The Diagnosis and Treatment of Glaucoma

p38 MAPK inhibitor SB202190 suppresses ferroptosis in the glutamate-induced retinal excitotoxicity glaucoma model

JOURNAL/nrgr/04.03/01300535-202410000-00031/figure1/v/2024-02-06T055622Z/r/image-tiff Glutamate excitotoxicity has been shown to play an important role in glaucoma, and glutamate can induce ferroptosis. The p38 mitogen-activated protein kinase (MAPK) pathway inhibitor SB202190 has a potential ability to suppress ferroptosis, and its downstream targets, such as p53, have been shown to be associated with ferroptosis. However, whether ferroptosis also occurs in retinal ganglion cells in response to glutamate excitotoxicity and whether inhibition of ferroptosis reduces the loss of retinal ganglion cells induced by glutamate excitotoxicity remain unclear. This study investigated ferroptosis in a glutamate-induced glaucoma rat model and explored the effects and molecular mechanisms of SB202190 on retinal ganglion cells. A glutamate-induced excitotoxicity model in R28 cells and an N-methyl-D-aspartate-induced glaucoma model in rats were used. In vitro experiments showed that glutamate induced the accumulation of iron and lipid peroxide and morphological changes of mitochondria in R28 cells, and SB202190 inhibited these changes. Glutamate induced the levels of p-p38 MAPK/p38 MAPK and SAT1 and decreased the expression levels of ferritin light chain, SLC7A11, and GPX4. SB202190 inhibited the expression of iron death-related proteins induced by glutamate. In vivo experiments showed that SB202190 attenuated N-methyl-D-aspartate-induced damage to rat retinal ganglion cells and improved visual function. These results suggest that SB202190 can inhibit ferroptosis and protect retinal ganglion cells by regulating ferritin light chain, SAT1, and SLC7A11/Gpx4 pathways and may represent a potential retina protectant.

Glaucoma Rehabilitation using ElectricAI Transcranial Stimulation (GREAT)-study protocol for randomized controlled trial using combined perceptual learning and transcranial electrical stimulation for vision enhancement

BACKGROUND

Glaucoma patients with irreversible visual field loss often experience decreased quality of life, impaired mobility, and mental health challenges. Perceptual learning (PL) and transcranial electrical stimulation (tES) have emerged as promising interventions for vision rehabilitation, showing potential in restoring residual visual functions. The Glaucoma Rehabilitation using ElectricAI Transcranial stimulation (GREAT) project aims to investigate whether combining PL and tES is more effective than using either method alone in maximizing the visual function of glaucoma patients. Additionally, the study will assess the impact of these interventions on brain neural activity, blood biomarkers, mobility, mental health, quality of life, and fear of falling.

METHODS

The study employs a three-arm, double-blind, randomized, superiority-controlled design. Participants are randomly allocated in a 1:1:1 ratio to one of three groups receiving: (1) real PL and real tES, (2) real PL and sham tES, and (3) placebo PL and sham tES. Each participant undergoes 10 sessions per block (~ 1 h each), with a total of three blocks. Assessments are conducted at six time points: baseline, interim 1, interim 2, post-intervention, 1-month post-intervention, and 2-month post-intervention. The primary outcome is the mean deviation of the 24-2 visual field measured by the Humphrey visual field analyzer. Secondary outcomes include detection rate in the suprathreshold visual field, balance and gait functions, and electrophysiological and biological responses. This study also investigates changes in neurotransmitter metabolism, biomarkers, self-perceived quality of life, and psychological status before and after the intervention.

DISCUSSION

The GREAT project is the first study to assess the effectiveness of PL and tES in the rehabilitation of glaucoma. Our findings will offer comprehensive assessments of the impact of these treatments on a wide range of brain and vision-related metrics including visual field, neural activity, biomarkers, mobility, mental health, fear of falling, and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05874258 . Registered on May 15, 2023.

Sustained release of brimonidine from conjunctival sac insert to reduce intraocular pressure for glaucoma treatment

BACKGROUND

Glaucoma is one of the major irreversible blinding eye diseases in the world. Reducing intraocular pressure (IOP) is the primary treatment option, and taking eye drops daily is the common method. However, short drug duration and poor bioavailability of eye drops may lead to unsatisfied therapeutic effects and inadequate patient compliance.

METHODS

A brimonidine-loaded silicone rubber insert (BRI@SR@PT) was prepared by loading brimonidine into a surface-modified silicone rubber ring, followed by polydopamine/thermoplastic polyurethane coatings. The physical properties, in vitro cytocompatibility and drug release of BRI@SR@PT were investigated. The BRI@SR@PT was administrated in the conjunctival sac of rabbit eyes, and its in vivo drug release, IOP-lowering efficacy and biosafety were assessed.

RESULTS

The BRI@SR@PT presented great thermal stability and excellent elasticity. The BRI@SR@PT was able to release BRI sustainably for 28 days with little toxicity in vitro. Compared to BRI eye drops, the BRI@SR@PT effectively lowered IOP for 21 days based on the sustained BRI release with great biosafety when administrated in conjunctival sac of rabbit eyes in a noninvasive fashion.

CONCLUSIONS

The conjunctival sac insert (BRI@SR@PT), as a promising drug-delivery platform, may provide a sustained IOP-lowering treatment for patients with ocular hypertension or glaucoma, without the need for invasive procedures.

Microglia depletion leads to increased susceptibility to ocular hypertension-dependent glaucoma

In recent years, microglia have been highlighted for playing integral roles in neurodegenerative diseases, like glaucoma. To better understand the role of microglia during chronic ocular hypertension, we depleted microglia from aged (9-12 months old) DBA/2 J (D2) mice, which exhibit age-related increases in intraocular pressure, using a dietary CSF1R antagonist, PLX5622. Retinal ganglion cell (RGC) somas were counted, and optic nerve cross-sections stained and assessed for glaucomatous damage. Sustained administration of dietary PLX5622 significantly reduced the numbers of retinal microglia. Dietary PLX5622 did not lead to changes in intraocular pressure in D2 or normotensive DBA/2 J-Gpnmb+ (D2-Gpnmb+ ) control mice. While PLX5622-treated D2-Gpnmb+ did not develop optic nerve damage, PLX5622-treated D2 mice showed a significant increase in moderate-to-severe optic nerve damage compared to D2 mice fed a control diet. In conclusion, global reduction of microglia exacerbated glaucomatous neurodegeneration in D2 mice suggesting microglia play an overall beneficial role in protecting from ocular hypertension associated RGC loss.

Antioxidant effect of gallic acid on retinal ganglion cells in glaucoma model

To evaluate the protective effect of gallic acid on the optic nerve by studying the inhibitory effect of gallic acid on oxidative stress in retinal ganglion cells. 100 male SD rats were randomly divided into four groups: normal control group, simple high IOP group, 0.5% gallic acid experimental group, and 1% gallic acid experimental group. HE staining, immunofluorescence, DHE staining, Western blot, and q-PCR were used to observe the antioxidant effect of gallic acid on the retina of acute ocular hypertension rats. HE staining of the retina of SD rats confirmed that the nucleus of RGCs was clear, the thickness of the RNFL was regular in the normal control group, and the nucleus of RGCs was ruptured and lysed in the simple high intraocular pressure (IOP) group and the gallic acid group, and the thickness of the RNFL was significantly thickened, but the thickness of the RNFL in the gallic acid group was significantly reduced compared with that in the simple high IOP group (p < 0.05). DHE staining showed that ROS content in the simple high IOP group was significantly increased compared with the normal control group, and ROS content was significantly decreased after the application of gallic acid (p < 0.05). Immunofluorescence staining with Brn-3a antibody confirmed that the number of RGCs was significantly reduced in the simple high IOP group compared with the normal control group, whereas after application of gallic acid, the number of RGCs was significantly more in the gallic acid group than in the simple high IOP group (p < 0.05). Western Blot and q-PCR confirmed that hypoxia-inducing factor 1α (HIF-1α) protein content and transcription level were significantly increased in the retinal tissue of the simple high IOP group, and gallic acid could inhibit HIF-1α protein content (p < 0.05) and reduce transcription factor level (p < 0.05). Gallic acid exerts a protective effect on RGC by inhibiting oxidative stress in rats with acute IOP elevation.

Choroidal thickness in juvenile open angle glaucoma: insights from a south asian case-control study

PURPOSE

The purpose of this study is to compare choroidal thickness in juvenile open angle glaucoma (JOAG) and healthy controls using spectral domain optical coherence tomography (SD-OCT) and study its correlations.

METHODS

In this case-control study, 56 eyes of 28 JOAG patients and an equal number of controls were recruited. SD-OCT was used to measure the choroidal thickness (ChT), in the macular region at 5 locations: subfoveal, 1500 µm and 3000 µm nasal and temporal to the foveal center, and in the peripapillary region at 6 locations: up to 1500 µm, nasal and temporal to the disc, respectively. The ChT and its correlations with age, intraocular pressure, cup-to-disc ratio, central corneal thickness, mean deviation, and axial length were studied.

