Variable Phenotype of Congenital Corneal Opacities in Biallelic CYP1B1 Pathogenic Variants

PURPOSE

The aim of this study is to describe the variable phenotype of congenital corneal opacities occurring in patients with biallelic CYP1B1 pathogenic variants.

METHODS

A retrospective chart review was conducted to identify patients with congenital corneal opacities and CYP1B1 pathogenic variants seen at UPMC Children's Hospital of Pittsburgh. Ophthalmic examination, high-frequency ultrasound, anterior segment optical coherence tomography, histopathologic images, and details of genetic testing were reviewed.

RESULTS

Three children were identified. All presented with raised intraocular pressure. Two patients showed bilateral limbus-to-limbus avascular corneal opacification that did not resolve with intraocular pressure control; 1 showed unilateral avascular corneal opacity with a crescent of clear cornea, iridocorneal adhesions, iridolenticular adhesions, and classical features of congenital glaucoma in the fellow eye (enlarged corneal diameter, Haab striae, and clearing of the corneal clouding with appropriate intraocular pressure control). The first 2 patients were visually rehabilitated with penetrating keratoplasty. Histopathology revealed distinct features: a variably keratinized epithelium; a thick but discontinuous Bowman-like layer with areas of disruption and abnormal cellularity; Descemet membrane, when observed, showed reduced endothelial cells; and no pathological changes of Haab striae were identified. Two patients had compound heterozygous pathogenic variants in CYP1B1 causing premature stop codons, whereas 1 was homozygous for a pathogenic missense variant.

CONCLUSIONS

Congenital corneal opacities seen in biallelic CYP1B1 pathogenic variants have a variable phenotype. One is that commonly termed as Peters anomaly type 1 (with iridocorneal adhesions, with or without iridolenticular adhesions) and the other is a limbus-to-limbus opacity, termed CYP1B1 cytopathy. Clinicians should be aware of this phenotypic variability.

Thygeson's superficial punctate keratitis in children

OBJECTIVE

To describe the first paediatric case series of Thygesons' superficial punctate keratitis (TSPK) with management outcomes.

METHODS

A retrospective chart review was done for all children either diagnosed at initial presentation or referred with TSPK from 01/2012 to 08/2021 at a tertiary children's hospital. Records were assessed for signs, symptoms, diagnosis, steroid and cyclosporine 0.05% use. The main outcome measures were visual acuity, treatment response and total steroid exposure.

RESULTS

Fifteen children (7 females), mean age at presentation 8 ± 4 years were included. All had bilateral disease and a BCVA of >20/40 in the better eye. All patients received topical fluorometholone 0.1%, (FML) initially. 80% had a good response to FML. Corneal scraping was done to exclude infectious causes in four cases due to poor initial response or clinical suspicion. All 4 needed EUA for scraping and anterior segment OCT, after which 2 had molecularly confirmed TGFBI-related stromal dystrophy. For the rest, slow steroid taper was done every 4-6 weeks and recurrences were treated by increasing steroid frequency. Cyclosporine 0.05% was started in nine patients (69%), 8 ± 6 months after initial presentation. The decrease in total steroid exposure per week after starting cyclosporine was statistically significant (p < 0.05).

CONCLUSION

Children with TSPK respond quickly to steroids, however, recurrences are common, necessitating a slow taper. Non-response to steroid needs careful reconsideration of the diagnosis and may necessitate the use of an EUA. Using cyclosporine 0.05% reduces the total steroid exposure in TSPK.

Retrospective evaluation of Postnatal Growth and Retinopathy of Prematurity (G-ROP) and Colorado Retinopathy of Prematurity (CO-ROP) screening algorithms in University of Pittsburgh Medical Centers cohort

Of the 70,000 infants screened for retinopathy of prematurity (ROP) each year in the United States, only 43% develop any ROP, and <10% develop treatment-requiring ROP. Investigators have tried to develop new methods for determining more specific screening criteria, including the Postnatal Growth and Retinopathy of Prematurity (G-ROP) and Colorado Retinopathy of Prematurity (CO-ROP), to reduce the number of infants being screened while maintaining a high degree of sensitivity. We evaluated the records of 138 premature infants who received treatment for ROP between 2010 and 2021 with respect to G-ROP (129 infants) and CO-ROP (102 infants) to test the sensitivity of each. Using the G-ROP criteria, 0.8% (1/129) of treated infants had type 1 ROP that would have been missed and 3.1% (4/129) of total infants treated were missed. These infants would not have been screened or received treatment if G-ROP guidelines were followed. Using the CO-ROP criteria, 2% (2/102) of treated infants had type 1 ROP that would have been missed and 4.9% (5/102) of total infants treated were missed. In our study cohort, both sets of criteria proved less sensitive than our current screening guidelines.

Pediatric oral fluorescein angiography: a retrospective review from a single institution

PURPOSE

To describe our experience with locally developed evidence-based guidelines for oral fluorescein angiography (FA) for retinal imaging in children.

