Clinical studies implicate low cerebrospinal fluid pressure (CSFP) or a high translaminar pressure difference in the pathogenesis of primary open angle glaucoma (POAG) and normal tension glaucoma ...(NTG). This study was performed to examine the effect of age, sex, race and body mass index (BMI) on CSFP.
Electronic medical records from all patients who had a lumbar puncture (LP) performed at the Mayo Clinic from 1996-2009 were reviewed. Information including age, sex, race, height and weight, ocular and medical diagnoses, intraocular pressure (IOP) and LP opening pressure was obtained. Patients using medications or with medical diagnoses known to affect CSFP, and those who underwent neurosurgical procedures or where more than one LP was performed were excluded from analysis.
Electronic medical records of 33,922 patients with a history of having an LP during a 13-year period (1996-2009) were extracted. Of these, 12,118 patients met all entry criteria. Relative to mean CSFP at age group 20-49 (mean 11.5±2.8 mmHg), mean CSFP declined steadily after age 50, with percent reduction of 2.5% for the 50-54 age group (mean 11.2±2.7 mmHg, p<0.002) to 26.9% for the 90-95 group (mean 8.4±2.4 mmHg, p<0.001). Females had lower CSFP than males throughout all age groups. BMI was positively and independently associated with CSFP within all age groups.
There is a sustained and significant reduction of CSFP with age that begins in the 6(th) decade. CSFP is consistently lower in females. BMI is positively and independently associated with CSFP in all age groups. The age where CSFP begins to decline coincides with the age where the prevalence of POAG increases. These data support the hypothesis that reduced CSFP may be a risk factor for POAG and may provide an explanation for the mechanism that underlies the age-related increase in the prevalence of POAG and NTG.
To evaluate the sensitivity and specificity of swept-source optical coherence tomography (SS-OCT) biometer compared with the gold standard spectral-domain optical coherence tomography (SD-OCT) for ...detecting macular pathology in patients with cataract.
Eye Centers of Tennessee, Crossville, TN.
Prospective, cross-sectional, observational, examiner-masked.
The study included 132 participants aged 50 years and older, who underwent precataract surgery work-up. All participants underwent fixation check retinal scans using SS-OCT biometer (IOLMaster 700) as well as full macular scans using Cirrus SD-OCT. 3 independent masked examiners evaluated the scans if they were normal or had a suspected pathology. Different measures of diagnostic accuracy were calculated for 3 examiners.
True positive rate (sensitivity) ranged from 71.1% (32/45) to 79.2% (42/53), and false negative rate was between 20.8% (11/53) and 28.9% (13/45) for the 3 examiners. True negative rate (specificity) ranged from 86.8% (59/68) to 94.1% (64/68), and false positive rate was between 5.9 (4/68) and 13.2% (9/68). The fitted receiver operating characteristic area ranged from 0.83 to 0.95.
Using retinal SS-OCT biometer scans as a replacement of the dedicated macular SD-OCT for screening or diagnosing macular health would not be appropriate because of its low sensitivity. SS-OCT biometer may potentially fail to identify approximately one-fourth of patients who actually have the disease. Therefore, the final decision on macular health should be based on the gold standard SD-OCT scans. When full macular SD-OCT scans are not accessible, the limited retinal scan information from SS-OCT biometer may still provide useful insights into the macular health.
To compare cerebrospinal fluid (CSF) pressure in patients with primary open-angle glaucoma (POAG) with that in nonglaucomatous patients.
Case-control study.
Thirty-one thousand, seven hundred and ...eighty-six subjects underwent lumbar puncture (LP) between 1996 and 2007 at the Mayo Clinic, Rochester, Minnesota. Of these, 28 patients who had POAG and 49 patients who did not have POAG were analyzed.
Retrospective review of medical records. Comparison of the 2 groups and factors associated with CSF pressure were analyzed by univariate and multivariate analyses.
Demographics (age and gender), medical history, medication use, indication for LP, intraocular pressure (IOP), optic disc cup-to-disc ratio, visual field assessment, and CSF pressure.
