Biodegradable material for glaucoma drainage devices - A pilot study in rabbits

PURPOSE

To study the morphological and histological characteristics of the fibrous capsule formed around a novel biodegradable glaucoma drainage device (GDD) implant made of oxidized regenerated cellulose (ORC) after 1 and 3 months of its implantation.

METHODS

It was a prospective, interventional, preclinical experimental study using New Zealand white rabbits. All animals underwent GDD implantation with a novel biodegradable device. The device's body was made of ORC and attached to a silicone tube, connecting the body to the anterior chamber. Histopathology (hematoxylin and eosin/Masson's trichrome staining) and immunohistochemistry (Alpha-Smooth Muscle Actin expression) characteristics of the bleb formed around the novel device were noted at 1 and 3 months.

RESULTS

One month post implantation, the biodegradable material produced a significant foreign body type of reaction evidenced by the exuberant infiltration by macrophages, lymphocytes, and multinucleated giant cells. The granulomatous response subsided by 3 months with disorganized collagen deposition on Masson's trichrome staining. The silicone tube was an internal control, and histopathology demonstrated well-organized collagen deposition around it at 3 months. Immunohistochemistry for α-smooth muscle actin also demonstrated more myofibroblast transformation at the site of the tube than the biodegradable implant.

CONCLUSIONS

Our results indicate that the tissue response around a biodegradable GDD was different from the response to conventional devices. A diffuse, loose vascularized mesh was observed to develop, which may be more compatible with sustained IOP control over a longer period, in contrast to the usual thick and dense capsule formed around the non-biodegradable devices.

Efficacy of a novel low-cost torchlight transcorneal transillumination for diode laser transscleral cyclophotocoagulation in adult glaucoma

PURPOSE

To study the outcomes of diode laser transscleral cyclophotocoagulation (TSCPC) with trans-corneal transillumination using a novel low-cost torchlight method in refractory glaucoma.

METHODS AND ANALYSIS

This prospective interventional study included patients with refractory glaucoma who underwent TSCPC with trans-corneal transillumination (TSCPC-TI) using a novel low-cost torchlight method. Patients completing a minimum 6-month follow-up were analyzed. They were compared to a historical control group of patients who underwent TSCPC without transillumination (TSCPC-No TI) at 6-month follow-up period. We analyzed the mean laser energy delivered, post-laser intraocular pressure (IOP) reduction, number of antiglaucoma medications (AGM), the requirement of retreatment and complications of the procedure in both groups.

RESULTS

32 eyes of 29 patients comprised the TSCPC-TI group and were compared with 39 eyes of 37 patients in the TSCPC-No TI group. The TSCPC-TI group required lower energy than the TSCPC-No TI group (46.15 ± 22.8 Vs 80.65 ± 56.1 J p < 0.001). At 6-month follow-up, the TSCPC-TI group required lesser AGM for IOP control (2.33 ± 1.02 vs 3.02 ± 1.32 p = 0.01). There was a significantly reduced dependence of oral acetazolamide in the TSCPC-TI group at 6 months follow-up (15.6% vs 41% p = 0.03%). The success and response rates were 71.8% Vs 23.1%; p < 0.0001 and 87.5% Vs 51.2%; p = 0.001 significantly high in the TSCPC-TI group. The TSCPC-No TI group had a significantly high failure rate (12.5% Vs 48.2% p = 0.001). Hypotony (n = 1) and phthisis (n = 2) were noted TSCPC-No TI group.

CONCLUSIONS

TSCPC with transillumination with a low-cost torchlight resulted in a more efficient and effective cycloablation than TSCPC without transillumination.

Efficacy of Ab Interno Revision for Trabeculectomy Bleb Failure using a Minimally Invasive Approach: A Prospective Study

PRCIS

Ab interno bleb revision using the Grover and Fellman spatula offers potential benefits in improved intraocular pressure control and spare the conjunctiva for enhanced bleb management.

PURPOSE

This study aimed to evaluate the safety and effectiveness of Ab-Interno Bleb Revision (AIBR) for treating failed trabeculectomy blebs.

METHODS

This non-comparative case series enrolled glaucoma patients with failed trabeculectomy blebs, who underwent AIBR and were followed up for one year. Eligible patients received subconjunctival Mitomycin C 0.1 mL of 0.2 mg/mL (20 μg) five days before the AIBR, performed using the Grover and Fellman spatula. The primary outcome measures were intraocular pressure (IOP) and the usage of IOP-lowering medications one year after the procedure. Secondary outcomes included the procedure's failure rate and complications. Complete success was defined as achieving an IOP between 5-21 mmHg without medication, while qualified success required additional medical treatment.

RESULTS

The study comprised 23 eyes from 23 patients, having a mean age of 59.66±14.93 years. Preoperatively, the mean IOP was 23.54±10.7 mmHg, and the mean anti-glaucoma medication requirement was 3.99±0.65, both significantly reduced to 15.7±6.9 mm Hg (P=0.009) and 1.26±1.2 (P <0.001) at one year, respectively. Overall, 19 eyes (82.6%) achieved success (Complete success: 39.2%, Qualified success: 43.4%), while in 4 (17.4%) patients the procedure failed (IOP >21 mmHg). 5 patients had transient hyphema, but there were no sight-threatening complications such as hypotony or choroidal detachment.

CONCLUSION

Ab-Interno Bleb Revision (AIBR) is a safe, effective, and minimally invasive intervention for managing failed trabeculectomy blebs. By eliminating the need to reopen the conjunctiva, this technique offers a promising alternative for the treatment of this challenging condition.

Effective concentration (EC50) of sevoflurane for intraocular pressure measurement in anaesthetised children with glaucoma: A dose-finding study

Background and Aim

Sevoflurane, a preferred anaesthetic for children, exhibits a dose-dependent reduction in intraocular pressure (IOP). However, consensus is lacking regarding optimal end-tidal sevoflurane concentration for safe IOP measurement. This study aimed to identify the concentration at which IOP measurement could be attempted without inducing movements in paediatric patients after inhalational induction.