METHODS

The medical records of consecutive pediatric patients (≤18 years of age) at University of Pittsburgh Medical Center Children's Hospital Eye Center who underwent oral FA between November 1, 2018, and April 1, 2022, were reviewed retrospectively. Adherence to or deviation from the guidelines was noted at the time of testing.

RESULTS

A total of 55 patients aged 3-18 with 79 examinations were included. No patient was excluded from the retrospective case review because of lack of recorded data. The main indications for oral FA included uveitis, retinal vasculopathy, disk pathology, and retinal lesions. Three children had transient side effects, and 1 had delayed urticaria 4 hours after examination. No child had anaphylaxis. One patient had suboptimal imaging due to nonadherence to the guidelines-recommended fasting protocol. All other examinations (78/79), where guidelines were followed, provided images adequate for clinical decision making.

CONCLUSIONS

Based on our experience, we recommend that oral FA be considered, especially in children where intravenous access is less well tolerated while awake. Informed consent that includes the possibility of delayed side effects is advisable.

Technique for the Management of Extensive Ocular Surface Lipodermoid Involving the Cornea of Children

PURPOSE

Ocular surface lipodermoids with corneal involvement may require surgical intervention; if deep, ocular surface reconstruction with lamellar corneal tissue or amniotic membrane may be needed. We describe a staged technique using autologous ipsilateral simple limbal epithelial transplantation.

METHODS

After verifying sparing of Descemet membrane, the conjunctival portion of the lipodermoid was debulked in the first stage. Six weeks later, the corneal portion was excised, followed by autologous ipsilateral simple limbal epithelial transplantation to promote rapid reepithelialization of the residual stromal bed. Temporary tarsorrhaphy was used for patient comfort and to expedite ocular surface healing.

RESULTS

Three eyes of 3 children with grade III large ocular surface lipodermoids that encroached the visual axis and hindered proper eyelid closure underwent surgery without complications. In all cases, the visual axis was cleared and eyelid closure was improved. At the last follow-up (mean 35.7 months, median 36.0 months), the bed of the original dermoid showed minimal haze in 1 case, while 2 eyes developed small pseudopterygium; best spectacle-corrected visual acuity improved from 20/200 to 20/70 in the first case, from fix and follow to 20/50 in the second case, and remained fix and follow in the last case, but this child had congenital hydrocephalus with severe developmental delay.

CONCLUSIONS

This surgical technique is a promising option for children with grade III large ocular surface lipodermoids given its effectiveness in clearing the visual axis and in improving eyelid closure. Moreover, it does not require lamellar corneal transplantation or intervention to the fellow eye.

OCT Angiography in Noninfectious Uveitis: A Description of Five Cases and Clinical Applications

BACKGROUND

Optical coherence tomography angiography (OCTA) is a noninvasive imaging modality used to analyze the retinochoroidal vasculature and detect vascular flow. The resulting images can be segmented to view each vascular plexus individually. While fluorescein angiography is still the gold standard for the diagnosis of posterior uveitis, it has limitations, and can be replaced by OCTA in some cases.

METHODS

This case series describes five patients with posterior noninfectious uveitis and their description by OCTA.

RESULTS

Cases included lupus retinopathy (n = 1) for which OCTA showed ischemic maculopathy as areas of flow deficit at the superficial and deep capillary plexus; choroidal granulomas (n = 1) with a non-detectable flow signal in the choroid; active punctate inner choroiditis and multifocal choroiditis (n = 1) with OCTA that showed active inflammatory chorioretinal lesions as non-detectable flow signals in choriocapillaris and choroid; dense type 2 inflammatory secondary neovascularization (n = 1) associated with active choroiditis; and acute posterior multifocal placoid pigment epitheliopathy (APMPPE) (n = 1) without flow abnormalities at the superficial and deep retinal plexuses but non-detectable flow at the levels of the choriocapillaris and choroid.

CONCLUSIONS

Ophthalmologists can use OCTA to identify inflammatory changes in retinal and choroidal vasculature, aiding in the diagnosis, management, and monitoring of posterior uveitis.

Peripheral visual field loss and activities of daily living

PURPOSE OF REVIEW

Peripheral visual field (VF) loss affects 13% of the population over 65. Its effect on activities of daily living and higher order visual processing is as important as it is inadequately understood. The purpose of this review is to summarize available literature on the impact of peripheral vision loss on driving, reading, face recognition, scene recognition and scene navigation.

RECENT FINDINGS

In this review, glaucoma and retrochiasmal cortical damage are utilized as examples of peripheral field loss which typically spare central vision and have patterns respecting the horizontal and vertical meridians, respectively. In both glaucoma and retrochiasmal damage, peripheral field loss causes driving difficulty - especially with lane maintenance - leading to driving cessation, loss of independence, and depression. Likewise, peripheral field loss can lead to slower reading speeds and decreased enjoyment from reading, and anxiety. In glaucoma and retrochiasmal field loss, face processing is impaired which impacts social functioning. Finally, scene recognition and navigation are also adversely affected, impacting wayfinding and hazard detection leading to decreased independence as well as more frequent injury.