RESULTS

The average macular ChT in JOAG was 306.30 ± 56.49 µm vs. 277.12 ± 64.68 µm in controls. The average peripapillary ChT in JOAG was 197.79 ± 44.05 µm vs. 187.24 ± 38.89 µm in controls. The average total ChT (p = 0.042), the average macular ChT (p = 0.022), the subfoveal ChT (p = 0.022), the ChT 1500 µm (p < 0.001), and 3000 µm temporal to the fovea (p = 0.002) were significantly thicker in the JOAG group. In the JOAG group, the average macular ChT had a significant negative correlation with age, whereas axial length was positively correlated with the average peripapillary ChT.

CONCLUSIONS

In this South Asian cohort of JOAG, the average total ChT, average macular ChT, subfoveal ChT, and ChT at 1500 µm, and 3000 µm temporal to the fovea were significantly thicker when compared to healthy controls.

Intraday repeatability of macular layers measurements in glaucomatous and non-glaucomatous patients using spectral-domain optical coherence tomography

PURPOSE

To assess the intraday repeatability of macular architecture measurements in glaucomatous and non-glaucomatous patients using spectral-domain optical coherence tomography (SD-OCT) and to evaluate the independence from intraindividual intraocular pressure (IOP) fluctuations.

METHODS

In this single-center, time-point comparison study, 88 eyes with glaucoma, 53 eyes with ocular hypertension (OHT), and 253 healthy eyes underwent two standardized SD-OCT and intraocular pressure (IOP) measurements on the same day with a 5-h time gap. Bland-Altman plots, intraclass correlation coefficients (ICC), and random-effects model were used to analyze repeatability of entire retinal thickness, retinal nerve fiber layer, ganglion cell layer, inner plexiform layer, and inner nuclear layer measurements.

RESULTS

Intraday measurements were highly reproducible in all 3 groups. ICC were greater than 0.90, respectively. The pairwise comparisons of morphometric parameters showed a statistically significant difference (P < 0.001, respectively) between groups (glaucoma vs. control, glaucoma vs. OHT) and a significant influence of time points. No correlation was found between IOP fluctuations and morphometric parameters (P > 0.05, respectively), except for a weak positive correlation with GCL (rho = 0.109, P = 0.031).

CONCLUSIONS

The evaluation of macular morphometric parameters of SD-OCT showed a high intraday repeatability and an excellent degree of agreement in glaucoma, ocular hypertension, and healthy groups. The fixed effects of time points were statistically significant. Except for a weak positive correlation of ganglion cell layer, variability did not appear to be affected by intraday IOP changes. Additional research is required to fully understand the impact of IOP fluctuations on macular morphometric parameters, considering the small observed IOP changes.

Epidemiological analysis of congenital glaucoma: a national scenario

INTRODUCTION

Congenital glaucoma is a disease that involves increased intraocular pressure and can result in irreversible visual deterioration. The study of epidemiology allows the delineation of the characteristics associated with patients and specific risk factors.

OBJECTIVE

The objective of this study was to examine epidemiological trends, place of residence, duration of gestation, sex, and race of the newborn diagnosed with congenital glaucoma in Brazil.

METHODS

Data from SINASC (National Live Birth System) were used to analyze the period from 2017 to 2021 in Brazil. Linear regression and analysis of variance tests were employed to assess significance. The statistical significance was determined by p<0.05.

RESULTS

A total of 47 cases of congenital glaucoma were identified in Brazil during the study period, with the highest incidence between the years of 2018 and 2021. The analysis of the distribution indicated that the states with the highest incidence were São Paulo, followed by Rio Grande do Sul and Pernambuco. Approximately 60% of cases occurred in male individuals, compared with 19 female cases. The ethnic analysis showed the highest incidence among whites and mixed. Regarding the length of pregnancy, statistical differences were observed between newborns of different periods of gestation. Infants born from pregnancies lasting between 28 and 31 weeks and 32 and 36 weeks were significant when analyzed with the group between 37 and 41 weeks.

CONCLUSION

Studies on the mechanisms of congenital glaucoma seek to improve knowledge about the disease. Epidemiological evaluation is essential for identifying demographic and clinical patterns of the disease.

Potential therapeutic effects of green tea (Camellia sinensis) in eye diseases, a review

This review aims to evaluate the therapeutic potential of green tea (GT), scientifically named Camellia sinensis, in treating eye diseases. We provide an overview of the ingredients and traditional use of Camellia sinensis, followed by a detailed discussion of its therapeutic uses in various eye diseases, including ocular surface diseases (allergic diseases, dry eye, pterygium, and infections), cataract, glaucoma, uveitis, retinal diseases, and optic nerve diseases. The pharmacologic activities related to ocular diseases, such as anti-vascular endothelial growth factor, aldose reductase inhibitor activity, anti-bacterial, anti-inflammatory, and antioxidant effects are also explored in this review. The dose and route of administration of GT in various studies are discussed. Safety issues related to the use of GT, such as the side effects associated with high doses and long-term use, are also addressed. The review highlights the potential of GT as a natural therapeutic agent for a variety of ocular diseases. Its various pharmacologic activities make it a promising treatment option. However, more well-designed studies are needed to determine the optimal dose and route of administration and to assess its long-term safety and efficacy. Overall, GT appears to be a promising adjunct therapy for various ocular diseases.

[Perioperative visual loss : Rare, unknown, relevant?]

Perioperative visual loss (POVL) is a rare but severe complication following non-ophthalmological surgery under general anesthesia. A POVL can be caused by lesions in any part of the optical system. The predominant causes include corneal injuries and particularly ischemic damage. The symptoms of POVL substantially vary ranging from reduced vision to complete blindness. The risks involve factors related to the surgery as well as patient-specific factors. In general, the prognosis in cases of mechanical damage is better than for ischemic lesions. The treatment measures depend on the underlying pathomechanism and due to the limited evidence only a few treatment options are available. Therefore, preventive measures and meticulous documentation play a crucial role.

Resveratrol Ameliorates Retinal Ischemia-Reperfusion Injury by Modulating the NLRP3 Inflammasome and Keap1/Nrf2/HO-1 Signaling Pathway

Glaucoma, as an ischemia-reperfusion (I/R) injury disease, leading irreversible blindness through the loss of retinal ganglion cells (RGCs), mediated by various pathways. Resveratrol (Res) is a polyphenolic compound that exerts protective effects against I/R injury in many tissues. This article aimed to expound the underlying mechanisms through which Res protects RGCs and reduces visual dysfunction in vivo. An experimental glaucoma model was created using 6-8-week wild-type male C57BL/6J mice. Res was injected intraperitoneally for 5 days. The mice were then grouped according to the number of days after surgery and whether Res treatment was administered. We applied the Brn3a-labeled immunofluorescence staining and flash electroretinography (ERG) to assess the survival of RGCs and visual function. The expression of components of the NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3) inflammasome, the interleukin-1-beta (IL-1β), and vital indicators of kelch-like ECH-associated protein 1 (Keap1)/nuclear factor erythroid 2-related factor 2 (Nrf2)/heme-oxygenase 1 (HO-1) pathway at the protein and RNA levels were detected respectively. The survival of RGCs was reduced after surgery compared to controls, whereas Res application rescued RGCs and improved visual dysfunction. In conclusion, our results discovered that Res administration showed neuroprotective effects through inhibition of the NLRP3 inflammasome pathway and activation of Keap1/Nrf2/HO-1 pathway. Thus, we further elucidated the potential of Res in glaucoma therapy.

Microglia Depletion leads to Increased Susceptibility to Ocular Hypertension-Dependent Glaucoma

In recent years, microglia have been highlighted for playing integral roles in neurodegenerative diseases, like glaucoma. To better understand the role of microglia during chronic ocular hypertension, we depleted microglia from aged (9-12 months old) DBA/2J (D2) mice, which exhibit age-related increases in intraocular pressure, using a dietary CSF1R antagonist, PLX5622. Retinal ganglion cell (RGC) somas were counted, and optic nerve cross-sections stained and assessed for glaucomatous damage. Sustained administration of dietary PLX5622 significantly reduced the numbers of retinal microglia. Dietary PLX5622 did not lead to changes in intraocular pressure in D2 or normotensive DBA/2J-Gpnmb+ (D2-Gpnmb+) control mice. While PLX5622-treated D2-Gpnmb+ did not develop optic nerve damage, PLX5622-treated D2 mice showed a significant increase in moderate-to-severe optic nerve damage compared to D2 mice fed a control diet. In conclusion, global reduction of microglia exacerbated glaucomatous neurodegeneration in D2 mice suggesting microglia play an overall beneficial role in protecting from ocular hypertension associated RGC loss.

Machine Learning Analysis Classifies Patients with Primary Angle-Closure Glaucoma Using Abnormal Brain White Matter Function

Objective

Primary angle-closure glaucoma (PACG) is a globally prevalent, irreversible eye disease leading to blindness. Previous neuroimaging studies demonstrated that PACG patients were associated with gray matter function changes. However, whether the white matter(WM) function changes in PACG patients remains unknown. The purpose of the study is to investigate WM function changes in the PACG patients.

Methods

In total, 40 PACG patients and 40 well-matched HCs participated in our study and underwent resting-state functional magnetic resonance imaging (rs-fMRI) scans. We compared between-group differences between PACG patients and HC in the WM function using amplitude of low-frequency fluctuations (ALFF). In addition, the SVM method was applied to the construction of the PACG classification model.

Results

Compared with the HC group, ALFF was attenuated in right posterior thalamic radiation (include optic radiation), splenium of corpus callosum, and left tapetum in the PACG group, the results are statistically significant (GRF correction, voxel-level P < 0.001, cluster-level P < 0.05). Furthermore, the SVM classification had an accuracy of 80.0% and an area under the curve (AUC) of 0.86 for distinguishing patients with PACG from HC.

