Effectiveness and safety of XEN45 implant over 12 months of follow-up: data from the XEN-Glaucoma Treatment Registry

OBJECTIVES

To evaluate the 1-year effectiveness and safety of the XEN45, either alone or in combination with phacoemulsification, in glaucoma patients.

METHODS

This multicentre, prospective, observational study included consecutive eyes of glaucoma patients from the Italian XEN-Glaucoma Treatment Registry (XEN-GTR) who underwent XEN45 alone or in combination with phacoemulsification, with at least 1 year of follow-up. Surgical success was defined as intraocular pressure (IOP) < 18 mmHg and ≥20% reduction from preoperative IOP, over 1 year of follow-up.

RESULTS

Two hundred thirty-nine eyes (239 patients) were analyzed, 144 (60.2%) eyes in the XEN-solo and 95 (39.8%) eyes in the XEN+Phaco groups. One hundred-sixty-eight (70.3%) eyes achieved overall success, without statistically significant differences between study groups (p = 0.07). Preoperative IOP dropped from a median (IQR) of 23.0 (20.0-26.0) mmHg to 14.0 (12.0-16.0) mmHg at month 12 (p < 0.001), with overall 39.9 ± 18.3% IOP reduction. The mean number of preoperative ocular hypotensive medications (OHM) was significantly reduced from 2.7 ± 0.9 to 0.5 ± 0.9 at month 12 (p < 0.001). Preoperative IOP < 15 mmHg (HR: 6.63; 95%CI: 2.61-16.84, p < 0.001) and temporal position of the surgeon (HR: 4.25; 95%CI: 2.62-6.88, p < 0.001) were significantly associated with surgery failure. One hundred-forty-six (61.1%) eyes had no intraoperative complications, whereas 91 (38.1%) and 56 (23.4%) eyes experienced at least one complication, respectively early (< month 1) and late (≥ month 1), all self-limiting or successfully treated without sequelae. Needling occurred in 55 (23.0%) eyes at least once during follow-up.

CONCLUSION

Over 1-year follow-up, XEN45 alone or in combination with phacoemulsification, had comparable success rates and effectively and safely lowered IOP and the need for OHM.

Italian Candidates for the XEN Implant: An Overview from the Glaucoma Treatment Registry (XEN-GTR)

Background The Italian XEN Glaucoma Treatment Registry (XEN-GTR) was created to acquire a comprehensive prospective dataset that includes the patient characteristics, intraoperative variables, and postoperative management of glaucoma patients undergoing the XEN gel stent implantation. Methods This was a prospective observational, longitudinal clinical study involving 10 centres throughout Italy. The baseline examination included a comprehensive evaluation of demographic parameters (age, sex, ethnicity, and systemic condition), specific ophthalmological parameters, and quality of life questionnaire score collection. Results The baseline data of 273 patients were analysed. The median (IQR) age was 72 (65.0 to 78.0) years. Of the 273 patients, 123 (45%) were female and 150 (55%) were male. A total of 86% of the patients had open-angle glaucoma with a mean intraocular pressure of 24 ± 6 (range 12.0–60.0) mmHg. The mean number of medications was 2.7 ± 0.9 at baseline for the patients with a prevalence of prostaglandin analogues combined with a beta-blocker and anhydrase carbonic inhibitor (31.8%). The mean scores of the NEI-VFQ 25 and GSS questionnaires were 78 ± 18 (range 26.5–100) and 85 ± 14 (range 79–93), respectively. Combined XEN/cataract surgeries were scheduled in 73.7% of the patients. The preferred place for the XEN implant was the supero-nasal quadrant (91.6%). Conclusions Observing the baseline characteristics of the typical Italian candidates for the XEN gel implant shows that they are patients affected by POAG and cataracts, with moderate to severe glaucoma damage, all of which has an impact on their quality of life.

The “Topography” of Glaucomatous Defect Using OCT and Visual Field Examination

Aim

To describe the modifications in the superior and inferior retinal nerve fiber layer (RNFL) thickness regarding the distribution of the VF defects for the horizontal meridians in glaucomatous patients and the differences in the RNFL thickness topography between glaucomatous and healthy subjects.

Methods

One hundred twenty eyes of 91 patients affected by glaucoma and 94 eyes of 51 normal patients were retrospectively reviewed. Computerized 30°VF (Octopus G1 Dynamic strategy) and optical coherence tomography (OCT) ONH and 3D disk analysis were performed in all cases. The RNFL thickness measures analyzed in both groups were superior-nasal (SN), superior-temporal (ST), inferior-nasal (IN), and inferior temporal (IT) sectors. The VFs were classified according to the distribution of the VF defect as for the horizontal meridian in the pattern deviation plot as superior, inferior, predominantly superior, or predominantly inferior.

Result

In the glaucomatous group, 78 eyes (65%) showed a predominantly superior VF defect, while 38 eyes (32%) showed a predominantly inferior VF defect. Fifty-six eyes (46.7%) presented an exclusively superior, and 27/120 eyes (22.5%) presented an exclusively inferior VF defect. In the control group, the thickest RNFL sector was IT. The ST sector showed the thickest RNFL in presence of an exclusive superior VF defect. In case of an exclusive inferior VF defect, the thickest RNFL was the IT sector. VF showing superior defect presented a more altered MD than the VF with an inferior defect.