Methods

Two paediatric groups (1-12 months and 12-36 months) with glaucoma undergoing examination under anaesthesia were recruited. After induction with 8% sevoflurane and 100% oxygen, the first child had an end-tidal sevoflurane concentration maintained at 2% for 4 min, followed by IOP measurement. Success was defined as 'no movement', and subsequent concentrations (adjusted in 0.2% steps) were determined using the Dixon and Massey method based on the previous patient's responses.

Results

The study included 75 children. The effective concentration of sevoflurane causing 'no movement' during IOP measurement in 50% of the study population for successful IOP measurement was 1.98% (95% confidence interval [CI] 1.63, 2.17, P = 0.017) for 1-12 months group and 0.55% (95% CI 0.39, 0.66, P = 0.002) for 12-36 months group. Probit regression analysis yielded effective concentration of sevoflurane causing 'no movement' during IOP measurement in 95% of the study population values of 2.47% (95% CI 2.24, 4.58, P = 0.017) for 1-12 months group and 0.94% (95% CI 0.78, 1.57, P = 0.002) for 12-36 months group.

Conclusion

In paediatric patients, a higher end-tidal sevoflurane concentration of 2% is needed for IOP measurement in 1-12 months age group compared to 0.5% required in 12-36 months age group, achieving success in 50% of the study population.

Correlation of anterior segment optical coherence tomography and ultrasound biomicroscopy in congenital corneal opacity

PURPOSE

To investigate the correlation between swept-source anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) in congenital corneal opacity (CCO).

METHODS

All children with unilateral or bilateral congenital corneal opacities who underwent examination under anesthesia (EUA) and anterior segment optical coherence tomography (AS-OCT) imaging from January 1, 2022, to December 31, 2022, were included. Main outcome measures were corneal and anterior segment evaluation and correlation of UBM and AS-OCT findings.

RESULTS

A total of 22 eyes of 15 patients were imaged using both technologies. The age at first EUA ranged from 11 days to 4 years. Different phenotypes were classified based on the clinical examination, UBM, and AS-OCT findings. Fourteen eyes were diagnosed with Peters anomaly, congenital corneal staphyloma was observed in 4 eyes, 2 eyes had coloboma, 1 eye had peripheral sclerocornea, and 1 eye was diagnosed with congenital primary aphakia. AS-OCT and UBM findings were closely correlated in 18 of 22 eyes (82%) but AS-OCT failed to provide detailed information in 4 eyes (18%) where UBM revealed more details.

CONCLUSIONS

Although AS-OCT offers valuable preliminary data for initial assessment and counseling, it may not consistently provide precise assessments in all cases. Therefore, UBM should be considered for definitive evaluation.

Long-Term Efficacy of Selective Laser Trabeculoplasty in Primary Angle-Closure Disease After Laser Peripheral Iridotomy

PURPOSE

To evaluate the long-term efficacy of selective laser trabeculoplasty (SLT) in eyes with primary angle-closure (PAC) and primary angle-closure glaucoma (PACG) following a laser peripheral iridotomy (LPI).

METHOD

In this prospective cross-sectional study, 45 eyes of 34 patients with PAC/PACG diagnosis, uncontrolled intraocular pressure (IOP), and visible pigmented trabecular-meshwork (TM) at least 180° on gonioscopy following a LPI were recruited. Following a detailed baseline ophthalmic evaluation, all eligible eyes underwent SLT, and the patients were examined on day1, at 1 week, 1-, 3-, and 6-months, and 1-, 2-, 3-, 4-, and 5-year subsequently. The main outcomes measured were IOP, number of IOP-lowering agents, and complications.

RESULTS

The mean age of the cohort was 57.80 ± 6.44 years, the male-female ratio was 8:26, and 17 eyes were PACG, and 28 were PAC. The baseline IOP was 23.81 ± 1.78 mm Hg, and was significantly declined at all follow-ups (p < .0001). The cumulative probability of overall success was 91% and 84% at 2-, and 5-year, respectively. At 5-year SLT provided drug-freedom in 80% of PAC and 23% of PACG eyes. Six eyes had IOP spike at 1-week and two patients underwent repeat SLT after 1-year. No other complications, such as pain/discomfort, inflammation, an increase in peripheral anterior synechiae and cystoid-macular-edema, were noted.

CONCLUSIONS

SLT appears a safe and cost-effective procedure in PAC/mild- moderate PACG eyes with uncontrolled IOP after laser iridotomy. The long-term effectiveness of SLT as adjuvant treatment was good, but need large sized randomized studies for more validation.

Use of the Aurolab Aqueous Drainage Implant as a buckling element in pediatric retinal detachment with a preexisting glaucoma drainage device

Purpose

To describe a novel technique for repair of rhegmatogenous retinal detachment in an eye with a previous non-valved glaucoma drainage device, the Aurolab Aqueous Drainage Implant (AADI).

Observations

A 5-year-old child with bilateral primary congenital glaucoma presented with an inferior retinal detachment (RD) in the left eye. The left eye had a history of multiple surgical interventions including combined trabeculotomy and trabeculectomy done twice, AADI implantation and subsequently phacoaspiration with IOL implantation, 18 months prior to presentation. The left eye retinal detachment was managed by scleral buckling technique using the plate of the AADI as a buckling element without its explantation.

Conclusions

AND IMPORTANCE: Management of retinal detachment in eyes with a pre-existing glaucoma drainage device (GDD) is uniquely challenging. Explantation of the GDD would likely result in intractable glaucoma post-operatively, requiring another surgery. Use of the trimmed plate of the GDD itself as the buckling element helped in settling the RD and preserving intraocular pressure control.

Diode Laser Transscleral Cyclophotocoagulation With a Novel Low-Cost Torchlight Method of Trans-Corneal Transillumination in Refractory Pediatric Glaucoma

PRCIS

Trans-corneal transillumination (TI) aided transscleral cyclophotocoagulation (TSCPC) for intraocular pressure control of refractory pediatric glaucoma was found to be effective at 1 year.