Conclusion

The findings of our study uncover abnormal WM functional alterations in PACG patients and mainly involves vision-related regions. These findings provide new insights into widespread brain damage in PACG from an alternative WM functional perspective.

A Systematic Review of Cyclophotocoagulation Techniques: Continuous Wave Versus Micropulse for Glaucoma Treatment

Objectives

Micro-pulse cyclophotocoagulation (MP-CPC) represents the latest iteration of minimally invasive laser procedures aimed at reducing intraocular pressure (IOP) through the disruption of pigmented ciliary body epithelium. This systematic review aims to assess the efficacy and safety profile of the MP-CPC procedure in comparison to CW-CPC for the treatment of glaucoma.

Methods

We initiated a search on PubMed, ScienceDirect, and the Cochrane Library databases for studies that compared micro-pulse and traditional CW-CPC in terms of their efficacy and safety profiles. We employed medical subject headings terms and keywords such as "cyclophotocoagulation," "cyclodestructive," "photocoagulation," "CPC," "micropulse," "micro-pulse," and "glaucoma" within the timeframe from 2015 to 2023. We assessed the success rate, IOP reduction, antiglaucoma medications, and complications of MP-CPC and CW-CPC.

Results

We included six articles in this study, comprising two randomized controlled trials, three retrospective, and one prospective cohort, published between 2015 and 2023. Five out of six reported a significant reduction in IOP for both procedures with comparable success rates observed in MP-CPC compared to CW-CPC. One article reported an increase in IOP in MP-CPC. Both groups reported a decrease in the number of antiglaucoma medications, while one study reported an increase in medications in both MP-CPC and CW-CPC groups. Complication rates were lower in the MP-CPC group with two articles reporting a significant decrease compared to the CW-CPC group.

Conclusion

MP-CPC has shown promising results in the treatment of glaucoma in the adult population. With comparable results in IOP reduction and fewer instances of serious ocular complications, MP-CPC may open new possibilities for the use of cyclophotocoagulation procedures in the earlier stages of glaucoma. However, its efficacy in the pediatric population and for neovascular glaucoma remains less defined, thus warranting further studies to establish optimal laser parameters for different types of glaucoma and specific populations of glaucoma patients.

Intraocular pressure spikes after gonioscopy-assisted transluminal trabeculotomy (GATT)

PURPOSE

Intraocular pressure (IOP) spikes (IOP > 30 mmHg or > 10 mmHg above baseline IOP) are a common and worrisome complication of gonioscopy-assisted transluminal trabeculotomy (GATT). The purpose of this study is to identify risk factors for IOP spikes and to describe their characteristics, management, and clinical course in a large cohort of patients.

METHODS

A retrospective, single-center study which included 217 consecutive eyes of patients that underwent GATT between December 2019 and April 2022 with follow-up of at least 90 days.

RESULTS

IOP spikes occurred in 52 of 217 (24%) eyes. Spikes occurred in 15.5% of patients in whom pre-operative IOP-lowering medications were continued after surgery (90 eyes), and in 29.9% in whom IOP-lowering medications were stopped after surgery (127 eyes). Spikes were diagnosed at a mean of 7.7 ± 6.5 days after surgery. All IOP spikes occurred within the first month of surgery. The mean duration of a spike was 4.9 ± 5.4 days. Management of IOP spikes included adding a mean of 3.13 ± 1.7 groups of glaucoma medications. Thirty-seven (72.5%) eyes were treated with oral carbonic anhydrase inhibitor, 11 (21.6%) were treated with IV mannitol, and anterior chamber paracentesis was performed in 16 (31.4%). Six (11.8%) eyes underwent additional glaucoma surgery to control IOP. Patients that continued their pre-operative IOP-lowering medications after surgery were 2.3 times less likely to develop a spike as compared to patients who discontinued their medications (P = 0.016). Spikes were found to be a risk factor for failure of GATT.

CONCLUSIONS

IOP spikes are a common occurrence after GATT. They most commonly appear during the first two post-operative weeks and usually resolve with topical and systemic IOP-lowering treatment. The continuation of IOP-lowering medications after GATT is recommended to lower the risk of IOP spikes.

From the past to the present, optical coherence tomography in glaucoma: a practical guide to a common disease

Glaucoma comprises a group of disorders of the optic nerve that cause degenerative optic neuropathy, characterised by failure of neuroretinal rim tissue in the optic nerve head, retinal nerve fibre layer, and retinal ganglion cells. Glaucoma imposes a serious epidemiological threat, with an steady increase in the global number of cases. In the current ophthalmological practice, glaucoma is diagnosed via a series of examinations, including routine funduscopic examination, ocular tonometry, gonioscopy, measurement of the visual field, and assessment using the optical coherence tomography (OCT) technique. Nowadays, the OCT technique helps in systematising the diagnostic pathway and is a basic diagnostic tool for detection of early glaucomatous eye changes. It is also vital in assessing progression and monitoring treatment results of patients. The aim of this review was to present the OCT technique as a main tool in diagnosing and monitoring glaucoma.

Patient satisfaction and follow-up adherence to glaucoma case management clinic in China

AIM

To assess glaucoma patient satisfaction and follow-up adherence in case management and identify associated predictors to improve healthcare quality and patient outcomes.

METHODS

In this cross-sectional study, a total of 119 patients completed a Patient Satisfaction Questionnaire-18 and a sociodemographic questionnaire. Clinical data was obtained from the case management system. Follow-up adherence was defined as completing each follow-up within ±30d of the scheduled time set by ophthalmologists during the study period.

RESULTS

Average satisfaction scored 78.65±7, with an average of 4.39±0.58 across the seven dimensions. Age negatively correlated with satisfaction (P=0.008), whilst patients with follow-up duration of 2 or more years reported higher satisfaction (P=0.045). Multivariate logistics regression analysis revealed that longer follow-up durations were associated with lower follow-up adherence (OR=0.97, 95%CI, 0.95-1.00, P=0.044). Additionally, patients with suspected glaucoma (OR=2.72, 95%CI, 1.03-7.20, P=0.044) and those with an annual income over 100 000 Chinese yuan demonstrated higher adherence (OR=5.57, 95%CI, 1.00-30.89, P=0.049).

CONCLUSION

The case management model proves effective for glaucoma patients, with positive adherence rates. The implementation of this model can be optimized in the future based on the identified factors and extended to glaucoma patients in more hospitals.

Short-term report of early glaucoma surgery with a clear lens extraction and an intraocular lens, OMNI canaloplasty, and a HYDRUS microstent: a case series in younger patients

Purpose

The purpose of this case series is to report the surgical outcomes from the combination of a clear lensectomy, OMNI® canaloplasty, and a HYDRUS® microstent with an adjacent goniotomy.

Methods

This is a retrospective non-comparative single-center case series of four black patients of African descent with glaucoma who were treated with a clear lensectomy, OMNI canaloplasty, and a HYDRUS microstent with an adjacent goniotomy. The surgeries were performed by an experienced cataract and glaucoma surgeon, Daniel Laroche, MD. The parameters investigated in this study were postoperative intraocular pressure (IOP) and the mean number of preoperative and postoperative medications needed.

Results

The mean age of the four patients was 44.5 years. All patients had a mean postoperative reduction in IOP of 17 mmHg to 12.7 mmHg. The mean number of preoperative medications was 2.2, while the mean number of postoperative medications was 0.3. Potential complications such as hyphema, IOP spikes, or corneal edema were not seen in this series. All patients achieved a lower IOP and stable vision with less refractive error. Patients also experienced improved visual fields, clearer vision, and more open angles.

Conclusion

Clear lensectomy and combined microinvasive glaucoma surgery (MIGS) in patients with primary open-angle glaucoma (POAG) and narrow-angle glaucoma (NAG) results in the safe lowering of IOP. The limitations of this study include the small series size and the retrospective potential for bias. Further research with a larger series and a prospective trial with follow-up should be performed.

Clinical value of cognitive behavioral nursing model to patients with congenital glaucoma

BACKGROUND

There have been studies on the use of cognitive behavioral nursing intervention (CBNI) but the main subjects were patients with secondary glaucoma and there are fewer studies on the care of congenital glaucoma.

OBJECTIVE

To explore the clinical value of cognitive behavioral nursing model in patients with congenital glaucoma.

METHODS

One hundred and fifty-three postoperative patients with congenital glaucoma treated in our hospital between January 2021 and December 2022 were prospectively selected for the study and randomly divided into a control group (n= 77) and an observation group (n= 76). The control group was given routine nursing, and the observation group was given cognitive behavioral nursing mode on the basis of the control group. Anxiety self-assessment scale (SAS), depression self-assessment scale (SDS), Connor-Davidson toughness scale, and treatment adherence evaluation scale were used to evaluate the psychological state, mental toughness, treatment adherence, treatment effect and nursing care satisfaction in the two groups before and after 2 weeks of intervention. The efficacy of the treatment was also assessed by determining the visual acuity (VA), intraocular pressure (IOP), and mean defective (MD) value of the visual field of the two groups of patients.