SUMMARY

Peripheral VF loss is an under-recognized cause of patient distress and disability. All peripheral field loss is not the same, differential patterns of loss affect parameters of activities of daily living (ADL) and visual processing in particular ways. Future research should aim to further characterize patterns of deranged ADL and visual processing, their correlation with types of field loss, and associated mechanisms.

Relentless placoid chorioretinitis: A review of four cases in pediatric and young adult patients with a discussion of therapeutic strategies

Introduction

Relentless placoid chorioretinitis (RPC) is a rare, bilateral disease of the retinal pigment epithelium. The clinical course is prolonged and relapsing. No standard treatment has been established to date. The purpose of this case series is to report four cases of RPC in pediatric and young adult patients in which varying treatments were used, comparing them to previously published cases.

Methods

A literature review was conducted to investigate currently published presentations and treatment options for RPC. A multicenter retrospective chart review was also performed on four consecutive patients. These patients were diagnosed with RPC because of new chorioretinitis lesions continuing to appear without or despite therapy for 5-36 months (2 patients), with a clinical course prolonged and relapsing, or because of the atypical location of the multiple lesions (>50) extending from the posterior pole to the equator and mid-peripheral retina (all four patients), which were not consistent with other entities like acute posterior multifocal placoid pigment epitheliopathy and serpiginous choroiditis.

Results

All four cases of RPC received oral or IV steroids acutely, and three of these patients were transitioned to a steroid-sparing agent and biologic therapy: anti-TNF alpha or anti-IL-6. Quiescence of the chorioretinitis lesions was obtained after 7 months, 1 month, and 36 months; however, the latter had issues with treatment adherence. Mycophenolate mofetil was insufficient to control the disease in one patient, but tocilizumab and infliximab thereafter were effective after cessation of adalimumab due to side effects. Adalimumab when started the first month after the presentation was effective in controlling the disease in one patient. After the failure of interferon-alpha-2a, one patient displayed long-term control with infliximab. One patient did not require a steroid-sparing agent after oral prednisone taper as there was no evidence of progression or recurrence.

Conclusion

This case series adds to the current knowledge regarding potential treatments for RPC, specifically the use of anti-TNF-alpha treatment and anti-IL-6 tocilizumab. In this case study, relapses of RPC were found among patients on mycophenolate mofetil and interferon-alpha-2a, and one case did not relapse on oral steroids without a steroid-sparing agent. Our findings suggest that adalimumab, infliximab, and tocilizumab may be useful medications to obtain quiescence of RPC.

Ocular and Systemic Factors Associated with Glaucoma

Glaucoma is one of the leading causes of irreversible blindness in the world. Although numerous factors have been implicated in the pathogenesis of glaucoma, the main focus of management still remains lowering the intraocular pressure (IOP) by medical or surgical therapy. However, a major challenge is that many glaucoma patients continue to progress despite good control of IOP. In this regard, the importance of other coexisting factors that may contribute to disease progression needs to be explored. Ophthalmologists need to be aware of ocular risk factors and the impact of systemic diseases and their medications, along with lifestyle modifications on the course of glaucomatous optic neuropathy and adopt a holistic approach in treating the eye as well as the patient to alleviate the suffering from glaucoma in a comprehensive manner.

How to cite this article

Dada T, Verma S, Gagrani M, et al. Ocular and Systemic Factors associated with Glaucoma. J Curr Glaucoma Pract 2022;16(3):179-191.

Pragmatic adjunctive usage of netarsudil: A retrospective chart review from a tertiary care center

Purpose

This retrospective chart review of netarsudil (Rhopressa) characterizes intra-ocular pressure (IOP) reduction, drug tolerance, drug cost, and compliance in a tertiary university Midwest clinic in a variety of glaucoma diagnoses on patients prescribed netarsudil 01/2017 to 5/2020.

Methods

Patient demographics, primary diagnosis, indication for medication, prescription date, prescription fill status, duration of use, discontinuation reason, and number of IOP-lowering medications were noted. Confounding medication changes were excluded from IOP analysis. The IOP difference between the first visit after starting netarsudil and the baseline (mean before starting netarsudil on the stable medication regimen) was calculated.

Results

A total of 133 patients were prescribed netarsudil (age 69 ± 20 years, 59% females, 79% white, 86% primary glaucoma) as adjunct glaucoma medication (mean medications 3.2 ± 0.9). Indications were lowering IOP (mean baseline IOP 20.0 ± 6 mmHg) and drug regimen simplification. Prescription was not filled by 22/133 subjects because of the cost (68%) and the need for surgery (23%). No demographic factors were associated with prescription fill status. A total of 101 eyes of 76 patients were used for IOP analysis. The mean change in IOP was -0.8 ± 6.4 mmHg, (IOP decrease in 67%, increase or no change in 33% eyes). Netarsudil was discontinued in 52% (50/96) patients; the reasons include surgery for IOP control (42%), allergies (30%), cost (14%), and paradoxical rise in IOP (12%).