PURPOSE

To study 1-year outcomes of diode laser TSCPC with trans-corneal TI using a novel low-cost torchlight method in refractory pediatric glaucoma.

METHODS

This prospective interventional study included children with refractory glaucoma who underwent TSCPC with the Oculight laser system (IRIS Medical Instruments) with trans-corneal TI (TSCPC-TI) using a novel low-cost torchlight method. Children completing a minimum 1-year follow-up were analyzed. They were compared with a historical control group of children who underwent TSCPC without TI (TSCPC-No-TI) at the 1-year follow-up period. We analyzed the mean laser energy delivered, post-laser intraocular pressure reduction, number of antiglaucoma medications (AGM), the requirement of retreatment and complications of the procedure in both groups.

RESULTS

Forty-two eyes of 35 patients comprised the TSCPC-TI group and were compared with 31 eyes of 21 patients in the TSCPC-No-TI group. The TSCPC-TI group required lower energy than the TSCPC-No-TI group (24.7±7.8 J vs. 47.2±10.9 J, P <0.0001). Mean topical antiglaucoma drug requirement decreased from 2.9±0.08 before treatment to 0.66±0.8 at the end of 1 year in TSCPC-TI and from 2.6±1.0 before treatment to 0.6±0.77 in the TSCPC-No-TI groups, respectively ( P =0.15). There was a significantly reduced dependence of oral acetazolamide in the TSCPC-TI group at 1-year follow-up [5.7% vs. 61.9%, respectively ( P <0.001%)]. No adverse event of hypotony or choroidal detachment was noted in any group.

CONCLUSIONS

TSCPC aided by TI with a low-cost torchlight for pediatric refractory glaucoma was found to be effective at 1 year in reducing intraocular pressure and the burden of medication.

Profile of Newly Diagnosed Childhood Glaucoma in India: Indian Childhood Glaucoma Study (ICGS) Group 1

OBJECTIVE

To report the profile of newly diagnosed childhood glaucoma using the Childhood Glaucoma Research Network (CGRN) classification, presenting over 1 year from across centers in India.

DESIGN

Prospective observational multicentric study.

SUBJECTS

Newly diagnosed children aged < 18 years diagnosed with childhood glaucoma according to CGRN criteria presenting between January and December 2019 to 13 centers across India.

METHODS

All children underwent a comprehensive ocular examination, including examination under anesthesia for younger children, and were diagnosed with childhood glaucoma as per CGRN. Data were entered in a standard Excel chart. Refraction and visual acuity assessments were done when feasible.

MAIN OUTCOME MEASURES

The profile of newly diagnosed childhood glaucoma in different parts of India and the severity of glaucoma at presentation.

RESULTS

A total of 1743 eyes of 1155 children fulfilled the definition of glaucoma and were analyzed. Primary congenital glaucoma (PCG) comprised the single largest group (34.4%), most of which were infantile onset (19%). Neonatal-onset PCG comprised 6.2% of all glaucoma. Secondary glaucoma constituted 53.4% of all glaucoma, one-half of which were acquired conditions (28%), followed by isolated ocular anomalies (14.7%), glaucoma after cataract surgery (6.7%), and glaucoma with nonacquired systemic diseases (4.5%). Of the 1743 eyes with glaucoma, all 3 parameters for severity grading were available in 842 eyes, of which 501 (59.5%) eyes presented with mild, 320 (38%) with moderate, and 21 (2.5%) with severe glaucoma. Nearly one-third of the children (28.5%) were not brought back for follow-up after the initial treatment given.

CONCLUSIONS

Our study has one of the largest numbers of consecutive children with glaucoma classified according to the CGRN classification. Despite a widely diverse population, the profile of childhood glaucoma was relatively uniform across India. Childhood glaucoma is a significant problem in India, primarily treated in tertiary care hospitals. The data presented may be the tip of the iceberg because we have only reported the children who reached the hospitals offering treatment for this challenging disease.

FINANCIAL DISCLOSURE(S)

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

Secondary developmental glaucoma

The basic pathophysiology of all childhood glaucoma results from impaired outflow through the trabecular meshwork. Anterior Segment Dysgeneses (ASD) are a group of nonacquired anomalies associated with secondary developmental glaucoma, characterized by impaired development of the structures of the anterior segment. Many genes impact the development of the anterior segment. The cause of the development of the abnormalities is thought to be multifactorial. Molecular research has helped our understanding of the molecular basis of ASD and the developmental mechanisms underlying these conditions. Identifying the genetic changes underlying ASD has gradually led to the recognition that some of these conditions may be parts of a disease spectrum rather than isolated anomalies. The characterization of the underlying genetic abnormalities responsible for glaucoma is the first step toward developing diagnostic and screening tests, which could identify individuals at risk for disease before irreversible optic nerve damage occurs. It is also crucial for genetic counseling and risk stratification of later pregnancies. It also aids prenatal testing by various methods allowing for effective genetic counseling. This review summarizes various ocular and systemic conditions that result in secondary developmental glaucoma and provide an overview of the phenotypes, the diagnosis and principles of management of the various disorders.

Visual field indices in children and adults with comparable retinal nerve fiber layer thickness

PURPOSE

To compare visual field indices in normal children and adults with similar retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT).

METHODS

This cross-sectional study included 59 eyes of 59 normal children 6-18 years of age compared to normal adults. The children underwent visual field testing on the Humphrey Field Analyzer (HFA) and RNFL thickness measurement on OCT. Normal adults who had undergone OCT and visual field testing were retrieved from the OCT database. The mean deviation (MD) in each child was compared with the MD in RNFL thickness-matched eyes of normal adults. Children 6-11 years and 12-18 years were analyzed separately.

RESULTS

Overall, the MD of children was significantly less than that of the normal adults despite having the same RNFL thickness (-2.42 ± 1.42 dB vs -1.61 ± 1.47 dB [P = 0.006]). When stratified by age, the difference in MD of children <12 years was significantly less than normal adults (-2.72 ± 1.5dB vs -1.53 ± 1.2 dB [P = 0.003) while in children >12 years, the difference did not reach statistical significance (-2.18 ± 1.2 vs -1.51 ± 1.32 [P = 0.12]).