RESULTS

After nursing, the SDS score (46.33 ± 6.16 versus 53.21 ± 5.94) and SAS score (44.41 ± 5.6 versus 52.82 ± 6.31) in the observation group were lower than those in the control group (P< 0.05). The scores of optimism (11.55 ± 1.90 versus 8.20 ± 1.95), self-improvement (22.05 ± 3.60 versus 17.60 ± 4.30), tenacity (37.45 ± 3.10 versus 28.90 ± 4.55) and total score (71.35 ± 8.00 versus 56.85 ± 8.50) in the observation group were higher than those in the control group (P< 0.05). After care, the VA of the observation group (0.95 ± 0.22) was greater than that of the control group (0.84 ± 0.16), and the IOP (14.25 ± 0.58 versus 15.89 ± 0.67) and the MD (5.42 ± 0.46 versus 6.68 ± 0.49) of the observation group were less than that of the control group. The difference between the two groups was statistically significant (P< 0.05). The compliance (96.05% versus 85.71%) and nursing satisfaction (96.10% versus 85.71%) of the observation group were higher than those of the control group (P< 0.05).

CONCLUSION

Cognitive-behavioural nursing care for glaucoma patients can improve patients' mental toughness, improve visual acuity, reduce intraocular pressure and mean visual field defect values, and have a positive effect on enhancing patients' treatment adherence and nursing satisfaction.

Artificial intelligence in retinal imaging: current status and future prospects

INTRODUCTION

The steadily growing and aging world population, in conjunction with continuously increasing prevalences of vision-threatening retinal diseases, is placing an increasing burden on the global healthcare system. The main challenges within retinology involve identifying the comparatively few patients requiring therapy within the large mass, the assurance of comprehensive screening for retinal disease and individualized therapy planning. In order to sustain high-quality ophthalmic care in the future, the incorporation of artificial intelligence (AI) technologies into our clinical practice represents a potential solution.

AREAS COVERED

This review sheds light onto already realized and promising future applications of AI techniques in retinal imaging. The main attention is directed at the application in diabetic retinopathy and age-related macular degeneration. The principles of use in disease screening, grading, therapeutic planning and prediction of future developments are explained based on the currently available literature.

EXPERT OPINION

The recent accomplishments of AI in retinal imaging indicate that its implementation into our daily practice is likely to fundamentally change the ophthalmic healthcare system and bring us one step closer to the goal of individualized treatment. However, it must be emphasized that the aim is to optimally support clinicians by gradually incorporating AI approaches, rather than replacing ophthalmologists.

Efficacy of Continuous-Wave Transscleral Cyclophotocoagulation Post-Pars Plana Vitrectomy in Glaucoma Patients: A Retrospective Study from Poland

BACKGROUND Glaucoma, a vision-threatening condition, results from optic nerve damage and affects millions of people worldwide. Often asymptomatic, it is hereditary, with risk factors like hypertension, diabetes, and steroid use. Despite its link with intraocular pressure (IOP), not everyone with high IOP develops glaucoma. After pars plana vitrectomy (PPV), patients face increased IOP risks. Traditional treatment includes pharmacotherapy, and, when ineffective, surgical interventions. Continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) is an alternative for refractory glaucoma but can have complications. Our study compares the efficacy and safety of CW-TSCPC after PPV. MATERIAL AND METHODS The study group consisted of 18 patients diagnosed with glaucoma who underwent the CW-TSCP procedure as the first-choice therapy after conservative treatment of glaucoma proved ineffective. The comparison group consisted of 12 patients who underwent the CW-TSCP procedure after conservative drug treatment and in whom surgical treatment of glaucoma had been unsuccessful. All patients had inadequate control of IOP after PPV. RESULTS Study and comparison group patients showed a decrease in IOP during the follow-up, independent of the type of endotamponade used (P<0.05). When the indication for PPV was retinal detachment hemorrhage into the vitreous chamber, a significant decrease in IOP between 0 days and 180 days was only found in the study group (P<0.05). In contrast, when the indication for PPV was the state after uveitis or proliferative diabetic retinopathy, a significant decrease in IOP was found at 180 days in the study and comparison groups (P<0.05). CONCLUSIONS The analysis showed that the CW-TSCPC procedure can be recommended as the first-choice invasive treatment in patients with increased IOP after PPV.

Glial metabolic alterations during glaucoma pathogenesis

Glaucoma is the leading cause of irreversible blindness. Current treatment options are limited and often only slow disease progression. Metabolic dysfunction has recently been recognized as a key early and persistent mechanism in glaucoma pathophysiology. Several intrinsic metabolic dysfunctions have been identified and treated in retinal ganglion cells to provide neuroprotection. Growing pre-clinical and clinical evidence has confirmed that metabolic alterations in glaucoma are widespread, occurring across visual system tissues, in ocular fluids, in blood/serum, and at the level of genomic and mitochondrial DNA. This suggests that metabolic dysfunction is not constrained to retinal ganglion cells and that metabolic alterations extrinsic to retinal ganglion cells may contribute to their metabolic compromise. Retinal ganglion cells are reliant on glial metabolic support under normal physiological conditions, but the implications of metabolic dysfunction in glia are underexplored. We highlight emerging evidence that has demonstrated metabolic alterations occurring within glia in glaucoma, and how this may affect neuro-glial metabolic coupling and the metabolic vulnerability of retinal ganglion cells. In other neurodegenerative diseases which share features with glaucoma, several other glial metabolic alterations have been identified, suggesting that similar mechanisms and therapeutic targets may exist in glaucoma.

GGT1 Suppresses the Development of Ferroptosis and Autophagy in Mouse Retinal Ganglion Cell Through Targeting GCLC

Background

Glaucoma is a neurodegenerative disorder characterized with optic nerve injury and the loss of retinal ganglion cells (RGCs). Ferroptosis has been proved to be associated with the degradation of RGCs. The aim of this study is to elucidate the relationship between ferroptosis and glaucoma pathogenesis, and unveil the underlying mechanism.

Methods

Methyl thiazolyl tetrazolium (MTT) assay was used to evaluate the proliferation of RGCs. The accumulation of cellular iron was measured by Iron assay kit, and the level of reactive oxygen species (ROS) was detected by fluorescence probe. The mitochondrial morphology and autophagosomes were analysed by using transmission electron microscopy (TEM). The contents of glutathione (GSH) and malondialdehyde (MDA) were tested by a GSH assay kit and an MDA detection kit, respectively. The expression of autophagy-related proteins was detected by Western blotting.

Results

A serious cell damage, aberrant iron homeostasis, and oxidative stress was shown in RGC-5 after oxygen-glucose deprivation/reoxygenation (OGD/R) treatment and gamma-Glutamyl transpeptidase 1 (GGT1) knockdown, but these effects were significantly alleviated by overexpression of GGT1 or ferroptosis inhibitors. The TEM and immunofluorescent results indicated that mitochondria impairment and autophagosome accumulation in OGD/R-treated cells was improved after GGT1 overexpression, while the phenomenon in GGT1-silenced cells was aggravated. Furthermore, we found that GGT1 can interact with glutamate cysteine ligase catalytic subunit (GCLC) to inhibit autophagy and ferroptosis in RGC-5 cells.

Conclusion

GGT1 represses autophagy in RGC-5 cells by targeting GCLC, which further restrains the development of ferroptosis in cells.

Trim9 regulates the directional differentiation of retinal Müller cells to retinal ganglion cells

OBJECTIVES

Glaucoma is a leading cause of irreversible blindness, and effective therapies to reverse the visual system damage caused by glaucoma are still lacking. Recently, the stem cell therapy enable the repair and regeneration of the damaged retinal neurons, but challenges regarding the source of stem cells remain. This study aims to investigate a protocol that allows the dedifferentiation of Müller cells into retinal stem cells, following by directed differentiation into retinal ganglion cells with high efficiency, and to provide a new method of cellular acquisition for retinal stem cells.

METHODS

Epidermal cell growth factor and fibroblast growth factor 2 were used to induce the dedifferentiation of rat retinal Müller cells into retinal neural stem cells. Retinal stem cells derived from Müller cells were infected with a Trim9 overexpression lentiviral vector (PGC-FU-Trim9-GFP), and the efficiency of viral infection was assessed by fluorescence microscopy and flow cytometry. Retinoic acid and brain-derived neurotrophic factor treatments were used to induce the differentiation of the retinal stem cells into neurons and glial cells with or without the overexpression of Trim9. The expressions of each cellular marker (GLAST, GS, rhodopsin, PKC, HPC-1, Calbindin, Thy1.1, Brn-3b, Nestin, Pax6) were detected by immunofluorescence, PCR/real-time RT-PCR or Western blotting.

RESULTS

Rat retinal Müller cells expressed neural stem cells markers (Nestin and Pax6) with the treatment of epidermal cell growth factor and fibroblast growth factor 2. The Thy1.1 positive cell rate of retinal stem cells overexpressing Trim9 was significantly increased, indicating their directional differentiation into retinal ganglion cells after treatment with retinoic acid and brain-derived neurotrophic factor.

CONCLUSIONS

In this study, rat retinal Müller cells are dedifferentiated into retinal stem cells successfully, and Trim9 promotes the directional differentiation from retinal stem cells to retinal ganglion cells effectively.