Conclusion

Netarsudil was used as adjunct third or fourth line medication at a glaucoma practice in Midwestern USA. 17% of prescriptions went unfilled; netarsudil was discontinued in 52% of patients. IOP response was variable in this population with severe complex glaucoma.

What do patients with glaucoma see: a novel iPad app to improve glaucoma patient awareness of visual field loss

Purpose

Glaucoma patients with peripheral vision loss have in the past subjectively described their field loss as ‘blurred’ or ‘no vision compromise’. We developed an iPad app for patients to self-characterise perception within areas of glaucomatous visual field loss.

Methods

Twelve glaucoma patients with visual acuity ≥20/40 in each eye, stable and reliable Humphrey Visual Field (HVF) over 2 years were enrolled. An iPad app (held at 33 cm) allowed subjects to modify ‘blur’ or ‘dimness’ to match their perception of a 2×2 m wall-mounted poster at 1 m distance. Subjects fixated at the centre of the poster (spanning 45° of field from centre). The output was degree of blur/dim: normal, mild and severe noted on the iPad image at the 54 retinal loci tested by the HVF 24-2 and was compared to threshold sensitivity values at these loci. Monocular (Right eye (OD), left eye (OS)) HVF responses were used to calculate an integrated binocular (OU) visual field index (VFI). All three data sets were analysed separately.

Results

36 HVF and iPad responses from 12 subjects (mean age 71±8.2y) were analysed. The mean VFI was 77% OD, 76% OS, 83% OU. The most common iPad response reported was normal followed by blur. No subject reported dim response. The mean HVF sensitivity threshold was significantly associated with the iPad response at the corresponding retinal loci (For OD, OS and OU, respectively (dB): normal: 23, 25, 27; mild blur: 18, 16, 22; severe blur: 9, 9, 11). On receiver operative characteristic (ROC) curve analysis, the HVF retinal sensitivity cut-off at which subjects reported blur was 23.4 OD, 23 OS and 23.3 OU (dB).

Conclusions

Glaucoma subjects self-pictorialised their field defects as blur; never dim or black. Our innovation allows translation of HVF data to quantitatively characterise visual perception in patients with glaucomatous field defects.

Glaucomatous visual fields and neurocognitive function are independently associated with poor lane maintenance during driving simulation

BACKGROUND

Driving simulators are a safe alternative to on-road vehicles for studying driving behavior in glaucoma drivers. Visual field (VF) loss severity is associated with higher driving simulator crash risk, though mechanisms explaining this relationship remain unknown. Furthermore, associations between driving behavior and neurocognitive performance in glaucoma are unexplored. Here, we evaluated the hypothesis that VF loss severity and neurocognitive performance interact to influence simulated vehicle control in glaucoma drivers.

METHODS

Glaucoma patients (n = 25) and suspects (n = 18) were recruited into the study. All had > 20/40 corrected visual acuity in each eye and were experienced field takers with at least three stable (reliability > 20%) fields over the last 2 years. Diagnosis of neurological disorder or cognitive impairment were exclusion criteria. Binocular VFs were derived from monocular Humphrey VFs to estimate a binocular VF index (OU-VFI). Montreal Cognitive Assessment (MoCA) was administered to assess global and sub-domain neurocognitive performance. National Eye Institute Visual Function Questionnaire (NEI-VFQ) was administered to assess peripheral vision and driving difficulties sub-scores. Driving performance was evaluated using a driving simulator with a 290° panoramic field of view constructed around a full-sized automotive cab. Vehicle control metrics, such as lateral acceleration variability and steering wheel variability, were calculated from vehicle sensor data while patients drove on a straight two-lane rural road. Linear mixed models were constructed to evaluate associations between driving performance and clinical characteristics.

RESULTS

Patients were 9.5 years older than suspects (p = 0.015). OU-VFI in the glaucoma group ranged from 24 to 98% (85.6 ± 18.3; M ± SD). OU-VFI (p = .0066) was associated with MoCA total (p = .0066) and visuo-spatial and executive function sub-domain scores (p = .012). During driving simulation, patients showed greater steering wheel variability (p = 0.0001) and lateral acceleration variability (p < .0001) relative to suspects. Greater steering wheel variability was independently associated with OU-VFI (p = .0069), MoCA total scores (p = 0.028), and VFQ driving sub-scores (p = 0.0087), but not age (p = 0.61).

CONCLUSIONS

Poor vehicle control was independently associated with greater VF loss and worse neurocognitive performance, suggesting both factors contribute to information processing models of driving performance in glaucoma. Future research must demonstrate the external validity of current findings to on-road performance in glaucoma.

Surgical interventions for primary congenital glaucoma

BACKGROUND

Primary congenital glaucoma (PCG) is an optic neuropathy with high intraocular pressure (IOP) that manifests within the first few years of a child's life and is not associated with other systemic or ocular abnormalities. PCG results in considerable morbidity even in high-income countries.