Conclusion

Glaucomatous damage affects both the superior and inferior neural rim almost simultaneously. However, the neural rim loss seems to be asymmetric, involving the inferior or superior rim depending on the predominant involvement of the superior or inferior hemifield at the VF test. Particularly, the IT sector appears to be the most compromised in glaucomatous eyes. Therefore, the asymmetry between superior and inferior RNFL could support the diagnosis of glaucoma.

How to cite this article

de Paula A, Perdicchi A, Pocobelli A, et al. The “Topography” of Glaucomatous Defect Using OCT and Visual Field Examination. J Curr Glaucoma Pract 2022;16(1):31-35.

Visual Field Endpoints Based on Subgroups of Points May Be Useful in Glaucoma Clinical Trials: A Study With the Humphrey Field Analyzer and Compass Perimeter

PRECIS

Visual field (VF) endpoints based on average deviation of specific subsets of points rather than all points may offer a more homogeneous data set without necessarily worsening test-retest variability and so may be useful in clinical trials.

PURPOSE

The purpose of this study was to characterize the outcome measures encompassing particular subsets of VF points and compare them as obtained with Humphrey [Humphrey visual field analyser (HVF)] and Compass perimeters.

METHODS

Thirty patients with imaging-based glaucomatous neuropathy performed a pair of 24-2 tests with each of 2 perimeters. Nonweighted mean deviation (MD) was calculated for the whole field and separate vertical hemifields, and again after censoring of points with low sensitivity (MDc) and subsequently including only "abnormal" points with a total deviation probability of <5% (MDc5%) or <2% (MDc2%). Test-retest variability was assessed using Bland-Altman 95% limits of agreement (95%LoA).

RESULTS

For the whole field, using HVF, MD was -7.5±6.9 dB, MDc -3.6±2.8 dB, MDc5% -6.4±1.7 dB, and MDc2% -7.3±1.5 dB. With Compass the MD was -7.5±6.6, MDc -2.9±1.7 dB, MDc5% -6.3±1.5, and MDC2% -7.9±1.6. The respective 95%LoA were 5.5, 5.3, 4.6, and 5.6 with HVF, and 4.8, 3.7, 7.1, and 7.1 with Compass. The respective number of eligible points were 52, 42±12, 20±11, and 15±9 with HVF, and 52, 41.2±12.6, 10±7, and 7±5 with Compass. With both machines, SD and 95%LoA increased in hemifields compared with the total field, but this increase was mitigated after censoring.

CONCLUSION

Restricting analysis to particular subsets of points of interest in the VF after censoring points with low sensitivity, as compared with using the familiar total field MD, can provide outcome measures with a broader range of MD, a markedly reduced SD and therefore more homogeneous data set, without necessarily worsening test-retest variability.

Do Additional Testing Locations Improve the Detection of Macular Perimetric Defects in Glaucoma?

PURPOSE

To evaluate the ability of additional central testing locations to improve detection of macular visual field (VF) defects in glaucoma.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS

Four hundred forty healthy people and 499 patients with glaucomatous optic neuropathy (GON) were tested with a fundus tracked perimeter (CMP; CenterVue) using a 24-2 grid with 12 additional macular locations (24-2+).

METHODS

Glaucomatous optic neuropathy was identified based on expert evaluation of optic nerve head photographs and OCT scans, independently of the VF. We defined macular defects as locations with measurements outside the 5% and 2% normative limits on total deviation (TD) and pattern deviation (PD) maps within the VF central 10°. Classification was based on the total number of affected macular locations (overall detection) or the largest number of affected macular locations connected in a contiguous cluster (cluster detection). Criteria based on the number of locations and cluster size were used to obtain equivalent specificity between the 24-2 grid and the 24-2+ grids, calculated using false detections in the healthy cohort. Partial areas under the receiver operating characteristic curve (pAUCs) were also compared at specificities of 95% or more.

MAIN OUTCOME MEASURES

Matched specificity comparison of the ability to detect glaucomatous macular defects between the 24-2 and 24-2+ grids.

RESULTS

At matched specificity, cluster detection identified more macular defects with the 24-2+ grid compared with the 24-2 grid. For example, the mean increase in percentage of detection was 8% (95% confidence interval, 5%-11%) and 10% (95% confidence interval [CI], 7%-13%) for 5% TD and PD maps, respectively, and 5% (95% CI, 2%-7%) and 6% (95% CI, 4%-8%) for the 2% TD and PD maps, respectively. Good agreement was found between the 2 grids. The improvement measured by pAUCs was also significant but generally small. The percentage of eyes with macular defects ranged from about 30% to 50%. Test time for the 24-2+ grid was longer (21% increase) for both cohorts. Between 74% and 98% of defects missed by the 24-2 grid had at least 1 location with sensitivity of < 20 dB.

CONCLUSIONS

Visual field examinations with additional macular locations can improve the detection of macular defects in GON modestly without loss of specificity when appropriate criteria are selected.

Volume Rendering of Angiographic Optical Coherence Tomography Angiography in Fovea Plana and Normal Foveal Pit

This paper aims to study adaptative vascular arrangements in idiopathic fovea plana with volume-rendered optical coherence tomography angiography (OCTA). A retrospective review of two cases of idiopathic fovea plana (mean age: 26.5 years) and two age-matched controls imaged with OCTA was conducted using spectral-domain OCTA (RTVue XR Avanti, Optovue, Inc., Fremont, CA) equipped with the AngioVue software. Both en face OCTA slabs and OCTA b scans were processed through Fiji software (http://fiji.sc; software version 2.0.0-rc-68/1.52e), and then extracted as image sequences for volume rendering reconstructions using the ImageVis3D volume rendering system (3.1.0 release). Eyes with idiopathic fovea plana demonstrated a regular superficial vascular plexus connecting to a single vascular monolayer representing the deeper vascular plexuses. At this location, several vertical short path connections were demonstrated, in contraposition with normal eyes where short path connections were infrequently observed. Advances in three-dimensional OCTA reconstruction increase the understanding of vascular connections and arrangement in retinal plexuses and possible anatomical variations that cannot be detected with conventional two-dimensional b scans.