Glaucoma and Dry Eye Disease: Opportunity to Assess and Treat

Dry eye disease (DED) has been found to occur at a higher prevalence in individuals with glaucoma than in individuals without glaucoma. The relationship between glaucoma and DED may be, in part, a result of glaucoma therapy. Greater number of antiglaucoma medications used and greater number of antiglaucoma eyedrops instilled per day have been associated with ocular surface disease in patients with glaucoma. Use of antiglaucoma medication has also been associated with higher levels of ocular surface inflammatory markers and ocular surface alterations. There is evidence to suggest that antiglaucoma medications with preservatives and, to some extent, antiglaucoma medication formulations without preservatives may contribute to ocular surface signs and symptoms. Trabeculectomy for glaucoma has also been associated with ocular surface signs related to DED; however, there may be benefits of trabeculectomy and other procedures for glaucoma due to reduced use of antiglaucoma medications. Patients with glaucoma with ocular surface disease have been found to have greater ocular surface symptoms, poorer vision-related quality of life, and poorer antiglaucoma medication adherence compared with patients with glaucoma without ocular surface disease. Because of the potential negative impact of DED on patients with glaucoma, patients with glaucoma may benefit from evaluation for DED. Management of DED in patients with glaucoma may include modifications to antiglaucoma medications and use of treatments for DED.

Aging, oxidative stress and degenerative diseases: mechanisms, complications and emerging therapeutic strategies

Aging accompanied by several age-related complications, is a multifaceted inevitable biological progression involving various genetic, environmental, and lifestyle factors. The major factor in this process is oxidative stress, caused by an abundance of reactive oxygen species (ROS) generated in the mitochondria and endoplasmic reticulum (ER). ROS and RNS pose a threat by disrupting signaling mechanisms and causing oxidative damage to cellular components. This oxidative stress affects both the ER and mitochondria, causing proteopathies (abnormal protein aggregation), initiation of unfolded protein response, mitochondrial dysfunction, abnormal cellular senescence, ultimately leading to inflammaging (chronic inflammation associated with aging) and, in rare cases, metastasis. RONS during oxidative stress dysregulate multiple metabolic pathways like NF-κB, MAPK, Nrf-2/Keap-1/ARE and PI3K/Akt which may lead to inappropriate cell death through apoptosis and necrosis. Inflammaging contributes to the development of inflammatory and degenerative diseases such as neurodegenerative diseases, diabetes, cardiovascular disease, chronic kidney disease, and retinopathy. The body's antioxidant systems, sirtuins, autophagy, apoptosis, and biogenesis play a role in maintaining homeostasis, but they have limitations and cannot achieve an ideal state of balance. Certain interventions, such as calorie restriction, intermittent fasting, dietary habits, and regular exercise, have shown beneficial effects in counteracting the aging process. In addition, interventions like senotherapy (targeting senescent cells) and sirtuin-activating compounds (STACs) enhance autophagy and apoptosis for efficient removal of damaged oxidative products and organelles. Further, STACs enhance biogenesis for the regeneration of required organelles to maintain homeostasis. This review article explores the various aspects of oxidative damage, the associated complications, and potential strategies to mitigate these effects.

Aqueous Outflow Facility after Periocular Triamcinolone Injection: A Preliminary Evaluation of the Falck Medical Applanation Tonometer

Aim

To evaluate the Falck Medical Applanation Tonometer 1 (FMAT-1) as a device for measuring intraocular pressure (IOP) and outflow facility (OF) in patients with uveitis after periocular triamcinolone injection in one eye.

Materials and methods

Retrospective observational comparison. IOP and OF measurements were recorded and analyzed, comparing Goldmann tonometry and FMAT-1 readings. Records were reviewed for adult patients with uveitis who had undergone recent periocular triamcinolone injection in one eye.

Results

A total of 19 patients' records were evaluated. In treated eyes, median IOPs (in mm Hg) by Goldmann and FMAT-1 were 21 and 21.0, respectively, and mean IOPs were 22.21 and 21.15, respectively. In untreated eyes, median IOPs by Goldmann and FMAT-1 were 15 and 15.7, respectively, and mean IOPs were 15.52 and 15.31, respectively. Median OF (in µL/mm Hg) in treated and untreated eyes was 0.17 and 0.22, respectively, and mean values were 0.17 and 0.23, respectively. Pearson correlation showed an inverse relationship between IOP and OF in treated eyes, and linear regression analysis showed that IOP strongly predicted outflow in this group.

Conclusion

The FMAT-1 generates IOP results substantially similar to Goldmann and OF readings with greater ease than prior tonography devices.

Clinical significance

The mechanism of corticosteroid-induced IOP elevation appears to be a reduction in aqueous OF, and its measurement is tonography. This technique has traditionally been cumbersome. FMAT-1 is a newly launched instrument that measures IOP and OF at the slit lamp simultaneously in a few seconds.

How to cite this article

Staso FD, Gaudio PA. Aqueous Outflow Facility after Periocular Triamcinolone Injection: A Preliminary Evaluation of the Falck Medical Applanation Tonometer. J Curr Glaucoma Pract 2023;17(4):197-204.

Knowledge and Awareness of Glaucoma Among People Living in Taif City in the Western Region of Saudi Arabia

Background Glaucoma represents a significant global health challenge, characterized by progressive and irreversible optic nerve damage, visual field impairment, and potential blindness. Limited awareness can lead to delayed diagnosis and increased healthcare burden. This research explored glaucoma awareness in Taif City, Saudi Arabia. It delved into the influence of demographics, socioeconomic factors, and cultural beliefs on awareness. The study aimed to inform tailored awareness campaigns and policy decision-makers about regional awareness, ultimately contributing to effective healthcare initiatives in the region. Methodology A cross-sectional study was conducted in Taif City including adults (>18 years) using a community-based approach. Data were collected using an electronic questionnaire. Results This study included 1,000 participants. Most participants were males, aged 18-29 years, with 51.1% (n = 511) having at least a bachelor's education. The media (n = 341, 34.1%) and relatives/friends (n = 336, 33.6%) were common sources of glaucoma information. Among all participants, 58.5% (n = 585) had heard of glaucoma, and many were uncertain about glaucoma's definition and normal eye pressure values. About 63.1% (n = 631) believed in a cure, and 43.1% thought vision loss could be restored. Gender, education, and family history significantly influenced awareness. Closed-angle glaucoma (n = 297, 29.7%) and open-angle glaucoma (n = 231, 23.1%) were recognized types, with surgery (n = 371, 37.1%) and laser treatment (n = 274, 27.4%) perceived as potential cures. Conclusions This study revealed glaucoma awareness among adults in Taif City. Gender, education, and family history played significant roles in shaping awareness levels. There is a need for targeted educational efforts to improve knowledge about glaucoma in the community.

HSP27 induced glaucomatous damage in mice of young and advanced age

Introduction

Age-related diseases such as glaucoma, a leading cause of blindness, are having an upward trend due to an aging society. In glaucoma, some patients display altered antibody profiles and increased antibody titers, for example against heat shock protein 27 (HSP27). An intravitreal injection of HSP27 leads to glaucoma-like damage in rats. We now aimed to investigate if aged mice are more prone to this damage than younger ones.

Methods

We intravitreally injected HSP27 into young (1-2 months) and aged (7-8 months) mice to compare glaucomatous damage. Respective age-matched controls received PBS. Not injected eyes served as naive controls.

Results

Optical coherence tomography 4 weeks after injection showed no changes in retinal thickness in all groups at both ages. Cell counts and RT-qPCR revealed a significant reduction in RGC numbers in HSP27 mice at both ages. Comparing aged and young HSP27 mice, no differences in Rbpms and Pou4f1 (RGCs) expression was detected, while the Tubb3 expression (neuronal cells) was significantly upregulated in aged HSP27 animals. Neither microglia/macrophages nor (resident) microglia counts revealed significant differences in HSP27 mice at both ages. Nevertheless, increased relative Iba1 and Tmem119 expression was detected in young and aged HSP27 mice. Aged HSP27 mice displayed a significantly lower Iba1 expression than young ones, whereas Cd68 levels were upregulated. A larger GFAP+ area and an upregulation of GFAP expression in HSP27 animals of both ages indicated a macrogliosis. Also, elevated Il1b and Nos2 expression levels were observed in young and aged HSP27 mice. However, only Il1b levels were upregulated when comparing 7-8 months to 1-2 months old animals. A larger HSP25+ area was seen in aged HSP27 animals, while Hspb2 expression levels were downregulated in both HSP27 groups. The aged HSP27 group displayed an upregulated Hspb2 expression compared to young mice. Furthermore, a higher optic nerve degeneration score was noted in young and aged HSP27 groups.

Discussion

These findings indicate that an intravitreal injection of HSP27 led to RGC loss accompanied by inflammation. Age-dependent effects (7-8 months vs. 1-2 months) were not very prominent. The results suggest a potential role of extracellular HSP27 in the development of glaucoma.