OBJECTIVES

To compare the effectiveness and safety of different surgical techniques for PCG.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2020, Issue 4); Ovid MEDLINE; Embase.com; PubMed; metaRegister of Controlled Trials (mRCT) (last searched 23 June 2014); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 27 April 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs comparing different surgical interventions in children under five years of age with PCG.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We included 16 trials (13 RCTs and three quasi-RCTs) with 587 eyes in 446 children. Eleven (69%) trials were conducted in Egypt and the Middle East, three in India, and two in the USA. All included trials involved children younger than five years of age, with follow-up ranging from six to 80 months. The interventions compared varied across trials. Three trials (on 68 children) compared combined trabeculotomy and trabeculectomy (CTT) with trabeculotomy. Meta-analysis of these trials suggests there may be little to no evidence of a difference between groups in mean IOP (mean difference (MD) 0.27 mmHg, 95% confidence interval (CI) -0.74 to 1.29; 88 eyes; 2 studies) and surgical success (risk ratio (RR) 1.01, 95% CI 0.90 to 1.14; 102 eyes; 3 studies) at one year postoperatively. We assessed the certainty of evidence as very low for these outcomes, downgrading for risk of bias (-1) and imprecision (-2). Hyphema was the most common adverse outcome in both groups (no meta-analysis due to considerable heterogeneity; I² = 83%). Two trials (on 39 children) compared viscotrabeculotomy to conventional trabeculotomy. Meta-analysis of 42 eyes suggests there is no evidence of between groups difference in mean IOP (MD -1.64, 95% CI -5.94 to 2.66) and surgical success (RR 1.11, 95% CI 0.70 to 1.78) at six months postoperatively. We assessed the certainty of evidence as very low, downgrading for risk of bias and imprecision due to small sample size. Hyphema was the most common adverse outcome (38% in viscotrabeculotomy and 28% in conventional trabeculotomy), with no evidence of difference difference (RR 1.33, 95% CI 0.63 to 2.83). Two trials (on 95 children) compared microcatheter-assisted 360-degree circumferential trabeculotomy to conventional trabeculotomy. Meta-analysis of two trials suggests that mean IOP may be lower in the microcatheter group at six months (MD -2.44, 95% CI -3.69 to -1.19; 100 eyes) and at 12 months (MD -1.77, 95% CI -2.92 to -0.63; 99 eyes); and surgical success was more likely to be achieved in the microcatheter group compared to the conventional trabeculotomy group (RR 1.59, 95% CI 1.14 to 2.21; 60 eyes; 1 trial at 6 months; RR 1.54, 95% CI 1.20 to 1.97; 99 eyes; 2 trials at 12 months). We assessed the certainty of evidence for these outcomes as moderate due to small sample size. Hyphema was the most common adverse outcome (40% in the microcatheter group and 17% in the conventional trabeculotomy group), with greater likelihood of occurring in the microcatheter group (RR 2.25, 95% CI 1.25 to 4.04); the evidence was of moderate certainty due to small sample size (-1). Of the nine remaining trials, no two trials compared the same two surgical interventions: one trial compared CTT versus CTT with sclerectomy; three trials compared various suturing techniques and adjuvant use including mitomycin C, collagen implant in CTT; one trial compared CTT versus Ahmed valve implant in previously failed surgeries; one trial compared CTT with trabeculectomy; one trial compared trabeculotomy to goniotomy; and two trials compared different types of goniotomy. No trials reported quality of life or economic data. Many of the included trials had limitations in study design, implementation, and reporting, therefore the reliability and applicability of the evidence remains unclear.

AUTHORS' CONCLUSIONS

The evidence suggests that there may be little to no evidence of difference between CTT and routine conventional trabeculotomy, or between viscotrabeculotomy and routine conventional trabeculotomy. A 360-degree circumferential trabeculotomy may show greater surgical success than conventional trabeculotomy. Considering the rarity of the disease, future research would benefit from a multicenter, possibly international trial, involving parents of children with PCG and with a follow-up of at least one year.

Extraocular muscle surgery on goats' eye: An inexpensive technique to enhance residents' surgical skills

Hands-on resident surgical training for various ocular procedures is essential to impart good surgical skills to the budding ophthalmologists. Here in this report, we demonstrate a simple and inexpensive technique of performing extraocular muscle surgery on goats’ eye. These animal eyes possess soft tissue resemblance to that of human eyes to a greater extent in terms of scleral rigidity, muscle elasticity, its width, thickness, and its insertion onto the sclera. Therefore, rectus muscle recession, resection, and plication surgeries can be performed repeatedly to improve an individual's orientation and practical experience before performing the procedure on human eyes.

Repeat keratoplasty in failed Descemet stripping automated endothelial keratoplasty

Purpose:

To evaluate the clinical factors associated with repeat Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty (PKP) in cases of failed DSAEK.