CONCLUSIONS

In our study cohort, children <12 years had lower visual field indices than adults. Their visual fields may appear worse than they would for an adult with the same RNFL thickness. Normal children >12 years of age seem to have a retinal sensitivity comparable to the adult normative database. It is worthwhile to consider the development of a separate pediatric normative database for the visual field assessment of children <12 years of age.

CYP1B1 and MYOC variants in neonatal-onset versus infantile-onset primary congenital glaucoma

OBJECTIVE

To compare CYP1B1 and MYOC variants in a cohort of neonatal-onset (NO) and infantile-onset (IO) primary congenital glaucoma (PCG).

METHODS

This prospective observational study included 43 infants with PCG (14 NO and 29 IO) presenting between January 2017 and January 2019 with a minimum 1-year follow-up. CYP1B1 and MYOC genes were screened using Sanger sequencing with in-silico analysis of the variants using Polymorphism Phenotyping v.2 and Protein Variation Effect Analyser platforms. Allelic frequency was estimated using Genome Aggregation Database (gnomAd). Disease presentation and outcome were correlated to the genetic variants in both groups.

RESULTS

Babies with CYP1B1 mutations had more severe disease at presentation and worse outcomes. Six of 14 (42.8%) NO glaucoma and 5 of 29 (17.2%) IO harboured CYP1B1 mutations. Five of six babies in the NO group and three of five in the IO group harboured the variant c.1169G>A, [p.R390H]. They required more surgeries and had a poorer outcome. On in-silico analysis c.1169G>A, [p.R390H] scored very likely pathogenic. Two patients in the IO group who had the c.1294C>G, [p.L432V] variant had a good outcome. Five of 14 NO-PCG and 8 of 29 IO-PCG harboured the variant c.227G>A, [p.R76K] in the MYOC gene, which was scored benign by in-silico analysis, and was also found in 2 of 15 normal controls.

CONCLUSIONS

Patients with CYP1B1 pathogenic variants had a poorer outcome than those without. We found more NO PCG babies with CYP1B1 mutations compared with IO PCG. This may be one of the reasons for NO PCG having a poorer prognosis compared with IO PCG.

Congenital glaucoma as a presenting feature of Rubinstein-Taybi syndrome in an infant with a novel pathogenic variant in the CREBBP gene

Rubinstein-Taybi syndrome, also known as broad thumb-hallux syndrome, is a rare autosomal dominant genetic disorder. This multiorgan syndrome is linked to a pathogenic mutation in the CREBBP or EBP300 genes.We present a patient with a hitherto unreported constellation of anterior segment abnormalities, including congenital glaucoma, congenital corneal keloid, cataract, and distinct facial and systemic features including a high-arched palate, low-set posteriorly rotated ears, Café-au-lait spots on the back, broad terminal phalanges of hands and feet, and bilateral cryptorchidism. The characteristic dysgenetic angle features and ultrasound biomicroscopic findings described in this case report show the occurrence of concomitant congenital keloid with glaucoma.Genetic testing revealed a heterozygous one-base pair duplication in exon 3 of the CREBBP gene (c.886dupC), a novel frameshift pathogenic mutation in the CREBBP gene that has not been previously reported in a clinical setting.

Lunar lenses - Acquired lens colobomas

Acquired lens colobomas secondary to ocular surgeries are scarcely described in the literature. We describe two cases of acquired lens coloboma in two infants with glaucoma who underwent ocular surgery. The coloboma in the first case was likely because of direct trauma to the lens zonules during an optical iridectomy with a vitrectomy cutter, resulting in localized loss of zonules and consequently localized lens coloboma. The coloboma in the second case was noticed during examination under anesthesia after scleral buckling and cryopexy for retinal detachment. The cause for coloboma development in this case could be disruption of the lens zonules because of stretching of the globe after scleral buckle surgery or because of injury to zonules during scleral buckling and the cryopexy procedure.

Unilateral advanced glaucoma in isolated congenital ectropion uveae with ipsilateral ptosis: A pictorial description of five children

Aim: To report the cases of five children with unilateral advanced glaucoma in isolated congenital ectropion uveae (CEU) with ipsilateral ptosis and myopia.

Methods: This is an ambispective observational case series. After diagnosing one patient with CEU and glaucoma, consecutive patients presenting with unilateral ptosis, congenital iris anomaly, and glaucoma between 2014 to 2020, and had completed a minimum one-year postoperative follow-up, were analyzed.

Results: Of the 1421 newly registered pediatric glaucoma patients in the period under review, five children were diagnosed with CEU. All patients presented with gradual painless diminution of vision in the left eye in early adolescence. The left eye of all patients had peculiar clinical features: mild congenital ptosis, high iris insertion, crypt-less smooth iris surface, congenital ectropion uveae, pigments over anterior lens capsule, high myopia, advanced glaucomatous optic disc cupping, and very high intraocular pressure (IOP), which was > 45 mmHg in all cases. The right eye showed signs of angle dysgenesis with mild anterior iris insertion and numerous fine iris processes. Antiglaucoma medications and angle surgery failed to control the IOP, and all children required glaucoma filtration surgery, resulting in reasonable IOP control. Despite the older age, postoperative strict amblyopia treatment resulted in significant improvement in vision.

Conclusions: Although ectropion uveae and ptosis have been present since birth, unilaterality, and the asymptomatic nature of the disease led to the late presentation with irreversible damage. Early surgical management and amblyopia therapy are the cornerstones of management.

Abbreviations: CEU = Congenital ectropion uvea, CIES = Congenital Iris Ectropion Syndrome, ASD = Anterior segment dysgenesis syndrome, BCVA = Best-corrected visual acuity, IOP = Intraocular pressure

Neonatal-Onset Congenital Ectropion Uveae May Be Caused by a Distinct CYP1B1 Pathologic Variant

PURPOSE

To report underlying genetic variants of recently described distinct phenotype of newborn glaucoma: neonatal-onset congenital ectropion uveae (NO-CEU).

DESIGN

Prospective cohort study.