Effect of intraocular pressure lowering on the capillary density of optic nerve head and retinal nerve fiber layer in patients with glaucoma

Purpose:

To evaluate the effect of IOP lowering on the capillary density of optic nerve head and retinal nerve fiber layer in patients with primary open angle glaucoma.

Methods:

Twenty eyes of 14 glaucomatous patients and 15 eyes of nine normal patients were enrolled. The most appropriate hypotonic treatment was applied to every patient. A HD Angio Disc 4.5 scan (Avanti-AngioVue) was performed at baseline and after a month in the glaucomatous eyes. The following parameters were analyzed: Radial Papillary Capillaries (RPC) density, inside disc, peripapillary, superior-hemi, inferior-hemi, quadrants, and peripapillary, hemi-superior, hemi-inferior, and quadrants RNFL thickness. Optic nerve head analysis was also evaluated. In addition, the RPC density and the RNFL were assessed in the eight sectors provided by the software.

Results:

The RPC density did not significantly change after IOP reduction ( p > 0.05). The inferior-temporal ( p = 0.005) and inferior-nasal sectors ( p < 0.001) showed a greater capillary density than the respective superior sectors in healthy eyes. In contrast in the glaucomatous eyes, the superior-nasal exhibited greater capillary density with respect to the inferior-nasal sectors. The aggregate RPC density of the inferior sectors was greater than the superior ones in the control group ( p < 0.001). An improvement of the average disc area ( p = 0.01) and the average cup volume ( p = 0.059) were also observed along with increased RNFL thickness at different locations (all, p < 0.05) after IOP lowering therapy was initiated.

Conclusion:

The glaucomatous eyes presented rarefaction of the radial papillary capillaries density in the inferior sectors, but no significant changes in the density after IOP-lowering medications.

An Iconic Case of Pigmentary Glaucoma: Brief Review of the Literature

Pigment dispersion syndrome and pigmentary glaucoma are two conditions characterized by pigment dispersion originating from the posterior part of the iris and its accumulation on the trabecular meshwork, corneal endothelium, and anterior surface of the lens. The pigment on the trabecular meshwork can cause chronic inflammation with a secondary reduction of its function and an increase in intraocular pressure. The case presented represents a typical example of pigmentary glaucoma in a myopic patient in which all the signs, symptoms, and complications typical of these pathologies were present. We report and describe an 8-year-long follow-up period with clinical and instrumental examinations.

Effect of fundus tracking on structure-function relationship in glaucoma

AIMS

To investigate the effect of fundus tracking perimetry on structure-function relationship in glaucoma.

METHODS

Perimetric data were acquired with the Humphrey Field Analyzer (HFA) and the Compass fundus perimeter (CMP, equipped with fundus tracking). We included data from 696 eyes from 360 healthy people and 711 eyes from 434 patients with glaucoma from the original study, for which the circumpapillary retinal nerve fibre layer optical coherence tomography scan (Cp-RNFL) was available. We explored the structure-function relationship using both global indices (mean deviation and average Cp-RNFL thickness loss) and anatomically defined visual field clusters comparing the R² values from mixed-effect models. We then measured the diagnostic ability of a combined Structure Function Index (SFI) using perimetric data from either perimeter. The comparisons were based on partial receiver operating characteristic curves with a minimum specificity of 75% and their areas under the curve.

RESULTS

The R² for the global structure-function relationship was 0.50 for the CMP and 0.48 for the HFA. When visual field clusters were included in the model, the R² was 0.29 for CMP and 0.30 for HFA. Overall, the discrimination ability of the SFI was not significantly higher than the Cp-RNFL for either the CMP (p=0.07) or the HFA (p=0.14). However, it was significantly better in eyes with perimetric damage (p<0.001), in which the CMP-SFI performed significantly better than the HFA-SFI (p=0.03).

CONCLUSIONS

Structure-function relationship is similar between the two perimeters. Fundus tracking might improve discrimination ability with a combined SFI.

TRIAL REGISTRATION NUMBER

ISRCTN13800424.

Ganglion Cell Complex Analysis in Glaucoma Patients: What Can It Tell Us?

Glaucoma is a group of optic neuropathies characterized by a progressive degeneration of retina ganglion cells (RGCs) and their axons that precedes functional changes detected on the visual field. The macular ganglion cell complex (GCC), available in commercial Fourier-domain optical coherence tomography, allows the quantification of the innermost retinal layers that are potentially involved in the glaucomatous damage, including the retinal nerve fiber (RNFL), ganglion cell and inner plexiform layers. The average GCC thickness and its related parameters represent a reliable biomarker in detecting preperimetric glaucomatous damage. The most accurate GCC parameters are represented by average and inferior GCC thicknesses, and they can be associated with progressive visual field loss. Although the diagnostic accuracy increases with more severe glaucomatous damage and higher signal strength values, it is not affected by increasing axial length, resulting in a more accurate discrimination of glaucomatous damage in myopic eyes with respect to the traditional RNFL thickness. The analysis of the structure-function relationship revealed a good agreement between the loss in retinal sensitivity and GCC thickness. The use of a 10-2° visual field grid, adjusted for the anatomical RGCs displacement, describes more accurately the relationship between RGCs thickness and visual field sensitivity loss.

