 groups. The average effect of IOP on BCVA (group II versus group III: effect size (ES): 0.41, p < 0.01; group I versus group III: ES: 0.66, p < 0.01) and vitreous opacity (group II versus group III: ES: 0.70, p < 0.01; group I versus group III: ES:1.09, p < 0.01) over the course of the study period was statistically significant. The only postoperative complication was recurrent VH in two patients allocating in group I and II, respectively.

CONCLUSIONS

A relatively higher IOP set at the end of vitrectomy resulted in a more stable and rapid recovery with fewer complications in patients with non-complex VH.

Concurrent Phacoemulsification and Encircling for Hypotony Maculopathy after Blunt Trauma

A 37-year-old Japanese man had his right eye hit by a fist. His right eye developed hypotony maculopathy and secondary cataract, and his visual acuity decreased to 20/200 with an intraocular pressure of 4 mmHg. He underwent phacoemulsification and aspiration, implantation of the intraocular lens, and encircling with a silicone tire. His visual acuity improved to 20/20 and stable for more than one year postoperatively. The intraocular pressure in his right eye increased to 12 mmHg, and maculopathy was resolved entirely. It was suggested that an encircling buckle obstructed the uveoscleral outflow through the cyclodialysis and increased intraocular pressure. Concurrent cataract surgery and encircling was sufficient to improve the vision.