The mean CSF pressure +/- standard deviation was 13.0+/-4.2 mmHg in nonglaucoma patients and 9.2+/-2.9 mmHg in POAG patients (P<0.00005). The CSF pressure was lower in POAG patients regardless of indication for LP or age. Linear regression analysis showed that cup-to-disc ratio correlated independently with IOP (P<0.0001), CSF pressure (P<0.0001), and the translaminar pressure difference (P<0.0001). Multivariate analysis demonstrated that larger cup-to-disc ratio (P<0.0001) was associated with lower CSF pressure.
Cerebrospinal fluid pressure is significantly lower in POAG patients compared with that in nonglaucomatous controls. These data support the notion that CSF pressure may play an important contributory role in the pathogenesis of POAG.
Glaucoma is a major cause of blindness, and IOP reduction remains the only clinically-validated therapy. In this study, we analyze a novel IOP-lowering strategy that uses a modest negative pressure ...(vacuum) applied locally to the periorbital region by a pair of goggles with each lens individually connected to a programmable pump. Motivated by clinical data showing an IOP reduction, we used an existing validated lumped-parameter model of the eye to understand the putative mechanism of this treatment. The model considers aqueous humor dynamics, episcleral venous pressure, and changes in ocular blood volume to describe how IOP changes with time in response to an external perturbation. We find that clinical data are qualitatively and quantitatively consistent with model predictions if we include two primary mechanisms in the model: first, negative pressure application causes a relatively rapid increase in globe volume accompanied by increased blood volume in the eye. Second, negative pressure application reduces episcleral venous pressure, causing a slower adjustment of IOP due to altered aqueous humor dynamics. These results provide testable hypotheses that hopefully will lead to a fuller experimentally-driven understanding of how negative periocular pressure influences IOP. Evaluating the long-term effects of such treatments on glaucoma patients requires further clinical study.
•A novel strategy for IOP management has been recently proposed: patients wear goggles to deliver a modest negative pressure to the anterior globe and orbit.•We used a lumped parameter mathematical model to investigate possible mechanisms of IOP lowering in this treatment.•Model predictions are consistent with clinical data if we include ocular blood volume changes and reduction of episcleral venous pressure.•The long-term benefit for vision preservation of goggle wear remains to be determined, but these results motivate further clinical studies.
The purpose of the study is to describe short-term efficacy and safety of goniotomy with trabecular meshwork excision using the Kahook Dual Blade (KDB, New World Medical Inc., Rancho Cucamonga, CA) ...in patients with severe or refractory glaucoma.
Retrospective multicentric case series of 53 eyes with severe or refractory glaucoma as defined by ICD-10 conducted in the United States, Mexico, and Switzerland. Primary efficacy outcome was a ≥20% decrease in intraocular pressure (IOP) from baseline at 6 months. Secondary efficacy outcome measures were probability of achieving an IOP≤14 or 18 mm Hg at 6 months and the mean IOP change from baseline at 6 months. Medication use required to obtain target IOP at last follow up and adverse effects were analyzed.
The proportion of eyes achieving an IOP reduction of >20% from preoperative baseline at 6 months was 57.7% (n=30). The mean IOP decreased from 18.4±6.1 mm Hg at baseline to 13.9±3.5 mm Hg at month 6 (23.9% reduction; P<0.001). At 6 months, 63.5% and 92.3% achieved an IOP≤14 and ≤18 mm Hg, respectively, and the mean number of glaucoma medications was reduced by 1.2±1.3 (36.6%) compared with baseline (P<0.001). The most common adverse event was hyphema (n=29, 34.9%) with spontaneous resolution in all cases. No severe complications were reported. One case presented with uncontrolled IOP and required glaucoma drainage device surgery at 1 month.
Goniotomy with trabecular meshwork excision using the KDB could be an alternative surgery for severe or refractory glaucoma, significantly reducing IOP and medication use at 6 months, with a low rate of complications.
To evaluate the rotational stability of the three monofocal toric intraocular lenses (IOLs) via data from an online toric IOL back-calculator.
A retrospective data review of an online toric IOL ...back-calculator, which allows users to input preoperative toric planning information, postoperative lens orientation, and subjective refraction. Inputted data were used to determine the optimal orientation of the toric IOL to minimize residual refractive astigmatism. Aggregate data from 3/11/2019 to 3/10/2020 were extracted and validated. Only data with ≥0.5D of residual refractive astigmatism were used in the study. Pre-operative intended IOL orientation and post-operative IOL orientation were used to calculate IOL rotation.