Postural changes revealing orbital venous malformation using ultrasound in blue rubber bleb nevus syndrome

A 62-year-old white woman presented with a diagnosis of blue rubber bleb nevus syndrome (BRBNS). The right eye appeared enophthalmic, yet the patient complained of episodes of right proptosis on bending forward. The remainder of the examination was unremarkable. Orbital ultrasound (US) in an upright posture revealed a single low reflectivity cavity (4.27 mm x 2.82 mm) of uncertain interpretation. In a forward-leaning posture the lesion increased in size (maximum thickness of 13.72 mm), demonstrating multiple low reflectivity spaces with highly reflective septae. This case first reports the use of US with postural changes to assess the presence of orbital venous malformation in BRBNS. The expansile nature upon postural changes supports the venous origin of the orbital lesion.

Cluster analysis of computerized visual field and optical coherence tomography–ganglion cell complex defects in high intraocular pressure patients or early stage glaucoma

Purpose:

The aim of the study is to evaluate the relationship between functional defects shown by cluster analysis of computerized visual field and anatomic defects from optical coherence tomography–ganglion cell complex examination in ocular hypertension or eyes affected by glaucoma.

Methods:

205 eyes affected by ocular hypertension (intraocular pressure > 22 mmHg) or early stage glaucoma were enrolled. The age of the patients ranged from 26 to 87 years (average: 61.83 ± 1.54 years). Computerized 30° visual field (Octopus G1x Dynamic strategy) and optical coherence tomography–ganglion cell complex (I-Vue Optovue) analyses were performed for each eye selected; 68 eyes were tested and retested from two to seven times for a total of 320 visual fields and 320 optical coherence tomography–ganglion cell complex examinations. The visual field was considered abnormal with a mean defect < –2 and loss variance > 6. The optical coherence tomography–ganglion cell complex was considered abnormal with a significant focal loss volume (p < 5%) and/or a significant thinning of total, superior, or inferior thickness (p < 5%). Four different groups of examinations were created according to the results of visual field and ganglion cell complex: normal visual field and normal ganglion cell complex (group 1), abnormal visual field and abnormal ganglion cell complex (group 2), normal visual field and abnormal ganglion cell complex (group 3), and abnormal visual field and normal ganglion cell complex (group 4). The cluster analysis of visual fields (EyeSuite software Interzeag CH) was performed only in the visual field of group 3, and the correlation between cluster values and topographical changes at optical coherence tomography–ganglion cell complex was analyzed.

Results:

The results of the ganglion cell complex and visual field examinations matched 247 (77.19%) times. In 143 cases, the examinations belonged to group 1, in 104 to group 2, in 23 to group 3, and, finally, in 50 to group 4. The visual field cluster analysis performed on group 3 showed that the correlation between optical coherence tomography–ganglion cell complex and visual field cluster analysis defects was 100% (both the exams altered). In 72% of them, there was also a topographical correspondence between the visual field and optical coherence tomography–ganglion cell complex defects.

Conclusion:

In the early stages of glaucoma, the visual field cluster analysis seems to be useful to detect some focal defects that can be otherwise underestimated when globally considering the visual field. In group 3, where the conventional analysis of visual field was normal while the optical coherence tomography–ganglion cell complex exam was abnormal, the visual field cluster analysis showed a topographical correlation with optical coherence tomography–ganglion cell complex defects in more than 70% of the examinations performed. In addition, the patients with abnormal visual field and normal optical coherence tomography–ganglion cell complex were older than those with normal visual field and abnormal optical coherence tomography–ganglion cell complex (66.44 ± 3.51 vs 57.04 ± 5.96 years, p < 0.001 (0.0002)). These results confirm that the reliability of a visual field examination is subjective and decreases with age because of its difficulty and the personal compliance of the patient toward this examination.

Evaluation of the progression of visual field damage in patients suffering from early manifest glaucoma

BACKGROUND

This retrospective study aimed to determine how often a perimetric examination should be carried out in order to identify visual field (VF) changes in patients with relatively early manifestation glaucoma.

MATERIALS AND METHODS

Patients included had a relatively recent manifestation of primary open-angle glaucoma. Patients with a minimum follow-up of 5 years and a minimum of seven VF tests were included. Statistical analysis was performed to verify the trend of variations in mean defect (MD) over time (PeriData). The results were subjected to a t-test for a comparative analysis of progression of VF changes over time. The annual rate of progression provided by PeriData considering all the VFs analyzed was compared with that obtained on half of the VF examinations during the same follow-up period. An analysis of the MD trend over time was also carried out in relationship to the number of VF tests done and by dividing the sample into a high-frequency group (more than eight VFs) and a low-frequency group (fewer than eight VFs) in the follow-up period.

RESULTS

A total of 96 eyes of 96 patients were included, and overall 846 VFs were examined. The paired t-test performed comparing the MD index of all the VFs against half of them did not show statistical significance (P=0.537). The high-frequency group comprised 39 eyes (average VF 11.05±1.91, average time interval 0.76 years) while the low-frequency group comprised 57 eyes (average VF 6.95±0.6, average time interval 1.21 years). The analysis of the MD trend in the high-frequency patients showed significance (P=0.017); the low-frequency group did not show statistical significance (P=0.08).