TRIM9 promotes Müller cell-derived retinal stem cells to differentiate into retinal ganglion cells by regulating Atoh7

Glaucoma is a multifactorial, irreversible blinding eye disease characterized by a large number of retinal ganglion cell (RGC) deaths. Müller cell-derived retinal stem cells (RSCs) can be induced to differentiate into RGCs under certain conditions. This study aimed to explore the regulatory effect and mechanism of TRIM9 on the differentiation of Müller cell-derived stem cells into RGCs. First, episcleral vein cauterization was used to induce high intraocular pressure (IOP) rat model. Next, Müller cells were isolated from rat retina, identified and induced to dedifferentiate into RSCs. Finally, RSCs were intervened with lentivirus PGC-FU-TRIM9-GFP transfection or siRNA Atoh7 and induced to redifferentiate into RGCs. In vivo, TRIM9 was highly expressed and Müller cells proliferated abnormally in the high IOP rat model. In vitro, S-100, GFAP, vimentin, and GS were positively expressed in Müller cells isolated from rat retina, and the purity of cells was 97.17%. Under the stimulation of cytokines, the proliferative capacity of the cells and the expression of Nestin and Ki67 gradually increased with the prolongation of culture time. Furthermore, RSCs transfected with the lentiviral vector PGC-FU-TRIM9-GFP displayed a striking morphological feature of long neurites. Additionally, there was a remarkable increase in the fluorescence intensity of Brn-3b and Thy1.1, accompanied by elevated mRNA and protein expression levels of Brn-3b, Thy1.1, and Atoh7. After knocking down Atoh7, the effect of TRIM9 on the above indicators was reversed. TRIM9 might promote the differentiation of Müller cells into RGCs by regulating the expression of Atoh7.

Diagnostic Accuracy of Imaging Devices in Glaucoma: An Updated Meta-Analysis

Background

Different devices have diverse accuracy in diagnosing glaucoma, and therefore choosing the best device is challenging. Thereby, this study was conducted to evaluate the diagnostic sensitivity and specificity of imaging devices in glaucoma and explore the need for an updated meta-analysis on this issue.

Methods

In this systematic review and meta-analysis, PubMed, Scopus, and Web of Science databases were searched for articles published between January 2004 and 2022. Cross-sectional or diagnostic studies were selected, and sensitivity, specificity, positive predictive value, and negative predictive value were measured.

Results

A total of 28 cross-sectional studies were included for meta-analysis. Devices were divided into 2 groups, based on the optic nerve area and the macular area. For the nerve area, the pooled sensitivity was 77% (CI 95%, 70-83; I2, 90.01%) and the pooled specificity was 89% (CI 95%, 84-92, I2, 93.22%), and for the macular area, the pooled sensitivity was 87% (CI 95%, 80-92, I2, 91.79%), and the pooled specificity was 90% (CI 95%, 84-94; I2, 86.30%). We analyzed each device separately. For optical coherence tomography(OCT), the pooled sensitivity was 85% (CI 95%, 81-89; I2, 87.82%) and the pooled specificity was 89% (CI 95%, 85-92; I2, 84.39%); for Heidelberg retinal tomography (HRT), the pooled sensitivity was 72% (CI 95%, 57-83; I2, 88.94%) and the pooled specificity was 79% (CI 95%, 62-90; I2, 98.61%), and for optical coherence tomography angiography (OCTA), the pooled sensitivity was 82% (CI 95%, 66-91; I2, 93.71%) and the pooled specificity was 93% (CI 95%, 87-96; I2, 64.72%).

Conclusion

The macular area was more sensitive and specific than the optic nerve head. Furthermore, OCT had higher sensitivity, and OCTA had higher specificity when compared with other imaging devices.

The regulatory role of microRNAs in common eye diseases: A brief review

MicroRNAs (miRNAs) are highly conserved, small non-coding RNA molecules (∼21 nucleotides) that regulate numerous biological processes, including developmental timing, hematopoiesis, organogenesis, apoptosis, cell differentiation, and proliferation either by mRNA degradation or translation repression. Since eye physiology requires a perfect orchestration of complex regulatory networks, an altered expression of key regulatory molecules such as miRNAs potentially leads to numerous eye disorders. In recent years, comprehensive progress has been made in demonstrating the precise roles of miRNAs, emphasizing their potential use in diagnostic and therapeutic purposes of chronic human diseases. Thus, this review explicitly illustrates the regulatory roles of miRNAs in four common eye disorders, such as cataract, glaucoma, macular degeneration, and uveitis, and their application in disease management.

Computational intelligence in eye disease diagnosis: a comparative study

In recent years, eye disorders are an important health issue among older people. Generally, individuals with eye diseases are unaware of the gradual growth of symptoms. Therefore, routine eye examinations are required for early diagnosis. Usually, eye disorders are identified by an ophthalmologist via a slit-lamp investigation. Slit-lamp interpretations are inadequate due to the differences in the analytical skills of the ophthalmologist, inconsistency in eye disorder analysis, and record maintenance issues. Therefore, digital images of an eye and computational intelligence (CI)-based approaches are preferred as assistive methods for eye disease diagnosis. A comparative study of CI-based decision support models for eye disorder diagnosis is presented in this paper. The CI-based decision support systems used for eye abnormalities diagnosis were grouped as anterior and retinal eye abnormalities diagnostic systems, and numerous algorithms used for diagnosing the eye abnormalities were also briefed. Various eye imaging modalities, pre-processing methods such as reflection removal, contrast enhancement, region of interest segmentation methods, and public eye image databases used for CI-based eye disease diagnosis system development were also discussed in this paper. In this comparative study, the reliability of various CI-based systems used for anterior eye and retinal disorder diagnosis was compared based on the precision, sensitivity, and specificity in eye disease diagnosis. The outcomes of the comparative analysis indicate that the CI-based anterior and retinal disease diagnosis systems attained significant prediction accuracy. Hence, these CI-based diagnosis systems can be used in clinics to reduce the burden on physicians, minimize fatigue-related misdetection, and take precise clinical decisions.

Application of diffusion tensor imaging technology in glaucoma diagnosis

Glaucoma is the first major category of irreversible blinding eye illnesses worldwide. Its leading cause is the death of retinal ganglion cells and their axons, which results in the loss of vision. Research indicates that glaucoma affects the optic nerve and the whole visual pathway. It also reveals that degenerative lesions caused by glaucoma can be found outside the visual pathway. Diffusion tensor imaging (DTI) is a magnetic resonance imaging (MRI) technique that can investigate the complete visual system, including alterations in the optic nerve, optic chiasm, optic tract, lateral geniculate nuclear, and optic radiation. In order to provide a more solid foundation for the degenerative characteristics of glaucoma, this paper will discuss the standard diagnostic techniques for glaucoma through a review of the literature, describe the use of DTI technology in glaucoma in humans and animal models, and introduce these techniques. With the advancement of DTI technology and its coupling with artificial intelligence, DTI represents a potential future for MRI technology in glaucoma research.

Does Diabetes Influence Adherence in Glaucoma Patients?

With chronic diseases, patient adherence plays a crucial role in delaying disease progression and in determining the success of therapy. Problems arise not only from low medication adherence, but also non-adherence to recommended follow-up examinations. Obtaining an accurate estimate of adherence is difficult, especially in glaucoma patients, due to the fact that most antihypertensive drugs are administered in the form of eye drops. There is great variability in the published adherence values for glaucoma patients. Most studies report an average medication adherence of approximately 70%, with around 50% of patients having good adherence (at least 80% of medication administered as planned). Furthermore, 6.8 - 31.4% of the eye drops do not end up in the patient's eye, which means there is even less active ingredient to achieve a therapeutic effect. Glaucoma patients also show low persistence and adherence to follow-up appointments. Since diabetes increases the risk for POAG and secondary glaucoma and given that diabetics have particularly low adherence, the question arose whether a diabetes diagnosis is associated with reduced adherence in glaucoma patients. Previous studies found no significant association between diabetes and reduced adherence in glaucoma patients, although a significant impact of elevated HbA_1c on adherence in glaucoma patients was found in one study. However, this connection still needs to be examined more closely in studies with larger samples.

Biomechanical homeostasis in ocular diseases: A mini-review

Diabetes mellitus-induced hyperglycemia is responsible for multiple pathological ocular alternations from vasculopathy to biomechanical dyshomeostasis. Biomechanical homeostasis is crucial to maintain the normal physiological condition of the eyes. Biomechanical features vary in eye tissues regarding different anatomical positions, tissue components, and cellular functions. The disturbance in biomechanical homeostasis may result in different ocular diseases. In this review, we provide a preliminary sketch of the latest evidence on the mechano-environment of the eyeball and its possible influencing factors, thereby underscoring the relationship between the dyshomeostasis of ocular biomechanics and common eye diseases (e.g., diabetic retinopathy, keratoconus, glaucoma, spaceflight-associated neuro-ocular syndrome, retinal vein occlusion and myopia, etc.). Together with the reported evidence, we further discuss and postulate the potential role of biomechanical homeostasis in ophthalmic pathology. Some latest strategies to investigate the biomechanical properties in ocular diseases help unveil the pathological changes at multiple scales, offering references for making new diagnostic and treatment strategies targeting mechanobiology.

[Micro-invasive glaucoma surgery]

Glaucoma is a severe, rapidly progressing disease that in the absence of proper treatment leads to blindness in 20% of patients. According to the World Glaucoma Association, this disease is the most socially significant in modern ophthalmology and requires searching for new and effective methods of treatment. This article presents the results of research and reviews on this issue, considers both conservative therapy and surgical methods of treatment, analyzes in detail modern methods of micro-invasive eye surgery actively used in clinical practice. The article also describes indications for a various types of interventions, as well as the effect achieved by them and the possible complications, and presents the conclusions about the possibility of using these procedures in wide clinical practice.