After validation, 5397 entries were determined to represent patient eyes, of which 3238 represented the three monofocal IOLs evaluated. The rate of rotation for AcrySof, TECNIS, and enVista Toric IOLs was 72.7%, 83.4%, and 83.0%, respectively, and location only significantly impacted TECNIS IOLs. The magnitude of rotation for rotated IOLs was similar for all models and was significantly more for IOLs initially placed in the oblique axis. All IOL models tended to rotate in a counterclockwise direction (53.2%, 73.0%, 69.7%, respectively; p<0.05), and the tendency was greater for IOLs initially located horizontally.
The AcrySof IQ Toric IOL was more rotationally stable than both the TECNIS and enVista Toric IOLs; there was no significant difference in rotational stability of the latter two.
To evaluate the safety and efficacy of a trabecular microbypass stent combined with cataract surgery in patients with severe open-angle glaucoma.
The series included 59 eyes with severe primary ...open-angle glaucoma and severe visual field loss as defined by American Academy of Ophthalmology preferred practice pattern criteria.
Retrospective case series. Patients were implanted with 1 trabecular microbypass stent with concomitant cataract surgery. Primary outcome measures were intraocular pressure (IOP) and number of glaucoma medications. Safety measures included postoperative IOP pressure spikes ≥15 mm Hg or IOP<6 mm Hg at any time point, and the need for additional surgery.
The mean preoperative IOP was 19.25±6.97 mm Hg. Postoperatively, the mean IOP was 14.38±3.63 mm Hg (P<0.01) at 12 months and 14.92±3.86 mm Hg (P<0.01) at 24 months. The mean number of glaucoma medications was 2.27±1.06 preoperatively and 1.63±1.17 (P<0.01) at 24 months postoperative, indicating a 28% reduction in medication use. In total, 4 (7%) eyes required additional surgery. In total, 5 eyes (8%) experienced IOP spikes ≥15 mm Hg, 14 (24%) eyes had IOP spikes ≥10 mm Hg. Overall 55% of eyes had a 20% IOP reduction after 24 months of surgery. Eyes with baseline IOP≤19 had a mean reduction of 2.24 mm Hg 36 months after surgery.
Trabecular microbypass stent implantation during cataract surgery safely and effectively lowers IOP and medication use in patients with severe primary open-angle glaucoma.
To determine the visual outcomes and complications of a new small-incision technique for 4-point fixation of a hydrophilic acrylic posterior chamber intraocular lens (IOL) in the absence of capsule ...support.
Three North American tertiary referral centers and a private practice.
Retrospective case series.
Secondary IOL placement was performed from 2011 to 2014. Indications for surgery, clinical results, and complications were analyzed. Primary outcomes included postoperative corrected distance visual acuity (CDVA) and surgical complications.
Charts of 35 patients (37 eyes) were reviewed. The mean age at surgery was 56 years, and the mean follow-up was 6 months (range 3 to 24 months). Clinical indications included a dislocated IOL (30%), ocular trauma (19%), crystalline lens subluxation (19%), uveitis-glaucoma-hyphema syndrome (5%), post-complicated cataract (8%), congenital cataract (8%), and decompensated cornea (3%). The mean CDVA improved from 20/80 preoperatively to 20/40 postoperatively (P < .01). Thirty-six eyes (97%) had an improved or unchanged CDVA, and 1 eye (3%) had a reduced CDVA because of worsening glaucoma. Postoperative complications included ocular hypertension (24%), iritis (5%), wound leakage (3%), transient corneal edema (3%), glaucoma requiring a tube shunt (3%), and IOL dislocation (3%).
Small-incision 4-point scleral fixation of the Akreos AO60 hydrophilic acrylic IOL in the absence of capsule support appears to be a safe and effective technique for secondary IOL placement.
Drs. Berdahl and Ayres are consultants to Bausch & Lomb, Inc. Drs. Ayres and Fram have received speaker fees from Bausch & Lomb. Dr. Terveen does not have a financial or proprietary interest in any material or methods mentioned.
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