Methods:

Retrospective observational study of cases with failed DSAEK admitted to our center for a repeat keratoplasty over 5 years (January 2013–Decemeber 2017) was undertaken. Demographic and perioperative details of all cases and type of repeat keratoplasty were recorded. Logistic regression analysis was performed to analyze the factors affecting the type of repeat keratoplasty.

Results:

A total of 94 eyes with failed DSAEK were evaluated. Repeat DSAEK was performed in 66% and PKP in 34% of cases. Significantly increased odds for requiring PKP were observed in association with stromal scarring [odds ratio (OR) = 2.9, P = 0.018)], trainee surgeons (OR = 4.05, P = 0.008), intraoperative complications (OR = 4.58, P = 0.003), scleral fixated intraocular lens or anterior chamber intraocular lens in situ (OR = 33.8, P < 0.001), secondary glaucoma (OR = 3.02, P = 0.015), peripheral anterior synechiae (OR = 8.6, P < 0.001), preoperative corneal thickness (OR = 1.01, P < 0001), time to primary surgery (OR = 1.03, P = 0.03), post-DSAEK host thickness (OR = 1.01, P < 0.001), and time interval from graft failure to regraft (OR = 1.18, P < 0.001). All eyes with congenital hereditary endothelial dystrophy, bee-sting-induced corneal decompensation, Axenfeld-Rieger syndrome, and multiple failed grafts underwent secondary PKP. All cases (nine eyes) that required surgical intervention for secondary glaucoma underwent secondary PKP (P < 0.001).

Conclusion:

Repeat DSAEK is feasible in up to two-third of cases of failed DSAEK. A PKP is required in one-third of cases, and various preoperative, intraoperative and postoperative factors are associated with unsuitability for repeat DSAEK.

Fulminant Sphingomonas paucimobilis keratitis: case study and review of literature

Sphingomonas paucimobilis is a low-virulence gram-negative bacillus known to cause various ocular infections such as endophthalmitis, panophthalmitis and keratitis that are usually associated with an underlying risk factor such as peri-partum or postpartum phase, cataract surgery, contact lens use, neurotrophic keratopathy or ocular trauma. We report a case of spontaneously occurring perforated corneal ulcer caused by the organism in a young man managed by penetrating keratoplasty. The course was followed by endophthalmitis with graft infection culminating in phthisis bulbi despite aggressive medical and surgical management. Along with reporting this case, we also present a review of literature on ocular infections caused by the same organism.

A Novel Mathematical Model of Glaucoma Pathogenesis

Background

Conventional experimental approaches to understand glaucoma etiology and pathogenesis and, consequently, predict its course of progression have not seen much success due to the involvement of numerous molecular, cellular, and other moieties. An overwhelming number of these moieties at different levels combined with numerous environmental factors further complicate the intricacy. Interaction patterns between these factors are important to understand yet difficult to probe with conservative experimental approaches.

Methods

We performed a system-level analysis with mathematical modeling by developing and analyzing rate equations with respect to the cellular events in glaucoma pathogenesis. Twenty-two events were enlisted from the literature survey and were analyzed in terms of the sensitivity coefficient of retinal ganglion cells. A separate rate equation was developed for cellular stress also. The results were analyzed with respect to time, and the time course of the events with respect to various cellular moieties was analyzed.

Results

Our results suggest that microglia activation is among the earliest events in glaucoma pathogenesis. This modeling method yields a wealth of useful information which may serve as an important guide to better understand glaucoma pathogenesis and design experimental approaches and also identify useful diagnostic/predictive methods and important therapeutic targets.

Conclusion

We here report the first mathematical model for glaucoma pathogenesis which provides important insight into the sensitivity coefficient and glia-mediated pathology of glaucoma.

How to cite this article

Faiq MA, Sidhu T, et al. A Novel Mathematical Model of Glaucoma Pathogenesis. J Curr Glaucoma Pract 2019; 13(1):3–8.

Aniridia with lenticular and choroidal coloboma

This case report presents a rare association of a complete aniridia with lenticular and choroidal coloboma. An 8-year-old female patient was referred to our glaucoma clinic with aniridia, nystagmus and bilateral corneal opacity with right eye being phthisical. Ultrasonography of the phthisical eye revealed the presence of an old closed funnel retinal detachment. Further examination under anaesthesia revealed lens coloboma in the inferonasal quadrant and presence of a choroidal coloboma in the left eye. The intraocular pressure was 28 mmHg with a central corneal thickness of 693 µm. A macula sparing laser barrage around the colobomatous area was done in the left eye and topical ocular hypotensives were started.

Meditation enhances brain oxygenation, upregulates BDNF and improves quality of life in patients with primary open angle glaucoma: A randomized controlled trial

BACKGROUND

Glaucoma (POAG) is a kind of neurodegenerative disease known to be closely associated with stress and adverse quality of life (QOL). Stress has also been shown to be involved in etiopathogenesis of primary open angle glaucoma (POAG). Complementary treatment in form of Meditation has been reported to improve QOL, brain oxygenation and decrease markers of stress. With this premise, a randomized controlled trial was carried out to assess the effect of Meditation on intraocular pressure, subjective QOL and objective markers of stress and brain oxygenation in patients with POAG.