CONCLUSION

The number of VFs in a determined time interval was not significant. However, a greater frequency of tests provides a predictive evaluation of the rate of progression of early manifestation open-angle glaucoma.

Glaucoma Management in Carotid Cavernous Fistula

Carotid cavernous fistulas (CCF) are vascular communications between the carotid artery and the cavernous sinus. Ophthalmologists are called to diagnose and manage the condition in cases that present with ocular features. A 73-year-old female was referred to our glaucoma center clinic. Eight years before, she had started receiving medication for glaucoma and had undergone laser iridotomy, but a satisfactory management of intraocular pressure (IOP) had not been achieved. The patient was complaining of intermittent diplopia, bilateral proptosis, and conjunctival chemosis over the past 6 months. Best-corrected visual acuity in the right (OD) and left eye (OS) was 9/10 and 10/10, respectively. Visual field testing showed slight paracentral field defects mostly in OS. IOP was 20 mm Hg in OD and 34 mm Hg in OS. We referred the patient to neuroradiology, and MRI angiography revealed a CCF with angiographic classification of Cognard grade 2. Closure of the CCF by transarterial embolization was performed in the neuroradiology department. One week following the procedure, the clinical signs of diplopia, proptosis, and conjunctival chemosis had greatly improved, and IOP was reduced to 12 mm Hg OD and 19 mm Hg in OS. Glaucoma treatment was maintained with topical brimatoprost, brinzolamide, and timolol. Owing to the risk of vision loss associated with vascular stasis, retinal ischemia, and high IOP, ophthalmologists must be aware of the clinical features of CCF and should request appropriate imaging studies such as MRI angiography in order to confirm the diagnosis and plan multidisciplinary treatment.

Rare Diseases Leading to Childhood Glaucoma: Epidemiology, Pathophysiogenesis, and Management

Noteworthy heterogeneity exists in the rare diseases associated with childhood glaucoma. Primary congenital glaucoma is mostly sporadic; however, 10% to 40% of cases are familial. CYP1B1 gene mutations seem to account for 87% of familial cases and 27% of sporadic cases. Childhood glaucoma is classified in primary and secondary congenital glaucoma, further divided as glaucoma arising in dysgenesis associated with neural crest anomalies, phakomatoses, metabolic disorders, mitotic diseases, congenital disorders, and acquired conditions. Neural crest alterations lead to the wide spectrum of iridocorneal trabeculodysgenesis. Systemic diseases associated with childhood glaucoma include the heterogenous group of phakomatoses where glaucoma is frequently encountered in the Sturge-Weber syndrome and its variants, in phakomatosis pigmentovascularis associated with oculodermal melanocytosis, and more rarely in neurofibromatosis type 1. Childhood glaucoma is also described in systemic disorders of mitotic and metabolic activity. Acquired secondary glaucoma has been associated with uveitis, trauma, drugs, and neoplastic diseases. A database research revealed reports of childhood glaucoma in rare diseases, which do not include glaucoma in their manifestation. These are otopalatodigital syndrome, complete androgen insensitivity, pseudotrisomy 13, Brachmann-de Lange syndrome, acrofrontofacionasal dysostosis, caudal regression syndrome, and Wolf-Hirschhorn syndrome.

Intravitreal injection of dexamethasone implant and ranibizumab in cystoid macular edema in the course of irvine-gass syndrome

PURPOSE

To evaluate the efficacy of 2 dexamethasone intravitreal implants and 1 ranibizumab intravitreal injection after a bilateral postoperative complication of cataract surgery as pseudophakic cystoid macular edema.

PATIENTS AND METHODS

A 70-year-old male patient with systemic hypertension developed a progressive cystoid macular edema (CME) in both eyes starting between 10 and 20 days after cataract surgery. Two intravitreal dexamethasone implants and 1 ranibizumab injection were administered; first in the right eye (RE) and then in the left eye (LE). The patient was checked for 1 whole week and then once a month for 5 months after the injections.

RESULTS

One month after the first dexamethasone implant in his RE, the spectral domain optical coherence tomography (SD-OCT) showed a progressive reduction of the foveal thickness until a complete resolution of the CME occurred, which was associated with an improvement of visual acuity. After 3 months, the SD-OCT showed a relapse of the CME, which was then treated with 1 injection of ranibizumab. One month after this injection, there was a complete resolution of the CME. A new CME in his RE was diagnosed 2 months after the last ranibizumab injection; it was treated with a new dexamethasone implant. A complete resolution of the CME was obtained; a normal foveal profile was still present 5 months after the last injection, and the best-corrected visual acuity was 20/20. His LE developed a CME 40 days after surgery. One intravitreal injection of ranibizumab was first administered in his LE, with a complete resolution of the CME at SD-OCT 2 weeks later. As observed in his RE, 40 days after the ranibizumab injection, there was a relapse of the CME that was treated with 1 intravitreal injection of dexamethasone implant. Five months later, the patient showed a worsening of the CME, but it was completely resolved with a second dexamethasone injection. After 3 months, the foveal thickness was back to normal with a BCVA of 20/20.

CONCLUSION

Treatment with dexamethasone implants (Ozurdex(®)) and ranibizumab injections (Lucentis(®)) induced a progressive reduction of our patient's CME after cataract surgery (Irvine-Gass syndrome) until a complete normal foveal thickness was restored and his visual function was improved despite the order of injections.