METHODS

Setting: tertiary care teaching institute.

SUBJECTS

Thirteen children with clinical diagnosis of NO-CEU who had completed 1-year follow-up after glaucoma surgery and had undergone clinical exome sequencing (CES) by selective capture and sequencing of the protein-coding regions of the genes including 19 candidate genes for NO-CEU were assessed. The same criteria were applied for evaluating pathogenicity of variants to all the candidate genes.

OUTCOME MEASURES

primary-genetic variants found on CES keeping in view the clinical indication of congenital glaucoma; secondary-corneal clarity and intraocular pressure (IOP) at baseline and 1-year follow-up, interventions required to control IOP, and postoperative visual acuity. The genetic variants were correlated with the outcome.

RESULTS

All 13 patients diagnosed with NO-CEU had onset of glaucoma at birth and severe bilateral disease. Twelve of 13 (92.3%) patients harbored CYP1B1 variants. Nine of these 12 patients (83.3%) were homozygous for [c.1169G>A(p.Arg390His)] in exon-3 of CYP1B, with 5 common homozygous single-nucleotide polymorphisms flanking the pathogenic variant. They had intractable glaucoma and required multiple surgeries. Six patients had persistent corneal opacities, necessitating optical iridectomies. Three patients were compound heterozygous for CYP1B1 variants, showing [c.1169G>A(p.Arg390His)] along with [c.1103G>A(p.Arg368His)], [c.1103G>A (p.Arg368His)] along with [c.1403_1429dup(p.Arg468_Ser476dup)], and [(c.1063C>T(p.Arg355Ter)] along with [c.1325del(p.Pro442GlnfsTer15)]. These patients had better visual outcomes.

CONCLUSIONS

NO-CEU appears to be a phenotypic marker for specific CYP1B1 genotypes, one of which is [c.1169G>A(p.Arg390His)] in our study population. Phenotype recognition is helpful to characterize the underlying genetic variants.

Anterior segment dysgenesis: Insights into the genetics and pathogenesis

Childhood glaucoma is a treatable cause of blindness, provided it is recognized, diagnosed, and treated in time. WHO has estimated that it is responsible for Blind Years second only to cataracts. The fundamental pathophysiology of all childhood glaucoma is impaired outflow through the trabecular meshwork. Anterior segment Dysgeneses (ASD) are a group of non-acquired ocular anomalies associated with glaucoma, characterized by developmental abnormalities of the tissues of the anterior segment. The cause is multifactorial, and many genes are involved in the development of the anterior segment. Over the last decade, molecular and developmental genetic research has transformed our understanding of the molecular basis of ASD and the developmental mechanisms underlying these conditions. Identifying the genetic changes underlying ASD has gradually led to the recognition that some of these conditions may be parts of a disease spectrum. The characterization of genes responsible for glaucoma is the critical first step toward developing diagnostic and screening tests, which could identify individuals at risk for disease before irreversible optic nerve damage occurs. It is also crucial for genetic counseling and risk stratification of later pregnancies. It also aids pre-natal testing by various methods allowing for effective genetic counseling. This review will summarize the known genetic variants associated with phenotypes of ASD and the possible significance and utility of genetic testing in the clinic.

Understanding factors associated with continuation of use of injectable contraceptives in Karnataka and Maharashtra, India: a cross-sectional household study

The Government of India has worked to expand access to injectable contraceptives through the introduction of a three-monthly injectable contraceptive MPA under the ‘Antara’ program in 2017. However, the uptake of injectable contraceptives has remained low, and few studies have investigated the experiences of public health facility injectable clients in India. We examined factors associated with continuing, discontinuing, and switching methods among injectable users obtaining services from public health facilities in the Indian states of Karnataka and Maharashtra. The study team recruited respondents (N=1009) that had received their first injectable dose from in public sector facilities between February – May 2019 and conducted a follow-up visit at their residence in December 2020. We used multivariate logistic regression to study the association of the demographic characteristics, service quality, satisfaction with services, follow-up visits, and decision-making on injectable continuation and switching to other family planning methods. Injectable usage rates declined significantly, with 44% of clients receiving a second dose and only 16% receiving a third dose. Over half of women (54%) cited problems related to periods as the reason for discontinuing injectable use after the first dose. Respondents were more likely to continue their method at third dose if they were older (25-35 years) (OR:1.68, p<0.05) and had received a reminder for a follow-up dose (OR: 2.41, p Our results also highlight the importance of addressing side-effects experience by women, which may be better managed by community-based follow-up visits and high-quality counselling services.

Post-trabeculectomy early bleb localization mimicking a 'ring of steel'

A 54-year-old-man underwent trabeculectomy with mitomycin-C (0.02%). At 4-week follow-up, there was an elevated, well-circumscribed bleb with raised intra-ocular pressure (IOP) of 32-mmHg, with a classic “ring of steel” appearance, typically seen in a tenon's cyst. A sub-tenon needle revision re-established aqueous flow. Two weeks later, the IOP was 8-mmHg without any anti-glaucoma medications. A diffuse well formed bleb was noted. Careful ocular examination helps to identify early post-operative localized bleb that may appear like a “ring of steel” but can be managed by needling, unlike a tenon's cyst, which would require more extensive intervention.

Newborn glaucoma: a neglected manifestation of Congenital rubella Syndrome

PURPOSE

To study the frequency of intrauterine rubella infection in a cohort of neonatal-onset glaucoma and its effect on the treatment outcomes.

MATERIAL AND METHODS

Infants with neonatal-onset glaucoma presenting to the pediatric glaucoma service at a tertiary care centre in northern India at Chandigarh between 1^st January and 30^th September 2018 with a minimum postoperative follow-up of one year were included in this study. Rubella-IgM antibodies were tested in all patients. Surgery for intraocular pressure (IOP) control comprised combined trabeculotomy-with-trabeculectomy or goniotomy. Presenting features and treatment outcomes at one year were compared among babies with and without rubella-IgM antibodies.

