Background Glaucoma is the leading cause of irreversible blindness. Normal tension glaucoma (NTG) is a subset of open-angle glaucoma, demonstrating glaucomatous optic nerve damage in the absence of ...raised intraocular pressure (IOP). NTG is more prevalent in Asian populations. While generally slow-progressing, NTG may be associated with significant central visual field loss. In recent years, minimally invasive glaucoma surgery has been added to the armamentarium of glaucoma surgery. This prospective study aims to evaluate 12-month surgical outcomes of combined iStent inject (Glaukos Corporation, Laguna Hills, CA) implantation and phacoemulsification in Asian eyes with NTG. Methods This is a prospective, single-centre case series of 30 eyes followed up until 12 months after surgery. Outcome measures included IOP, number of glaucoma medications, best-corrected visual acuity (BCVA) and intra and postoperative complications. Results Mean age of subjects was 73.1 + or - 6.3 years. Majority were ethnic Chinese (n = 27, 90%). Baseline medicated mean IOP was 13.8 + or - 2.4 mmHg and mean number of glaucoma medications was 1.3 + or - 0.7. Mean Humphrey visual field mean deviation was - 13.7 + or - 7.6. The mean IOP reduction at all timepoints from postoperative month (POM) 3 onwards was statistically significant (all P < 0.05), with mean reduction of 1.2 mmHg (95% CI: 0.1-2.2, P = 0.037) by POM12. There was statistically significant reduction in mean number of medications from postoperative day (POD) 1 onwards (all P < 0.05), with mean decrease of 1.0 medication (95% CI: 0.9-1.1, P < 0.001) by POM12. By POM12, 25 (83.3%) eyes were medication-free. Three (10%) eyes had stent occlusion by iris requiring laser iridoplasty. One eye had gross hyphema which resolved on conservative management before POM1. Mean BCVA improved from the baseline 0.3 + or - 0.3 logMAR to 0.1 + or - 0.1 logMAR postoperatively (P < 0.001). There were no major adverse or sight-threatening events. No eyes required further glaucoma surgery during the 12-month follow-up period. Conclusion Asian eyes with NTG which underwent combined iStent inject implantation and phacoemulsification demonstrated a significant and sustained reduction in IOP and glaucoma medications, up to 12 months postoperatively. Keywords: iStent inject, Normal tension glaucoma, Minimally invasive glaucoma surgery, Asian
PURPOSETo compare the performance of the Glaucoma Probability Score (GPS), Mikelberg linear discriminant function (LDF), Burk LDF, and Moorfield regression analysis (MRA) in classifying optic disc ...images acquired from normals and glaucoma patients with the Heidelberg Retina Tomograph (HRT).
PATIENTS AND METHODSThis is a retrospective comparative study of 110 eyes of 110 subjects clinically categorized as glaucoma or normal. Topographic images of the optic nerve head were obtained from HRT. Data analysis of the HRT images were carried out using GPS, Mikelberg LDF, Burk LDF, and MRA. Diagnostic performances and agreement in classification between the data analysis tools were calculated and compared for GPS, Mikelberg LDF, Burk LDF, and MRA.
RESULTSThe highest specificity but lowest sensitivity value was obtained using the Burk LDF. The highest sensitivity but lowest specificity was obtained using the GPS. The GPS and MRA were however similar in performance. Sensitivity and specificity values of the GPS and other LDFs were affected by disc size.
CONCLUSIONSThe GPS compared similarly with the MRA without the need of additional contour line placements. Disc size is still an important factor in classification by the GPS and the other LDFs.
AIM: To determine angle closure agreements between gonioscopy and anterior segment optical coherence tomography(AS-OCT), as well as gonioscopy and spectral domain OCT(SD-OCT). A secondary objective ...was to quantify inter-observer agreements of AS-OCT and SD-OCT assessments.METHODS: Seventeen consecutive subjects(33 eyes)were recruited from the study hospital’s Glaucoma clinic.Gonioscopy was performed by a glaucomatologist masked to OCT results. OCT images were read independently by 2 other glaucomatologists masked to gonioscopy findings as well as each other’s analyses of OCT images.RESULTS: Totally 84.8% and 45.5% of scleral spurs were visualized in AS-OCT and SD-OCT images respectively(P <0.01). The agreement for angle closure between AS-OCT and gonioscopy was fair at k =0.31(95% confidence interval, CI: 0.03-0.59) and k =0.35(95%CI: 0.07-0.63) for reader 1 and 2 respectively. The agreement for angle closure between SD-OCT and gonioscopy was fair at k =0.21(95% CI: 0.07-0.49) and slight at k =0.17(95% CI: 0.08-0.42) for reader 1 and 2 respectively. The inter-reader agreement for angle closure in AS-OCT images was moderate at 0.51(95% CI: 0.13-0.88). The inter-reader agreement for angle closure in SD-OCT images was slight at 0.18(95% CI: 0.08-0.45).CONCLUSION: Significant proportion of scleral spurs were not visualised with SD-OCT imaging resulting in weaker inter-reader agreements. Identifying other angle landmarks in SD-OCT images will allow more consistent angle closure assessments. Gonioscopy and OCT imaging do not always agree in angle closure assessments but have their own advantages, and should be used together and not exclusively.