Pupillary response to chromatic light stimuli as a possible biomarker at the early stage of glaucoma: a review

Glaucoma is a multifactorial neurodegenerative disease of the optic nerve currently considered a severe health problem because of its high prevalence, being the primary cause of irreversible blindness worldwide. The most common type corresponds to Primary Open-Angle Glaucoma. Glaucoma produces, among other alterations, a progressive loss of retinal ganglion cells (RGC) and its axons which are the key contributors to generate action potentials that reach the visual cortex to create the visual image. Glaucoma is characterized by Visual Field loss whose main feature is to be painless and therefore makes early detection difficult, causing a late diagnosis and a delayed treatment indication that slows down its progression. Intrinsically photosensitive retinal ganglion cells, which represent a subgroup of RGCs are characterized by their response to short-wave light stimulation close to 480 nm, their non-visual function, and their role in the generation of the pupillary reflex. Currently, the sensitivity of clinical examinations correlates to RGC damage; however, the need for an early damage biomarker is still relevant. It is an urgent task to create new diagnostic approaches to detect an early stage of glaucoma in a prompt, quick, and economical manner. We summarize the pathology of glaucoma and its current clinical detection methods, and we suggest evaluating the pupillary response to chromatic light as a potential biomarker of disease, due to its diagnostic benefit and its cost-effectiveness in clinical practice in order to reduce irreversible damage caused by glaucoma.

Role of extracellular vesicles in mitochondrial eye diseases

Extracellular vesicles (EVs) are small packages that are released by almost all types of cells. While the role of EVs in pathogenesis of certain diseases such as cancer is well established, EVs role in ocular health and disease is still at early stages of investigation. Given the significant role of EVs in pathological development and progression of diseases such as cancer, EVs present a similar opportunity for investigation in ocular pathophysiology. Studies have shown the presence of EVs in fluids from the ocular environment have close links with ocular health and disease. Hence, the cargo carried in EVs from ocular fluids can be used for monitoring disease phenotypes or therapeutic outcomes in eye-related disorders. Furthermore, in recent times EVs have increasingly gained attention as therapeutics and drug-delivery vehicles for treatment of eye diseases. There is a close relationship between EVs and mitochondria functioning with mitochondria dysfunction leading to a significant number of ophthalmic disorders. This review discusses the current knowledge of EVs in visual systems with a special focus on eye diseases resulting from dysfunctional mitochondria.

Refractive Changes after Glaucoma Surgery-A Comparison between Trabeculectomy and XEN Microstent Implantation

Best-corrected visual acuity often decreases temporarily or permanently after trabeculectomy (TE). The purpose of this study was to compare visual acuity and refractive changes after TE or XEN microstent implantation (XEN) in primary open-angle glaucoma (POAG) or pseudoexfoliation glaucoma (PEX) cases naïve to prior glaucoma surgery over a 24-month follow-up period. We analyzed 149 consecutive glaucoma patients who received either TE or XEN because of medically uncontrollable POAG or PEX. Intraocular pressure (IOP), IOP-lowering medication use, subjective and objective refraction and best-corrected visual acuity were evaluated. In addition, surgically induced astigmatism (SIA) was calculated and compared using the vector analysis method described by Jaffe and Clayman. A total of 93 eyes (85 POAG; 8 PEX) were treated with TE and 56 eyes (50 POAG; 6 PEX) with XEN. After 24 months, the mean IOP and number of IOP-lowering medications used decreased significantly after TE (p < 0.01) and XEN (p < 0.01). In the TE group, mean best-corrected visual acuity (BCVA) changed from 0.16 ± 0.26 to 0.23 ± 0.28 logMAR (p < 0.01) after 24 months, while mean BCVA did not change significantly in the XEN group (preoperative: 0.40 ± 0.50 logMAR, postoperative: 0.36 ± 0.49 logMAR; p = 0.28). SIA was almost the same in both groups at the end of the 24-month follow-up period (0.75 ± 0.60 diopters after TE and 0.81 ± 0.56 diopters after XEN; p = 0.57). In addition, there was no significant correlation between SIA and the observed BCVA changes or SIA and IOP reduction 12 or 24 months after TE or XEN. Our results demonstrate that TE and XEN are effective methods for reducing IOP and IOP-lowering medication use. The SIA was nearly similar in both groups. The SIA does not seem responsible for the decreased visual acuity after TE.

[Glaucoma care in Germany-results of a survey among German ophthalmologists-part 2: treatment]

BACKGROUND

The options for glaucoma treatment are quite diverse. The question therefore arises what is considered beneficial and feasible in daily practice. Our anonymized survey among members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists in Germany (BVA) intends to explore treatment patterns and strategies in routine glaucoma care in Germany.

OBJECTIVE

The current article reflects current opinions of German ophthalmologists regarding glaucoma care, therapeutic strategies, and the role of glaucoma surgery.

MATERIALS AND METHODS

The survey was conducted using an online questionnaire with 26 questions (107 items) regarding care practice for glaucoma diagnosis and treatment. Complete responses were available from 1361 participants.

RESULTS

A total of 84.8% of responders define a target pressure regularly. A systemic therapeutic approach is followed by 44.9%. Two thirds consider side effects of eye drops to impair quality of life. Most common are conjunctival hyperemia and burning. Non-adherence to treatment is estimated to occur in 32% of patients. Approximately 5-10% of glaucoma patients are treated surgically. Among interventional treatment options, 90% consider trabeculectomy beneficial, followed by minimally invasive glaucoma surgery (MIGS) and selective laser trabeculoplasty (SLT), which are, however, the most commonly performed procedures.

CONCLUSION

The choice of treatment should intend a long-lasting reduction of intraocular pressure and yet to be reasonable and manageable. There is a demand for more overview and structured care.

Clinical Efficacy of Topical Tacrolimus on Conjunctival Hyperemia Caused by Prostaglandin Analogues

Objective

To evaluate the clinical efficacy of tacrolimus ophthalmic solution on conjunctival hyperemia caused by prostaglandin analogues.

Methods

A retrospective analysis was performed on 120 patients diagnosed with bilateral primary open-angle glaucoma (POAG). The enrolled patients developed symptoms of conjunctival hyperemia during the administration of travoprost ophthalmic solution. The patients were divided into two groups: 0.004% travoprost solution was administered in the control group. A combination of 0.004% travoprost solution with tacrolimus was administered in the experimental group. Clinopathological parameters including intraocular pressure (IOP), subjective dry eye symptom score (SDES), hyperemia score, and noninvasive tear break-up time (NIBUT) were recorded at week 0, 1, 2, and 4. Two-way ANOVA for repeated measurement was employed for statistical analysis using SPSS 22.0 software.

Results

At week 1, 2, and 4, the IOP and SDES of both the control and experimental groups were significantly lower when compared the values at week 0 (before treatment). No significant differences in the IOP values between the two groups were observed at all time points. At week 2, the SDES and hyperemia score were lower in the experimental group than those in the control group, and the NIBUT was significantly longer in the experimental group. The above parameters showed no significant difference at week 4 between the two groups, although the average SDES and hyperemia score were slightly lower in the experimental group.

Conclusion

Tacrolimus ophthalmic solution can relieve conjunctival hyperemia, improve ocular surface conditions, and reduce discomfort caused by prostaglandin analogues.

Clinical pharmacology and pharmacogenetics of prostaglandin analogues in glaucoma

Glaucoma is the main cause of irreversible visual loss worldwide, and comprises a group of progressive, age-related, and chronic optic neuropathies. Prostaglandin analogs are considered a first-line treatment in the management of glaucoma and have the best efficacy in reducing intraocular pressure. When comparing these therapeutic agents between them, long-term therapy with 0.03% bimatoprost is the most effective followed by treatment with 0.005% latanoprost and 0.004% travoprost. The prevalence of adverse events is lower for latanoprost than for other prostaglandin analogs. However, some patients do not respond to the treatment with prostaglandin analogs (non-responders). Intraocular pressure-lowering efficacy differs significantly between individuals partly owing to genetic factors. Rs1045642 in ABCB1, rs4241366 in SLCO2A1, rs9503012 in GMDS, rs10306114 in PTGS1, rs11568658 in MRP4, rs10786455 and rs6686438 in PTGFR were reported to be positive with the response to prostaglandin analogs in patients with glaucoma. A negative association was found between single nucleotide polymorphisms of PTGFR (rs11578155 and rs6672484) and the response to prostaglandin analogs in patients with glaucoma. The current review is an analysis of the information relevant to prostaglandin analog treatments based on previous literatures. It describes in detail the clinical pharmacology and pharmacogenetics of drugs belonging to this therapeutical class to provide a sound pharmacological basis for their proper use in ophthalmological clinical practice.