METHODS

Sixty patients were randomized into intervention and control groups. Intervention group underwent 45 minutes of Meditation daily for 6 weeks in addition to standard medical treatment while controls received only standard medical treatment. Inclusion criteria were patients with POAG, age >45 years, best corrected visual acuity >6/60. Patients with other ocular co-morbid conditions contributing to vision loss, systemic diseases, patients already practicing meditation in any form were excluded. An assessment of IOP, brain oxygenation using functional near infrared spectroscopy (fNIRS), QOL (WHO-BREF QOL) and stress markers in serum (cortisol, β-endorphins, interleukin-6, brain derived neurotrophic factor (BDNF), reactive oxygen species) was made at baseline and at 6 weeks.

RESULTS

21 female and 39 male patients were enrolled with a mean age of 57.28±9.37 years. All parameters were comparable between two groups at baseline. At 6 weeks mean level of IOP decreased significantly in intervention group (15.9±1.8 mmHg to 14.4±1.21 mm Hg, p-value 0.0001) as compared to control group (15.7±1.4 mmHg to 15.65±1.41, p-value 0.41). fNIRS showed significant improvement in oxygenated hemoglobin change (ΔHbO) in intervention group in the prefrontal cortex (p-value <  0.0001) as compared to control group (p-value 0.52). WHO-BREF QOL score increased significantly in intervention group (86.6±6.16 to 93.3±5.66, p-value 0.0001) as compared to control (89±7.25 to 89.07±3.24, p-value 0.74).Mean serum cortisol decreased significantly in intervention group (497±46.37 ng/ml to 447±53.78 ng/ml, p-value 0.01) as compared to control group (519.75±24.5 to 522.58±26.63 ng/ml, p-value 0.64). Mean β-endorphin levels increased significantly (33±5.52pg/ml to 43.27pg/ml, p-value <  0.0001) as compared to control group (34.78±4.1pg/ml to 36.33pg±4.07pg/ml p-value 0.27). Interleukin-6 decreased significantly in intervention group (2.2±0.5 ng/ml to 1.35±0.32 ng/ml, p-value <  0.0001) as compared to control group (2.03±0.37 to 2.17±0.34 ng/ml p-value 0.25). BDNF increased significantly in intervention group (52.24±6.71 to 63.25±13.48 ng/ml p-value 0.004) as compared to control group (53.23±5.82 to 54.42±5.66 ng/ml p-value 0.54). ROS decreased significantly in intervention group (1596.19±179.14 to 1261±244.31 RLU/min/104 neutrophils p-value 0.0001) as compared to control group (1577.5±172.02 to 1662.5±84.75 RLU/min/104 neutrophils p-value 0.16).

CONCLUSIONS

A short term course of Meditation was associated with significant improvement in brain oxygenation and QOL along with a reduction in IOP and stress markers. Meditation may be a useful as an adjunct to standard treatment in patients with POAG and potentially decrease the risk of glaucoma progression.

Mindfulness Meditation: Can Benefit Glaucoma Patients?

How to cite this article: Dada T, Gagrani M. Mindfulness Meditation Can Benefit Glaucoma Patients J Curr Glaucoma Pract 2019; 13(1):1–2.

Polypoidal choroidal vasculopathy: a comprehensive clinical update

Polypoidal choroidal vasculopathy as a disease is yet to be comprehended completely. The clinical features consisting of huge serosanguineous retinal pigment epithelial and neurosensory layer detachments, although unique may closely mimick neovascular age-related macular degeneration and other counterparts. The investigative modalities starting from indocyanine angiography to optical coherence tomography angiography provide diagnostic challenges. The management strategies based on the available therapies are plenty and not vivid. A detailed review with clarifying images has been compiled with an aim to help the readers in getting a better understanding of the disease.

Phacomorphic glaucoma in a high myope with phakic intraocular lens

We report a case of a young, one-eyed woman with high myopia who presented to our emergency department with sudden onset painful diminution of vision in the right eye after undergoing laser treatment. Her right eye had a phakic intraocular lens (pIOL) implantation 4 years back and her left eye had absent light perception. She was diagnosed as right eye lens induced secondary angle closure glaucoma with pIOL touching the corneal endothelium and left eye atrophic bulbi. She was admitted under eye emergency for medical intraocular pressure control followed by pIOL explantation with lens aspiration of the cataractous lens and posterior chamber intraocular lens implantation.