PURPOSEPigment dispersion syndrome (PDS) and pigmentary glaucoma (PG) are characterized by loss of iris pigment because of reverse pupillary block. The loss of iris pigment is manifested as ...transillumination defects. Differences in ocular anatomy have been found between subjects with PDS and controls. Our study aims to see if differences in interocular anatomic features are also related to differences in the quantity of transillumination defects between eyes.
PATIENTS AND METHODSThis is an observational case series of 30 eyes of 15 subjects with PDS/PG in at least 1 eye. Patients underwent refraction, exophthalmometry, corneal and anterior chamber analysis by Pentacam, biometry, A-scan, ultrasound biomicroscopy, and anterior segment digital photography.
RESULTSThe Pentacam mean central radii of the posterior corneal surface (cornea back Rm), vertical central radius of curvature of the posterior corneal surface (cornea back Rv), and keratometric power deviation (influence of the posterior surface of the cornea on refractive power) were statistically different between eyes with greater pigment loss and eyes with lesser pigment loss. Eyes with greater pigment loss had a larger back radius of corneal curvature and a correspondingly numerically smaller keratometric power deviation. Other measurements of ocular anatomy were not statistically significant.
CONCLUSIONSA flatter curvature of the posterior corneal surface of the eye is associated with increased pigment loss in PDS and PG. The authors postulate that this could result in a difference in the biomechanical properties of the cornea, increased deformation with blinking, and a pumping action resulting in the reverse pupil block of PDS.
Background: We aim to establish normative values and evaluate test‐retest variability for the central and foveal field tests of version 4 of rarebit perimetry.
Design: This was a prospective study ...undertaken in collaboration between Tan Tock Seng Hospital, Singapore, and Singapore Polytechnic.
Participants: Fifty‐four normal subjects were recruited and included in the study.
Methods: Subjects underwent rarebit perimetry testing, studying the central and foveal fields. All subjects repeated the test within 1 month of the initial visit. The ‘mean hit rates’ of one eye of every subject were analysed.
Main Outcome Measures: Mean hit rates of subjects were analysed to establish normative values for the central and foveal fields. Test‐retest variability was also analysed.
Results: Overall normative mean hit rates were 86.3 ± 13.95% for the central field and 91.6 ± 6.35% for the foveal field. For every increasing year of age, we found a 0.47% decrease in the central mean hit rates (P < 0.001). Normative mean hit rate for central and foveal fields were 90.6 ± 12.3% and 98.2 ± 3.7% respectively, in ‘young’ subjects, and 81.9 ± 15.6% and 85.0 ± 9.0% respectively, in ‘mature’ subjects. We found no significant test–retest variability in the foveal field (P = 0.554). There was significant test–retest variability in the central field (P < 0.001), but the difference was a 3.5 unit mean hit rate increase, which may be clinically significant.
Conclusions: Rarebit perimetry is repeatable and reliable. We have established normative values for two age groups.
To assess the degree of visual field (VF) loss in subjects diagnosed with primary angle-closure glaucoma (PACG), and to compare the severity of such loss between those with symptomatic and ...asymptomatic disease.
Observational case series.
Seventy-six consecutive subjects with PACG who presented at a Singapore hospital.
Primary angle-closure glaucoma was defined as the presence of glaucomatous optic neuropathy and compatible VF loss associated with closed angles. There were 2 groups of subjects studied: group A consisted of those who presented with acute symptomatic angle closure, and group B consisted of those who were asymptomatic. Subjects underwent static automated threshold perimetry, and the first reliable VF was analyzed using the Advanced Glaucoma Intervention Study (AGIS) scoring system. The field tests were graded according to severity as mild, moderate, severe, and end-stage VF defects, based on AGIS scores of 0 to 5, 6 to 11, 12 to 17, and 18 to 20 respectively.
Advanced Glaucoma Intervention Study scores of the first reliable threshold VF test.
The mean age of study subjects was 61.4±9.6 years (range: 33–84), and the majority of subjects were female (59%) and Chinese (91%). In group A (n = 40), most eyes had mild or moderate VF defects (23 eyes 57.5%), whereas 7 eyes (17.5%) had end-stage defects. This was in contrast to group B (n = 36), in which the majority of eyes had end-stage VF loss (19 eyes 52.8%), with only 5 eyes (13.7%) having mild VF defects. Mean AGIS scores were 9.1±7.6 for group A and 14.2±6.9 for group B (
P = 0.004). Cup-to-disc ratio was a significant predictor for VF loss, but age, gender, and level of presenting intraocular pressure were not correlated with VF outcome.
Eyes with asymptomatic PACG often present with severe to end-stage VF loss at the time of first presentation to hospital. In contrast, most PACG eyes with previous symptomatic angle closure present with mild or moderate VF defects. The visual morbidity of PACG may be related to the finding that the asymptomatic form of the disease is visually destructive.