RESULTS

Of twenty-seven eligible infants, 7(25.9%) were rubella-IgM positive, and all had bilateral glaucoma. One eye in a rubella-positive baby was an unsightly blind eye and required a prosthesis. 13 eyes of 7 patients were compared to thirty-four eyes of 20 rubella-negative patients. There was no significant difference in mean age and IOP at presentation. Rubella-positive babies had significantly more opaque corneas (p< 0.001), shorter eyes (p<0.001) and smaller corneal diameters (p=0.007) at presentation. Two patients in the rubella group had bilateral cataracts, 3 had heart disease, and 1 had sensorineural deafness. Salt-and-pepper-retinopathy was noted in both rubella positive babies where fundus evaluation was possible. Despite comparable IOP control (p=0.51), the corneal clarity remained significantly worse in the rubella-positive patients (p=0.02).

CONCLUSION

Twenty-five percent of newborn glaucoma had underlying intrauterine rubella infection thus making them susceptible for development of congenital rubella syndrome. Neonatal-onset glaucoma is an important component of congenital rubella syndrome, which may present without buphthalmos and persistent corneal clouding despite good IOP control.

Goniotomy for initial and re-surgery for childhood glaucoma in Northern India

Purpose

The aim of this study was to describe the effectiveness of goniotomy for childhood glaucoma in Indian eyes.

Methods

Consecutive patients with pediatric glaucoma who underwent goniotomy between July 2017 and June 2020, in a single center in Northwest India were prospectively analyzed. Goniotomy was done as a primary procedure or a re-do surgery of the untreated angle in failed filtering surgery. Success was defined as intraocular pressure (IOP) ≦18 mm Hg with or without 2 topical medications.

Results

A total of 172 eyes of 126 children underwent goniotomy during this period (37.9% of all pediatric glaucoma surgeries). Goniotomy comprised 132 of 211 (62.5%) primary pediatric glaucoma surgeries and 40 of 243 (16.5%) re-do surgeries. 145, 112, and 54 eyes had a six months, 1-year and 2-year follow-up, respectively. At 1 year, success rates in Primary Congenital Glaucoma (PCG) were 79.7% for primary surgery and 68.4% for re-do surgery. For non-PCG eyes, the success rate was 62% at 1 year. Among PCG subgroups, infantile and newborn glaucoma had 87.5% and 57.1% success rates, respectively. On logistic regression analysis, lower baseline IOP and lesser axial length at presentation were significantly predictive of successful outcomes (P = 0.03 and P = 0.02, respectively). At 1 year, in the primary surgery group, 50% had good vision (better than logMAR 0.5), 28.9% had moderate (better than LOGMAR 1.0) and 20% had severe visual impairment. There were no significant intraoperative or post-operative complications.

Conclusion

Goniotomy appears to be an effective surgery for childhood glaucoma in Indian eyes. Being minimally invasive, it obviates the need for conjunctival and scleral dissection and antifibrotic agents.

Understanding factors associated with continuation of intrauterine device use in Gujarat and Rajasthan, India: a cross-sectional household study

The Government of India has promoted the expansion of access to and uptake of intrauterine devices (IUDs), during both the interval (IIUD) and postpartum (PPIUD) periods, as part of its Family Planning 2020 initiative. This study, conducted by EngenderHealth as part of the Expanding Access to IUD Services in India project, examines IIUD and PPIUD continuation rates over time and investigates factors associated with IUD continuation. We recruited respondents (N = 5024) through a repeated cross-sectional household study between February and December 2019. We identified respondents using IUD client data from public health facility registers in 20 districts of Gujarat and Rajasthan. We compared continuation rates for IIUD and PPIUD adopters and used regression analyses to measure the association between continuation and demographic, quality of care, and counselling variables. IIUD continuation rates decreased from 85.6% to 78.3% and PPIUD rates decreased from 78.5% to 70.7% between month 3 and month 12. Clients experiencing side effects or other problems were 15 times more likely to discontinue IUD use than clients who did not. Clients who received IUD counselling prior to insertion were more likely to continue than those who did not. IUD continuation increased significantly in cases where both partners jointly selected the method compared to situations where women decided alone. Several sociodemographic factors were associated with continuation. Our study demonstrates the value and benefits of programmes offering IUD services emphasising quality counselling and client-centred care to increase access, uptake, and continuation.

Naturalistic Evaluation of Prescription Pattern in Glaucoma Clinic of a Tertiary Care Hospital: A Developing Country's Perspective

Background:

Glaucoma is a chronic, gradual and progressive eye disorder characterized by visual loss and involving the typical changes in optic nerves and associated structures. Currently, the mainstay treatment lies in the reduction of intraocular pressure (IOP) involving the usage of two or three medications concurrently. However, prescription pattern of antiglaucoma drugs remains largely unstudied so far. Therefore, there is a dire need of drug utilization studies to ensure rational prescribing for better treatment outcomes.

Aim:

This study was conducted to assess the prescription pattern in glaucoma patients to encourage rational use of drugs.

Materials and Methods:

The pertinent data of confirmed glaucoma patients were entered in a predesigned case record form (CRF) including patient demographic details, type of glaucoma, number of drug prescribed, drug dosage and dosage formulation with prior patient consent, and finally, the data were analyzed using Microsoft Excel.

Results:

A total of 247 glaucoma patients were recorded in the study. The mean SD number of drugs per prescription was 2.18 (1.68). Monotherapy was prescribed to 72 (29.15%) patients, and the most common monotherapy prescribed was timolol, whereas in fixed-dose combinations (FDCs), brimonidine and timolol FDCs were most commonly encountered. Furthermore, prescriptions consisting of generic drugs only and prescribed as per the National List of Essential Medicines (NLEM) were 48 (19.43%) and 41 (16.59%), respectively.

Conclusion:

This study showed the judicious use of medications in tune with principles of rational drug use in our center, and the rationale practices can be extended to the peripheral centers of the country for better drug utilization.