Intravitreal Injection of Dexamethasone Implant in Serous Macular Detachment Associated with Waldenström's Disease

Purpose

To evaluate the efficacy of one intravitreal injection of dexamethasone (Ozurdex^®; Allergan, Inc., Irvine, Calif., USA) in serous macular detachment (SMD) of one eye, associated with bilateral central retinal vein occlusion (CRVO) in a patient affected by Waldenström's macroglobulinemia (WM).

Patients and Methods

A female patient, affected by WM, complained of a progressive decrease in visual acuity, mainly in the left eye (LE). SMD in the LE associated with bilateral CRVO was diagnosed. One intravitreal injection of dexamethasone was administered in the LE and the patient was tested 1, 2, and 6 months after the injection.

Results

1, 2, and 6 months after the injection, the spectral domain optical coherence tomography (SD-OCT) showed a progressive slight reduction of foveal thickness that was not related to any improvement of visual function.

Conclusions

Treatment with dexamethasone (Ozurdex) induced a progressive slight reduction of SMD but no improvement of visual acuity, and it is possible that this is related to the condition of hematic hyperviscosity that is present in WM.

Evaluation of recurrent hyphema after trabeculectomy with ultrabiomicroscopy 50-80 MHz: a case report

Background

Hyphema is a complication that can occur after glaucoma filtering surgery. Biomicroscopic examination of the anterior segment is commonly used to diagnose it and gonioscopy may provide a useful support to find the source of the haemorrhage. Unfortunately, when the blood hides the structure of the anterior segment the gonioscopic examination fails. In this case we performed ultrabiomiscroscopy with 50–80 MHz probes to overcome the limits of gonioscopy. The use of this technique to study the anterior segment of the eye has previously been reported in literature, but we illustrates its importance for performing a correct diagnosis in a specific case of hyphema.

Case presentation

We report a case of a sixty-year-old caucasian male with recurrent hyphema in the left eye. The episodes of hyphema were four in two years and the patient came to the hospital for the first time in the last occasion. The past episodes were managed with topical corticosteroids and mydriatic drops. He referred surgical trabeculectomy in both eyes 5 years before the first symptoms and no specific eye trauma before the first episode. The examination of the anterior segment revealed a 2 mm hyphema in the left eye due to blood leakage through the superior iridectomy. Gonioscopy could not identify the source of the haemorrhage. B-scan ultrasound and ultrabiomiscroscopy, with 50–80 MHz probes, were performed. Ultrabiomiscroscopy, mainly with the probe of 80 MHz, provided images of high resolution of the structures of the anterior segment and it allowed the visualization of an abnormal vessel at the inner margin of the trabeculectomy opening, probably responsible of the recurrent hyphema.

Conclusion

Ultrabiomicroscopy proved to be a useful diagnostic technique for identifying the cause of the recurrent hyphema when other examination techniques are not applicable.

Intravitreal ranibizumab and laser photocoagulation in the management of idiopathic juxtafoveolar retinal telangiectasia type 1: a case report

Background

Idiopathic juxtafoveolar retinal telangiectasia (IJRT) type 1 represents an uncommon cause of congenital unilateral visual loss and it typically affects males. Decrease in visual acuity is caused by serous and lipid exudation into the fovea with cystoid macular edema. In some cases, spontaneous resolution may be observed, but when there is a progressive loss of visual acuity, laser photocoagulation is often necessary. This treatment is not always successful and therapy for this condition is still controversial.

Case Presentation

A 57-year-old man referred a 2-month history of blurred and distorted vision in the right eye. Best-corrected visual acuity was 20/50 in the right eye and 20/20 in the left eye. Fundus examination showed temporal macular edema, confirmed by optical coherence tomography. Fluorescein angiography showed a localized area of hyperfluorescence probably due to telangiectasia type 1 located below the inferior temporal area of the fovea. A combined therapy of intravitreal ranibizumab injection and laser photocoagulation was performed. Visual acuity improved from 20/50 to 20/32 and the therapy was well tolerated by the patient. After 3 years of follow-up, both visual acuity and fundus examination were stable.

Conclusions

This case suggests that the combined use of ranibizumab and laser photocoagulation may be considered an effective treatment for JRT type 1, leading to an improvement in both visual acuity and macular edema. We believe that intravitreal ranibizumab injection associated with laser photocoagulation should be considered as treatment for IJRT type 1.

Efficacy of 2% ibopamine on the dilation of patients with pseudoexfoliation syndrome

PURPOSE

To compare the mydriatic effects of 2% ibopamine and collyrium containing 10% phenylephrine + 0.5% tropicamide and to study the associated drug in patients with ocular pseudoexfoliation (PEX) syndrome.

METHODS

This was a prospective, comparative, interventional clinical study. The study group consisted of 20 patients with ocular PEX syndrome. Intervention procedures included administration of 10% phenylephrine-0.5% tropicamide versus 2% ibopamine versus 2% ibopamine followed by the combination drug. Main outcome measurement was mydriatic efficacy measured in terms of mean pupil diameter. Adverse effects on intraocular pressure (IOP) were measured with a Goldmann applanation tonometer. Mean premedication pupil diameters in all patients were less than 3.5 mm.