24-hour Intraocular pressure monitoring: the way ahead

Aim: Large diurnal intraocular pressure (IOP) fluctuation is a single most independent risk factor for glaucoma progression besides raised IOP. The major limitation of Goldman applanation tonometer (GAT) is its inability to measure night IOP without disturbing the patient's sleep. We discussed the methods available for the 24-hour IOP monitoring and its relevance in glaucoma. Methods: A PUBMED search was performed using the 24 Hour tonometry, newer tonometry devices, contact lens sensors, as keywords and all relevant articles were studied. Results and Conclusion: A number of methods are available for the 24 hour IOP monitoring. These devices allow home monitoring of IOP without affecting the daily routine. These devices, like Rebound tonometry, Contact lens sensor (CLS), etc., were briefly discussed. Triggerfish is one CLS device that has the capability to measure IOP without affecting the patient's sleep. Besides being safe and easily tolerable, it has shown reproducible results with other tonometry methods. Triggerfish has also been proven the device of choice in measuring IOP in different glaucoma subtypes and determining the efficacy of treatment in them, the only challenge being that it presently provides data on relative IOP rather than absolute IOP. With future research, triggerfish CLS can become an important device to measure the 24 hour IOP values especially in patients whose office measured IOPs seemingly fit in patient's target range but still the patients' disease shows glaucomatous progression. The utility of this device in relation to progressive vision loss is a matter of future study. Abbreviations: CCT = Central Corneal Thickness; CLS = Contact lens sensor; GAT = Goldmann Applanation Tonometer; IOP = Intraocular Pressure; NTG = Normal Tension Glaucoma; PACG = Primary angle closure glaucoma; POAG = Primary open angle glaucoma; VAS = Visual Analogue Score.

Paediatric ocular super glue injuries: assessment of two cases

In this report, we elaborate the clinical findings and the optimal management of two cases with ocular glue injuries in two paediatric patients. Both the patients were presented to the ocular emergency with completely closed eyelid and periocular erythema. The eyelids were completely closed due to matting of the eyelashes with glue retention up to lash roots. Thus, in both cases, after the application of local anaesthetic agent, immediate lash trimming was performed along with the removal of crystallised glue particles. However, the ocular surface showed only congestion in absence of any added corneal complications. Patients were followed up with standard treatment protocol as per chemical injuries. Until the end of 5 months, the clinical course was uneventful.

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives

Refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface. It has similar safety, efficacy, and predictability as femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and is associated with better patient satisfaction. The conventional technique of small incision lenticule extraction (SMILE) involves docking, femtosecond laser application, lenticule dissection from the surrounding stroma, and extraction. It has a steep learning curve compared to conventional flap-based corneal ablative procedures, and the surgical technique may be challenging especially for a novice surgeon. As SMILE is gaining worldwide acceptance among refractive surgeons, different modifications of the surgical technique have been described to ease the process of lenticule extraction and minimize complications. Good patient selection is essential to ensure optimal patient satisfaction, and novice surgeons should avoid cases with low myopia (thin refractive lenticules), difficult orbital anatomy, high astigmatism, or uncooperative, anxious patients to minimize complications. A comprehensive MEDLINE search was performed using “small incision lenticule extraction,” “SMILE,” and “refractive lenticule extraction” as keywords, and we herein review the patient selection for SMILE and various surgical techniques of SMILE with their pros and cons. With increasing surgeon experience, a standard technique is expected to evolve that may be performed in all types of cases with optimal outcomes and minimal adverse effects.

Impact on the pattern of ocular injuries and awareness following a ban on firecrackers in New Delhi: A tertiary eye hospital-based study

Purpose

To review the nature of firecracker-related ocular injuries at a tertiary eye hospital in northern India following the firecracker ban and also to review the level of awareness among the victims.

Methods

A cross-sectional observational study involving the patients presenting with firecracker-related ocular injuries from October 18 to 27, 2017 were assessed for demographic distribution, detailed ocular evaluation, and a questionnaire related to the awareness about the injuries.

Results

A total of 68 patients were observed. Fifty patients (74.5%) were males. This year, a majority of patients were from outside Delhi. Uttar Pradesh constituted the most 38.23% of the patients followed by Haryana 30.88%, Delhi 23.5%, and Bihar 7.35%. Visual acuity varied from 6/6 to no perception of light. Open globe injury was observed in 56 patients (82.35%) who commonly had zone I injury. A significant number of patients (88.23%) were aware of firecracker-related injuries, and a large number of such injuries (58.8%) occurred in those who were not actively involved in the ignition of firecrackers but were in the vicinity.

Conclusion

This year, following a ban, the number of firecracker-related ocular injuries reported from areas outside Delhi outnumbered as compared to within Delhi. However, firecracker-related ocular injuries are still a major cause of significant visual loss, especially involving the bystanders. Thus, firecracker-related celebrations should be monitored with a stringent protocol.

Aborted choroidal coloboma: fundus imaging and optical coherence tomography

Choroidal coloboma is characterised by poor embryonic development of chorioretinal structures and is of different types. We present a case of choroidal coloboma where the retinal pigment epithelium was present, clinically and on imaging, but rest of the structures were poorly formed. This observation suggests that in some cases, fusion of the fetal cleft may occur aberrantly, resulting in an aborted choroidal coloboma.