The XEN45 Gel Stent (Allergan Inc., Irvine, CA) allows the drainage of aqueous into the sub-conjunctival space, through a minimally-invasive approach. This systematic review and meta-analysis ...evaluates its intraocular pressure (IOP)-lowering efficacy and complications in the treatment of open-angle glaucoma. Fourteen studies comprising 963 eyes were included. IOP decreased significantly (P < 0.001) across all timepoints (1 day, 1 week, 1, 3, 6, 12, 18, and 24 months) with a mean decrease of 7.44 mm Hg (95%CI:4.91–9.97) at 24 months. IOP-lowering medications decreased significantly (P < 0.001) across all timepoints (1 week, 1, 3, 6, 12, 18, 24 months) with a mean reduction of 1.67 medications (95%CI:1.28–2.06) at 24 months. Numerical hypotony occurred in 39% (95%CI:14%–67%) and stent exposure in 1% (95%CI:0%–2%) of eyes. 38% (95%CI:30%–46%) of eyes required at least one postoperative needling, with an average of 0.6 (95%CI:0.37–0.81) needlings per eye. Standalone XEN45 Gel Stent implantation is effective in lowering IOP in open-angle glaucoma. Transient numerical hypotony is the most common postoperative complication. Sight-threatening complications are rare. Postoperative needling may be required to maintain IOP-lowering outcomes; however, the overall quality of current evidence is low, with the need for more randomized controlled trials and outcomes measured with a clinically meaningful definition of success.
To describe variations in the presentation of monocular visual loss associated with intracranial aneurysm rupture. The clinical course, possible etiologies and management of visual loss in three ...patients are described.
The first patient developed Terson's syndrome (vitreal hemorrhage associated with raised intracranial pressure secondary to subarachnoid hemorrhage). Following aneursymal clipping, her postoperative management was conservative and there was no improvement in visual acuity. The second patient underwent surgical clipping of internal carotid aneursysms and sustained visual loss subsequent to surgical dissection and temporary clipping around the optic nerve and anterior choroidal artery. The vessel subsequently thrombosed. Potential contributing factors to visual loss in this case included intraoperative hypotension and anemia. This patient received anti-platelet medications, and experienced subsequent improvement in visual acuity to 6/9. A third patient underwent a right orbito-frontal keyhole craniotomy with the cranial flap retracted across the orbit. Elevated intraocular pressure secondary to external orbital compression may have compromised retinal and choroidal perfusion. This patient also developed vasospasm of both anterior cerebral arteries which resolved partially with papaverine therapy. Hypertension-hypervolemia therapy was instituted, with subsequent partial recovery of visual acuity in her right eye.
Perioperative monocular visual loss associated with intracranial aneurysm repair is an infrequent occurrence, and clinical presentations may be quite variable. The primary pathophysiological mechanisms are intraocular hemorrhage and ischemia of ocular structures, including the optic nerve. Early detection, via regular fundoscopic examination and treatment aimed at decreasing intraocular pressure and augmenting ocular perfusion may improve outcomes.
The pathophysiology of Primary Open Angle Glaucoma (POAG) remains poorly understood. Through proteomic analysis of aqueous humour (AH) from POAG patients, we aim to identify changes in protein ...composition of these samples compared to control samples.
High resolution mass spectrometry-based TMT6plex quantitative proteomics analysis is performed on AH samples collected from POAG patients, and compared against a control group of patients with cataracts. Data are available via ProteomeXchange with identifier PXD033153.
1589 proteins were quantified from the aqueous samples using Proteome Discoverer version 2.2 software. Among these proteins, 210 were identified as unique master proteins. The proteins which were up or down-regulated by ±3 fold-change were considered significant. Human neuroblastoma full-length cDNA clone CS0DD006YL02 was significantly upregulated in patients with severe POAG on >2 medications, while actin, cytoplasmic 1, V2-7 protein (fragment), immunoglobulin-like polypeptide 1 and phosphatidylethanolamine-binding protein 4 were only present in these patients with severe POAG on >2 medications.
Beta-crystallin B1 and B2, Gamma-crystallin C, D and S were significantly downregulated in the severe POAG ≤2 glaucoma medications group.
Beta-crystallin B2, Gamma-crystallin D and GCT-A9 light chain variable region (fragment) were significantly downregulated in the non-severe POAG group.
Actin, cytoplasmic 1 was significantly upregulated in subjects with severe POAG who required more than 2 glaucoma medications. Crystallins (Beta-crystallin B1 and B2, Gamma-crystallin C, D and S) were significantly downregulated in subjects with severe POAG who required less than 2 glaucoma medications.
•Mass spectrometry of aqueous humour samples found differences of protein expressions in glaucoma.•Actin cytoplasmic 1 protein is upregulated in glaucoma.•This may be associated with increased trabecular meshwork resistance.•Beta And gamma crystallins are downregulated in primary open angle glaucoma.•Decreased crystallin levels may affect survival of retinal ganglion cells.
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