RESULTS

Instillation of 10% phenylephrine-0.5% tropicamide caused significantly greater mydriasis than 2% ibopamine (pupil diameters: 6.17 mm, SD=1.14 versus 5.33 mm, SD=1.34; p<0.001). Combined use of both collyria significantly increased mydriasis (7.19 mm; SD=0.69) compared with that induced by either of the products alone (p<0.001). Inadequate mydriasis (pupil diameters < 5.5 mm) was observed in 2 patients after administration of 10% phenylephrine-0.5% tropicamide and in 10 following instillation of 2% ibopamine, but the addition of 10% phenylephrine -0.5% tropicamide to ibopamine-treated eyes resulted in adequate dilation in all cases. IOP increases of 4 mmHg over baseline values were observed in 12 (60%) patients after 2% ibopamine.

CONCLUSIONS

In patients with ocular PEX, instillation of 2% ibopamine exerts a significant additive effect on mydriasis induced with 10% phenylephrine-0.5% tropicamide with only minimal increases in IOP.

Standard automated perimetry and algorithms for monitoring glaucoma progression

Despite increasingly sophisticated techniques for the computerized analysis of the optic nerve and retinal nerve fiber layer, standard automated perimetry (SAP) is still the primary test for assessing functional damage in glaucoma. Most of the diseases affecting the visual field can be studied analyzing the central visual field with a fixed grid of points set at 6 degrees or at a variable density within central 30 degrees, using a III white target stimulus (program 30/2 or 24/2 Humphrey, G1/G2 or 30/2 Octopus). Although there is lack of a true gold standard for glaucoma, SAP results were the primary endpoint in most of the clinical trials in glaucoma. New thresholding strategies allowed a considerable reduction of examination time without substantial loss of accuracy. Moreover, recent findings on structure-function correlation in glaucoma validate the clinical role of this well-known and widespread method of examination.

Visual field damage and progression in glaucomatous myopic eyes

PURPOSE

To make a visual field retrospective analysis on a group of patients with primary open angle glaucoma (POAG) and to evaluate whether different refractive errors could have different progression of the 30 degrees central sensitivity.

METHODS

A total of 110 patients with POAG (52 men and 58 women) were included in the study. All the patients were divided into four subgroups based on the refractive error. The visual field of all the included patients was assessed by an Octopus 30 degrees central visual field every 6 months, for a total of 837 visual fields examined. The resulting data were analyzed by PERIDATA for Windows 1.7 TREND function. Mean defect (MD) and loss variance (LV) were considered for the analysis.

RESULTS

At the first examination, 82% of eyes showed a global decrease of differential light sensitivity (MD >2 dB) and in 67% the distribution of the defect was nonhomogeneous (LV >6 dB). The analysis of variance for subgroups showed a more significant decrease of MD in highly myopic patients. A linear regression analysis highlighted a statistically significant change in time of MD in 36% and of LV in 34% of the eyes studied. Highly myopic patients had the highest (p<0.01) percentage of change of MD and LV (46% and 42%, respectively). Among the four subgroups, there was no difference in progression of MD decrease in time.

CONCLUSIONS

These results showed that after 5 years of glaucoma, the visual field was altered in most of the eyes examined (82%) and that in 67% of cases, its defect was nonhomogeneous and worsened with the increase of myopia. The regression linear analysis of visual field changes in time showed a progressive increase of MD and LV in approximately one third of all the eyes examined.

The Influence of Learning Effect on Frequency Doubling Technology Perimetry (Matrix)

PURPOSE

To determine learning effect in healthy patients without perimetric experience, tested with the frequency doubling technology perimetry, with the new model Matrix.

PATIENTS AND METHODS

Frequency doubling technology in the 30-2 threshold mode was performed on 37 healthy subjects. Each subject was tested twice in different sessions. The test always began with the right eye (RE) and continued with the left eye (LE). To evaluate learning effect the results of the REs at the first session were compared with those of the LE. The following parameters were evaluated: foveal threshold (FT), reliability indexes, mean defect (MD), pattern standard deviation (PSD), glaucoma hemifield test (GHT), duration of examination.

RESULTS

At the first session the average values of RE were FT=30.81 db, MD=-1 db, PSD=3.01 db, and duration of the examination=383.27 "and of LE were FT=30.73, MD=-0.79 db, PSD=2.97 db, and duration of examination 382.62." At the second session the average values of RE were FT=32.22 db, MD=+0.16 db, PSD 2.75 db, and duration of examination=374.97 db. The reliability was different and the GHT between the RE and LE in the first and second session was also different.

CONCLUSIONS

A learning effect was observed between the first and the second sessions and the results of the GHT appeared improved. This above all should be taken into account when considering the clinical use of this test to avoid erroneous diagnostic conclusions.

Ultrabiomicroscopy (UBM) in flap dislocation following LASIK: a case report

PURPOSE

To describe postoperative laser-assisted in situ keratomileusis (LASIK) flap dislocation occurred after trauma

METHODS

Ultrabiomicroscopy (UBM) is used to obtain a high-resolution imaging of the cornea.

RESULTS

The UBM results are presented and compared with histologic and confoscan findings

CONCLUSIONS

The technique is useful and easy to perform, offering more opportunities to study the anatomical changes in LASK flap dislocation occurred after trauma.

Comparative efficacy of acetazolamide and apraclonidine in the control of intraocular pressure following phacoemulsification

PURPOSE

The purpose of our study was to compare the effects of systemically administered acetazolamide and topical apraclonidine 0.5% in the control of intraocular pressure (IOP) following phacoemulsification of senile cataracts.

SETTING

The study was conducted on patients affected by cataract and followed at the Department of Ophthalmology.