Neovascular glaucoma - A review

Neovascular glaucoma (NVG) is a sight-threatening secondary glaucoma characterized by appearance of new vessels over the iris and proliferation of fibrovascular tissue in the anterior chamber angle. Retinal ischemia is the common driving factor and common causes are central retinal vein occlusion, proliferative diabetic retinopathy, and ocular ischemic syndrome. The current rise in the prevalence of NVG is partly related to increase in people with diabetes. A high index of suspicion and a thorough anterior segment evaluation to identify the early new vessels on the iris surface or angle are essential for early diagnosis of NVG. With newer imaging modalities such as the optical coherence tomography angiography and newer treatment options such as the anti-vascular endothelial growth factor, it is possible to detect retinal ischemia early, tailor appropriate treatment, monitor disease progression, and treatment response. The management strategies are aimed at reducing the posterior segment ischemia, reduce the neovascular drive, and control the elevated intraocular pressure. This review summarizes the causes, pathogenesis, and differential diagnoses of NVG, and the management guidelines. We also propose a treatment algorithm of neovascular glaucoma.

Safety and efficacy of oral Triclofos in the ophthalmic evaluation of children with pediatric glaucoma: An observational study

Purpose:

Oral Triclofos is widely used as a sedative agent in children. However, the role of Triclofos as a sedative agent in children undergoing ophthalmological procedures has not been adequately studied. The aim of this study was to determine the safety and efficacy of oral Triclofos in children suffering from pediatric glaucoma who were undergoing ocular examination.

Methods:

80 children aged less than 5 years were assessed for eligibility for the trial after taking hospital ethical committee approval. The children were administered 80 mg/kg of oral Triclofos and Ramsay sedation score was measured every 5 min starting from 20 min after administration of the drug. If the child was not adequately sedated after 30 min, additional dose of 05 mg/kg was administered every 5 min till 60 min of drug administration. The procedure was considered a failure and general anesthesia (GA) administered if Ramsay sedation score was ≤4 after 60 min of initial drug administration. Heart rate and arterial oxygen saturation were measured throughout the period of sedation. The duration of sedation and incidence of side effects was also noted.

Results:

A total of 73 patients underwent the study. The mean age of children was 23.4 months (SD – 14.72) and mean weight was 12 kg (SD – 3.84). The mean dose of Pedicloryl (Triclofos) used was 83.8 mg/kg and the median duration of onset was 25 min. 64 children completed examination successfully, 2 children had to be administered GA during the procedure. There were no major side effects.

Conclusion:

Administration of oral Triclofos in a dose of 80 mg/kg body weight was safe and effective in children less than 5 years of age undergoing ocular examination.

Neonatal-Onset Congenital Ectropion Uveae: A Distinct Phenotype of Newborn Glaucoma

PURPOSE

To describe neonatal-onset congenital ectropion uveae (N-CEU) as a distinct clinical entity of newborn glaucoma (NG) and to study its significance toward the severity and outcome of NG.

DESIGN

Prospective clinical cohort study.

METHODS

The study took place at a tertiary care postgraduate teaching institute. It included consecutive patients with NG who presented between July 1, 2016 and September 30, 2017, with a minimum postoperative follow-up of 1 year. Infants with any ocular anomaly apart from CEU were excluded. Patients with N-CEU were compared with those with neonatal-onset primary congenital glaucoma (N-PCG). All infants underwent goniotomy or trabeculotomy, with trabeculectomy depending on corneal clarity. Clinical features at presentation and outcome 1 year after surgery were defined as good or satisfactory if intraocular pressure was ≤16.0 mm Hg under anesthesia without or with topical medications, respectively, and poor if the infant required additional surgery.

RESULTS

Twenty eyes of 10 patients with N-CEU were compared with 16 eyes of 9 patients with N-PCG. Infants with N-CEU had significantly worse corneal clarity (mean grade 2.0 ± 0.7 vs 1.4 ± 0.8; P = .026) and poorer outcomes compared with those with N-PCG. Seven of 16 (43.7%) eyes with N-PCG had a cornea clear enough at presentation for a goniotomy compared with only 2 of the 20 (10%) eyes with N-CEU (P = .026). Thirteen of 16 (81.2%) eyes with N-PCG had a good or satisfactory outcome compared with 6 of 20 (30%) eyes with N-CEU (P = .001).

CONCLUSIONS

N-CEU appears to be distinct from the unilateral CEU in older patients described in the literature and may be considered a poorer prognosis phenotype of neonatal-onset glaucoma.

Chaperone-mediated autophagy sustains haematopoietic stem-cell function

The activation of mostly quiescent haematopoietic stem cells (HSCs) is a prerequisite for life-long production of blood cells¹. This process requires major molecular adaptations to allow HSCs to meet the regulatory and metabolic requirements for cell division^2-4. The mechanisms that govern cellular reprograming upon stem-cell activation, and the subsequent return of stem cells to quiescence, have not been fully characterized. Here we show that chaperone-mediated autophagy (CMA)⁵, a selective form of lysosomal protein degradation, is involved in sustaining HSC function in adult mice. CMA is required for protein quality control in stem cells and for the upregulation of fatty acid metabolism upon HSC activation. We find that CMA activity in HSCs decreases with age and show that genetic or pharmacological activation of CMA can restore the functionality of old mouse and human HSCs. Together, our findings provide mechanistic insights into a role for CMA in sustaining quality control, appropriate energetics and overall long-term HSC function. Our work suggests that CMA may be a promising therapeutic target for enhancing HSC function in conditions such as ageing or stem-cell transplantation.

Bilateral Chandler's syndrome: Uncommon entity diagnosed by ultrasound biomicroscopy and confocal microscopy

A 22‑year‑old female presented with bilateral, progressive diminution of vision. Slit‑lamp examination revealed bilateral sectoral corneal edema. Gonioscopy showed broad‑based peripheral anterior synechiae and a membrane obscuring angle structure in both the eyes. On ultrasound biomicroscopy (UBM), a membrane extending from corneal endothelium to anterior iris surface causing traction was seen. Confocal microscopy showed an "epithelium‑like" transformation of the corneal endothelium. This case demonstrates a bilateral Chandler variant of the iridocorneal endothelial (ICE) syndrome where the diagnosis of Chandler's disease was confirmed by confocal microscopy, after the mechanism of secondary angle closure was demonstrated by the UBM.