Two Year Functional and Structural Changes-A Comparison between Trabeculectomy and XEN Microstent Implantation Using Spectral Domain Optical Coherence Tomography

The aim of this study was to analyze retinal nerve fiber layer (RNFL) thickness after trabeculectomy (TE) versus XEN microstent implantation (XEN) in primary open-angle glaucoma (POAG) cases naïve to prior incisional glaucoma surgery. We examined 119 consecutive glaucoma patients retrospectively, who received a TE or XEN for medically uncontrolled POAG. Intraocular pressure (IOP), amount of IOP-lowering medication, mean deviation of standard automated perimetry and peripapillary RNFL thickness were evaluated during the first 24 months after surgery. Fifty eyes were treated with TE and 69 eyes with XEN. Mean IOP decreased from 25.1 ± 0.8 to 13.3 ± 0.6 mm Hg (p < 0.01) and mean number of IOP-lowering eye drops from 3.2 ± 0.2 to 0.4 ± 0.1 (p < 0.01) 24 months after TE. In 69 eyes undergoing XEN, mean IOP dropped from 24.8 ± 0.6 to 15.0 ± 0.4 mm Hg (p < 0.01) and medication from 3.0 ± 0.1 to 0.6 ± 0.1 (p < 0.01) during the 24 months follow-up. Mean deviation of standard automated perimetry remained stable in TE (8.5 ± 0.7 to 8.1 ± 0.8 dB; p = 0.54) and XEN group (11,0 ± 0.5 to 11.5 ± 0.5 dB; p = 0.12) after 24 months, while mean RNFL thickness further deteriorated in the TE (−2.28 ± 0.65 µm/year) and XEN (−0.68 ± 0.34 µm/year) group. Postoperative RNFL loss develops after TE and XEN despite effective and significant lowering of IOP and amount of IOP-lowering medication. RNFL loss was more pronounced in the first year after glaucoma surgery.

The Role of IL-6 in Fibrotic Diseases: Molecular and Cellular Mechanisms

Fibrosis is a detrimental outcome of most chronic inflammatory disorders and is defined by the buildup of excess extracellular matrix (ECM) components, which eventually leads to organ failure and death. Interleukin 6 (IL-6) is promptly produced by immune cells in response to tissue injuries and has a wide range of effects on cellular processes such as acute responses, hematopoiesis, and immune reactions. Furthermore, high levels of IL-6 have been found in a variety of chronic inflammatory disorders characterized by fibrosis, and this factor plays a significant role in fibrosis in various organs via Janus kinase/signal transducer and activator of transcription 3 (JAK/STAT3) activation. Here, we review what is known about the role of IL-6 in fibrosis and why targeting IL-6 for fibrotic disease treatment makes sense.

Deep learning and optical coherence tomography in glaucoma: Bridging the diagnostic gap on structural imaging

Glaucoma is a leading cause of progressive blindness and visual impairment worldwide. Microstructural evidence of glaucomatous damage to the optic nerve head and associated tissues can be visualized using optical coherence tomography (OCT). In recent years, development of novel deep learning (DL) algorithms has led to innovative advances and improvements in automated detection of glaucomatous damage and progression on OCT imaging. DL algorithms have also been trained utilizing OCT data to improve detection of glaucomatous damage on fundus photography, thus improving the potential utility of color photos which can be more easily collected in a wider range of clinical and screening settings. This review highlights ten years of contributions to glaucoma detection through advances in deep learning models trained utilizing OCT structural data and posits future directions for translation of these discoveries into the field of aging and the basic sciences.

Potential role of extracellular granzyme B in wet age-related macular degeneration and fuchs endothelial corneal dystrophy

Age-related ocular diseases are the leading cause of blindness in developed countries and constitute a sizable socioeconomic burden worldwide. Age-related macular degeneration (AMD) and Fuchs endothelial corneal dystrophy (FECD) are some of the most common age-related diseases of the retina and cornea, respectively. AMD is characterized by a breakdown of the retinal pigment epithelial monolayer, which maintains retinal homeostasis, leading to retinal degeneration, while FECD is characterized by degeneration of the corneal endothelial monolayer, which maintains corneal hydration status, leading to corneal edema. Both AMD and FECD pathogenesis are characterized by disorganized local extracellular matrix (ECM) and toxic protein deposits, with both processes linked to aberrant protease activity. Granzyme B (GrB) is a serine protease traditionally known for immune-mediated initiation of apoptosis; however, it is now recognized that GrB is expressed by a variety of immune and non-immune cells and aberrant extracellular localization of GrB substantially contributes to various age-related pathologies through dysregulated cleavage of ECM, tight junction, and adherens junction proteins. Despite growing recognition of GrB involvement in multiple age-related pathologies, its role in AMD and FECD remains poorly understood. This review summarizes the pathophysiology of, and similarities between AMD and FECD, outlines the current knowledge of the role of GrB in AMD and FECD, as well as hypothesizes putative contributions of GrB to AMD and FECD pathogenesis and highlights the therapeutic potential of pharmacologically inhibiting GrB as an adjunctive treatment for AMD and FECD.

Glaucoma in Adults-diagnosis, Management, and Prediagnosis to End-stage, Categorizing Glaucoma's Stages: A Review

Importance

Most frequent worldwide cause of permanent blindness is glaucoma. Early in the course of the disease, glaucoma affects many patients without any symptoms. In order to examine for indications of glaucoma and to ascertain whether systemic illnesses or drugs can raise a patient's risk of developing glaucoma, primary care practitioners should be aware of which patients to send to an eye care specialist. A review of the pathogenesis, risk factors, screening, disease monitoring, and treatment options for open-angle and narrow-angle glaucoma are included.

Observations

The optic nerve and retinal nerve fiber layer (rNFL) are damaged in glaucoma, a chronic, progressive optic neuropathy that can result in a permanent loss of peripheral or central vision. The only risk factor that is known to be controllable is intraocular pressure (IOP). A family history of glaucoma, older age, and non-white race are additional significant risk factors. Numerous systemic diseases and drugs, such as corticosteroids, anticholinergics, certain antidepressants, and topiramate, can put people at risk of developing glaucoma. Open-angle and angle-closure glaucoma are the two main types of disease. Measurement of IOP, perimetry, and optical coherence tomography are diagnostic procedures to evaluate glaucoma and track the course of the condition. In order to treat glaucoma, IOP must be decreased. This is possible with a variety of glaucoma medication classes, laser surgery, and incisional surgery.

Verdicts and relevance

By identifying systemic illnesses and drugs that raise a patient's chance of developing glaucoma and referring high-risk individuals for a thorough ophthalmologic examination, vision loss from glaucoma can be reduced. Clinicians should make sure that patients continue taking their glaucoma drugs as prescribed and should keep an eye out for any negative side effects from any medical or surgical procedures used to treat glaucoma.

How to cite this article

Joshi P, Dangwal A, Guleria I, et al. Glaucoma in Adults-diagnosis, Management, and Prediagnosis to End-stage, categorizing Glaucoma's Stages: A Review. J Curr Glaucoma Pract 2022;16(3):170-178.

Terrestrial health applications of visual assessment technology and machine learning in spaceflight associated neuro-ocular syndrome

The neuro-ocular effects of long-duration spaceflight have been termed Spaceflight Associated Neuro-Ocular Syndrome (SANS) and are a potential challenge for future, human space exploration. The underlying pathogenesis of SANS remains ill-defined, but several emerging translational applications of terrestrial head-mounted, visual assessment technology and machine learning frameworks are being studied for potential use in SANS. To develop such technology requires close consideration of the spaceflight environment which is limited in medical resources and imaging modalities. This austere environment necessitates the utilization of low mass, low footprint technology to build a visual assessment system that is comprehensive, accessible, and efficient. In this paper, we discuss the unique considerations for developing this technology for SANS and translational applications on Earth. Several key limitations observed in the austere spaceflight environment share similarities to barriers to care for underserved areas on Earth. We discuss common terrestrial ophthalmic diseases and how machine learning and visual assessment technology for SANS can help increase screening for early intervention. The foundational developments with this novel system may help protect the visual health of both astronauts and individuals on Earth.

Meta-Analysis of the Comprehensive Efficacy of Intraocular Lens Implantation in Glaucoma Patients

This study is aimed at investigating the efficacy of intraocular lens (IOL) implantation in patients suffering from glaucoma through meta-analysis of the previously published research. For this purpose, different literature databases were searched for identification of clinical studies published between January 2000 and January 2022 on evaluating IOL's efficacy in treating glaucoma. RevMan 5.3 was used to conduct a meta-analysis of the pertinent data. The central anterior chamber depth (ACD), corneal endothelial cell counts, best-corrected visual acuity (BCVA), intraocular pressure (IOP), anti-glaucoma medications (AGM), and axial length (AL) changes were compared, and the incidence of postoperative complications was thoroughly evaluated. The Cochran chi-square test was used to examine the heterogeneity of the evaluation results. According to the inclusion and exclusion criteria, 20 studies included 948 glaucomatous eyes. IOP was significantly lower than before treatment (MD = 8.64, 95 CI: 5.75-11.53; Z = 5.86, P < 0.0001), while ACD increased significantly (MD = -1.38, 95 percent CI: -1.74-1.02; Z = 7.49, P < 0.0001). The corneal endothelial cell counts were homogeneous (MD = 225.08, 95% CI: -64.17 to -514.33; Z = 1.53, P = 0.20). AGM utilisation decreased (MD = 1.43, 95% CI: 0.752.12, Z = 4.09, P < 0.0001). AL decreased significantly (MD = 0.31; 95% CI: 0.09-0.54; Z = 2.71; P = 0.007). The incidence of complications remained insignificant after IOL treatment (OR = 1.05, 95% CI: 0.42 to 2.60; Z = 0.10, P = 0.92; P = 0.92). These findings indicate that IOL treatment can significantly reduce intraocular pressure, glaucoma drug use, and aqueous level (AL) in glaucoma patients while increasing the depth of the central anterior chamber. This study offers a theoretical foundation for selecting glaucoma treatment methods.