METHODS

Seventy-eight eyes in 78 patients were selected. Twenty-six eyes were randomly assigned to postoperative treatment with topical apraclonidine 0.5%, 26 received oral acetazolamide and the remaining 26 received no hypotensive treatment (control group). Statistical analyses were performed mainly by means of analyis of variance.

RESULTS

IOPs measured 24 h after surgery were significantly (p = 0.01) lower in the apraclonidine group compared to the control group.

CONCLUSIONS

Our double-blind prospective study conducted on patients randomly assigned to treatment with apraclonidine or acetazolamide shows that the former drug is undoubtedly effective in the prevention of IOP increases following phacoemulsification. IOPs recorded in patients treated with this drug were lower than those observed in the acetazolamide and the control groups. Considering the lower risk of toxicity associated with topical administration, apraclonidine 0.5% seems to be preferable to oral acetazolamide in this postoperative setting.

Comparison Between GDx VCC Parameter and Achromatic Perimetry in Glaucoma Patients

PURPOSE

To evaluate the correlation between polarimetry parameters and standard threshold perimetry indices.

PATIENT AND METHODS

One hundred and eight consecutive glaucomatous patients were recruited in this study. Glaucomatous patients were classified when an abnormal visual field and/or an abnormal optic nerve head were present. One eye was chosen randomly from all the subjects. All optic nerve heads were examined with the GDx variable corneal compensator (VCC) (Laser Diagnostic Technologies, Inc, San Diego, CA) and visual fields were assessed by Humphrey Perimeter, program 24-2, SITA standard (Humphrey Instrument, Inc, San Leandro, CA). GDx VCC parameters and visual field indices were considered. Correlation coefficient was used to compare the 2 sets of data. A linear regression model was also used to calculate the independent contribution of each GDx VCC parameter and to determine which parameter was the most predictive of visual field damage.

RESULTS

The mean age (+/-standard deviation) was 61+/-10.3, the average of the mean deviation (MD) was -2.31+/-3.2 dB and the mean pattern standard deviation (PSD) was 3.32+/-2.83 dB. Significant (P<0.05) correlation was found between MD and the nerve fiber indicator (NFI) (r=-0.35), the superior average (r=0.28), the Temporal-Superior Nasal-Inferior Temporal average (r=0.24) and the inferior average (r=0.21). The linear regression model found NFI to be the predictor variable of MD. Significant (P<0.05) correlation was found between PSD and the NFI (r=0.39), the superior and the inferior average (r=0.30), and the Temporal-Superior Nasal-Inferior Temporal average (r=0.29). The linear regression model found NFI to be the predictor variable of PSD.

CONCLUSIONS

Some of the GDx VCC indices were significantly correlated to visual field indices in glaucomatous patients, but NFI was the best indicator of visual field damage.

Visual Acuity in Central and Branch Vein Retinal Occlusion in the Presence of Macular Edema: 1 Year of Follow-Up

One year after laser treatment of 117 eyes with central or branch retinal vein occlusion in the presence of macular edema, visual acuity was equally improved in the central retinal vein occlusion laser-treated and branch retinal vein occlusion non-laser-treated eyes. We concluded that fluorangiographically evident ischemic areas or significant macular edema are indications for laser therapy, and that a poor long-term functional prognosis is always related to more severe macular damage at the onset.

Parry-Romberg Syndrome

The authors report an unusual case of Parry-Romberg syndrome (PRS). Magnetic resonance imaging and computed tomography scan of the craniofacial region and surgical correction of enophthalmos were performed. Results after the operative intervention included persistent palpebral edema and ecchymosis and transient choroid vasculitis of the right eye, highlighted with echography and fluorescein angiography. The fundus oculi examination showed retinal choroid folds. Immunological test results were weakly positive. The authors conclude enophthalmos, associated with right side hemi atrophy, and the transient choroids vasculitis support the diagnosis of PRS. Furthermore, it is suggested the case had an autoimmune etiology, rather than a hemi facial asymmetry caused by a facial trauma that occurred in puberty.

Short-term effects of bimatoprost in glaucoma patients from an outpatient clinic

PURPOSE

A drug utilization trial was performed to investigate acute versus short-term effects after switching or adding bimatoprost in open-angle glaucoma patients over a 3- month observation period.

METHODS

One (1) eye was randomly chosen from 47 glaucomatous patients (abnormal visual field and/or abnormal optic nerve and intraocular pressure (IOP) above 21 mmHg without treatment). Only patients who did not reach the target IOP with their ongoing treatment were recruited in this study. IOP was measured at baseline, after 1 hour, and 2 hours from the first instillation and after 1 week, 1, and 3 months of treatment.

RESULTS

The IOP before bimatoprost administration was 20.16+/-3.6 mmHg (mean+/-standard deviation). There was no statistically significant decrease of IOP after 1 hour (mean IOP, 19.96+/-4.25 mmHg) and after 2 hours (mean IOP, 17.73+/-3.24 mmHg). Statistically significant (p<0.001) decreases after 1 week (mean IOP, 16.48+/-2.9 mmHg), after 1 month (mean IOP, 16.48+/-2.9 mmHg) and after 3 months (mean IOP, 16.15+/-2.7 mmHg) were found.

CONCLUSION

The results suggested that bimatroprost had a significant acute effect on IOP in monotherapy, while no significant effect was found when the therapy was switched or added. The effect for primary open-angle glaucoma was very evident. There was no specific side effect attributable to combining bimatoprost with any of the treatments in use.