Functional role of iNOS-Rac2 interaction in neutrophil extracellular traps (NETs) induced cytotoxicity in sepsis

BACKGROUND

Recent reports from this lab have demonstrated a higher incidence of NETs, nitrosative, as well as oxidative stress, and have a direct correlation with the severity of sepsis and organ damage. However, the mechanistic perspective of NETs induced organ damage has not been understood at the cellular and molecular level. Interaction of inducible nitric oxide synthase (iNOS) with Rac2 in regulating reactive oxygen species (ROS) and reactive nitrogen species (RNS) generation and its implications in microbial killing has been reported. This study was, therefore, undertaken in neutrophils of sepsis patients to investigate the functional importance of iNOS-Rac2 interaction in ROS/ RNS, peroxynitrite generation, NETs generation, and NETs mediated cell death.

METHODS

The study was conducted on 100 patients with sepsis and 50 healthy volunteers. Interaction between iNOS and Rac2 was performed using co-immunoprecipitation and co-immunolabeling assay. Free radicals involving ROS and RNS were evaluated using cytochrome c reduction assay. NETs formation was evaluated by fluorescence microscopy. The cytotoxic effect of NETs was assessed on lung carcinoma cell line (A549) using colorimetric Alamar blue assay.

RESULTS

Enhanced interaction between iNOS and Rac2 was found in sepsis neutrophils in comparison with control. This was accompanied by an increased level of superoxide (O2.-), nitric oxide (NO), and peroxynitrite (ONOO-) which were decreased in the presence of NAC, DPI, and 1400 W, signifying the role of iNOS-Rac2 interaction. Enhanced NETs release from activated sepsis neutrophils were abrogated in the presence of DPI. NETs from sepsis neutrophils exert a cytotoxic effect on lung epithelial cells (A549) in a concentration-dependent manner.

CONCLUSION

Our findings exhibit the functional role of iNOS-Rac2 interaction in ROS/RNS, peroxynitrite generation, NETs generation, and NETs mediated cell death.

Clinical profile and outcome of early surgery in neonatal-onset glaucoma presenting over a 5-year period

BACKGROUND

Neonatal-onset glaucoma (NOG) is a severe form of childhood glaucoma and is not always due to primary congenital glaucoma (PCG). Due to advances in neonatal care, the incidence of NOG is rising, but it remains an under-reported entity. The objective of the paper was to study the clinical profiles, surgical and visual outcomes of NOG at least 1 year following early surgery.

METHODS

Prospective interventional cohort study at a tertiary care referral centre. Babies with NOG, who presented between January 2013 and December 2017, had a history suggestive of disease onset within 1 month of birth, and underwent surgery by 3 months of age, were prospectively enrolled. Those who completed a 1-year follow-up after surgery were analysed.

RESULTS

94 eyes of 53 babies were analysed. 35 (66%) had PCG. Neonatal congenital ectropion uveae, congenital rubella syndrome, Peter's anomaly and Sturge-Weber syndrome comprised the non-PCG group. The mean age at presentation and surgery was 24.8±21.9, and 36.7±29.9 days. Additional glaucoma surgery was required in 43 of the 94 eyes (45.7%). PCG had significantly better outcomes than other glaucomas at all time points. 28.3% of eyes had good vision (LogMar (0-0.5)), 34.7% had moderate visual impairment (LogMar 0.7-1.0) and 16% were blind (LogMar <1.62) .

CONCLUSION

Our study shows that NOG does not always have a dismal prognosis. A small but significant proportion could have other underlying conditions than PCG. Timely surgery and rigorous amblyopia therapy resulted in good outcomes in terms of intraocular pressure control and vision in this cohort.

Mirtazapine-induced bilateral secondary angle closure in a female

Purpose: To report a case of bilateral secondary angle closure in a female using mirtazapine for 6 months.

Patient and method: A 55-year-old female was diagnosed with secondary angle closure in both eyes with raised intraocular pressure, and ultrasound biomicroscopic findings suggestive of ciliary body effusion. It was associated with adjoining cyst presumably because of the use of mirtazapine for depression and sleep disturbances.

Results: After the planned discontinuation of mirtazapine, the ocular angle opened, the ciliary body edema decreased, and the cyst regressed in size. The intraocular pressure was controlled with topical timolol (0.5%).

Conclusion: Patients with risk factors for angle closure should be prescribed antipsychotic drugs with caution. The peripheral laser iridotomy is not indicated in secondary angle closure due to ciliary body effusion.

Differential diagnosis of acute ocular pain: Teleophthalmology during COVID-19 pandemic - A perspective

Ocular pain is a common complaint which forces the patient to seek immediate medical attention. It is the primeval first response of the body to any severe condition of the eye such as trauma, infections and inflammation. The pain can be due to conditions directly affecting the eye and ocular adnexa; or indirect which would manifest as referred pain from other organ structures such as the central nervous system. Paradoxically, there are several minor and non-sight threatening conditions, which also leads to ocular pain and does not merit urgent hospital visits. In this perspective, we intend to provide guidelines to the practising ophthalmologist for teleconsultation when a patient complains of pain with focus on how to differentiate the various diagnoses that can be managed over teleconsultation and those requiring emergency care in the clinic. These guidelines can decrease unnecessary hospital visits, which is the need of the hour in the pandemic era and also beyond. Patients who are under quarantine and those who are unable to travel would be benefitted, and at the same time, the burden of increased patient load in busy hospital systems can be reduced.

Anterior segment dysgenesis and secondary glaucoma in Goldenhar syndrome

A 3-year-old girl presented with a history of watering, haze and increase in the size of the right eye for two months. The child had bilateral preauricular skin tags, limbal dermoid and dermolipoma, consistant with the diagnosis of Goldenhad syndrome. In addition, her right eye manifested enlarged cornea, flat anterior chamber, atrophic iris and elevated intraocular pressure. This case report highlights a possible association of anterior segment dysgenesis and glaucoma with Goldenhar syndrome.