Anand V. Mantravadi

Short-term intraocular pressure changes immediately after intravitreal injections of anti-vascular endothelial growth factor agents.

PURPOSE To assess short-term trends and the need to monitor intraocular pressure (IOP) changes immediately after intravitreal injections of ranibizumab, bevacizumab, pegaptanib, and triamcinolone acetonide. DESIGN Retrospective, interventional case series. METHODS Charts of 213 consecutive injections to 120 eyes of 112 patients were reviewed. Pressures were measured before injection, immediately after injection (T0), and at five-minute intervals until IOP was less than 30 mm Hg. Optic nerve perfusion was assessed by testing for hand movement vision and by indirect ophthalmoscopic examination. Kaplan-Meier and Chi-square analyses of IOP after injections and correlation of IOP spikes to drug, needle bore size, injection volume, and history of glaucoma were performed. RESULTS Mean preinjection IOP was 14 mm Hg (range, 7 to 22 mm Hg). Mean IOP at T0 was 44 mm Hg (range, 4 to 87 mm Hg). All but one eye had at least hand movement vision and a perfused optic nerve at T0. IOP was reduced to less than 30 mm Hg in 96% of injections by 15 minutes and in 100% by 30 minutes. Eyes with a history of glaucoma took longer to normalize the IOP (P = .002). Statistically significant IOP spikes were observed with a smaller needle bore size (P < .0001) and in eyes with a history of glaucoma (P = .001). CONCLUSIONS Elevations in IOP immediately after intravitreal injections are common, but are transient. Prolonged monitoring of IOP may not be necessary on the day of injection in most cases if hand movement vision, optic nerve perfusion, and lack of intraocular complications have been verified. However, cautious monitoring should be considered in select cases.

The Early Flat Anterior Chamber After Trabeculectomy A Randomized, Prospective Study of 3 Methods of Management

PurposeTo evaluate prospectively 3 different approaches to the management of a flat anterior chamber (FAC) because of overfiltration in the early postoperative period after trabeculectomy. Materials and MethodsThirty-six eyes diagnosed with a FAC with total iridocorneal touch, but no lenticular touch (grade II) because of overfiltration in the first 14 days after trabeculectomy were randomized prospectively into 3 groups: group 1—anterior chamber reformation with viscoelastic substance; group 2—anterior chamber reformation with balanced salt solution and concurrent drainage of choroidal effusion; and group 3—pharmacologic therapy with atropine, phenylephrine, and in select cases oral acetazolamide. Outcome measures were visual acuity, amount of intraocular pressure (IOP) reduction, and achievement of predetermined target IOP. ResultsTreatment group 2 had a greater number of eyes with acuity decline of two or more lines relative to group 3 (P=0.04). Group 1 had more eyes with acuity decline of two or more lines relative to group 3, but this was not significant (P>0.05). ConclusionsFor grade II FACs because of overfiltration in the early postoperative period after trabeculectomy, reformation of the anterior chamber with drainage of choroidal effusion may be associated with greater long-term trabeculectomy success, but is associated with greater visual acuity loss relative to medicinal therapy alone. Reformation with viscoelastic resulted in a trend toward lowest final IOP in comparison to medicinal therapy alone.

Accuracy of surrogate decision making in elective surgery

PURPOSE: To assess the accuracy of surrogate decision making for elective cataract surgery. SETTING: Comprehensive Ophthalmology Department of Tertiary Care Hospital. METHODS: Decisions regarding elective cataract surgery of currently competent, elderly patients were compared with the predictions of patient‐identified surrogate decision makers in scenarios of current state of mental health and progressive dementia. Patients were identified (age >50 years, Mini‐Mental Status Score >20, absence of significant noncataract pathology) consecutively at a scheduled clinic visit to a single provider. Preferences for cataract surgery in the current state of health and hypothetical progressive dementia were assessed on a Likert scale. The same interviewer contacted patient‐identified surrogate decision makers within 48 hours. Independently, a survey of community ophthalmologists was performed. The concordance of surrogate predictions with patient preferences (32 pairs) was assessed using percentage agreement, the κ coefficient with dichotomous Likert scale data, and chi‐square analyses (concordance beyond chance). RESULTS: In their current state of health, most patients said they would prefer to have surgery if they were deemed to have a visually significant cataract, which was accurately predicted by surrogates (72% agreement, κ = 0.65, chi square = 16.5). In a hypothetical dementia scenario, contrary to perceptions of patients and their surrogates, proxies were unable to accurately represent a patients wishes for elective cataract surgery (34% agreement, κ = 0.23, chi square = 14.4). Physicians tended to withhold intervention in the dementia scenario. CONCLUSIONS: The findings suggest that current methods of decision making in elective surgery for patients unable to make autonomous decisions may be seriously flawed. This extends previous findings of inaccuracy with the substituted judgment approach to end‐of‐life issues to reflect elective surgical scenarios.

Comparing Gonioscopy With Visante and Cirrus Optical Coherence Tomography for Anterior Chamber Angle Assessment in Glaucoma Patients.

Purpose:The aim of this study was to compare gonioscopy with Visante and Cirrus optical coherence tomography (OCT) for identifying angle structures and the presence of angle closure in patients with glaucoma. A secondary objective was to assess interrater agreement for gonioscopy grading among 3 independent examiners. Methods:Gonioscopy grading using Spaeth Classification and determination of angle-closure risk was performed on 1 randomly selected eye for 50 phakic patients. Images of the same eye using both Visante and Cirrus OCT were obtained in both light and dark conditions. Agreement of angle closure among 3 devices and interrater agreement for gonioscopy were determined using Cohen’s &kgr; (K) or Kendall’s coefficient of concordance (W). Results:Of the 50 patients, 60% were female, 64% were white, and the mean age was 62 years. Angle closure was detected in 18%, 16%, and 48% of quadrants with Visante, Cirrus, and gonioscopy, respectively. The scleral spur was identified in 56% and 50% of quadrants with Visante and Cirrus OCT, respectively. Visante and Cirrus OCT showed moderate agreement in detecting angle closure (K=0.42 light, K=0.53 dark) but slight-to-fair agreement with gonioscopy (Visante K=0.25, Cirrus K=0.15). Gonioscopy demonstrated substantial agreement in angle closure (K=0.65 to 0.68) and angle-closure risk assessment (W=0.83) among 3 examiners. Conclusions:Visante and Cirrus OCT imaging may have limited ability to identify angle closure because of difficulty identifying angle structures. Gonioscopy by well-trained clinicians had remarkably consistent agreement for identifying angle-closure risk.PURPOSE The aim of this study was to compare gonioscopy with Visante and Cirrus optical coherence tomography (OCT) for identifying angle structures and the presence of angle closure in patients with glaucoma. A secondary objective was to assess interrater agreement for gonioscopy grading among 3 independent examiners. METHODS Gonioscopy grading using Spaeth Classification and determination of angle-closure risk was performed on 1 randomly selected eye for 50 phakic patients. Images of the same eye using both Visante and Cirrus OCT were obtained in both light and dark conditions. Agreement of angle closure among 3 devices and interrater agreement for gonioscopy were determined using Cohens κ (K) or Kendalls coefficient of concordance (W). RESULTS Of the 50 patients, 60% were female, 64% were white, and the mean age was 62 years. Angle closure was detected in 18%, 16%, and 48% of quadrants with Visante, Cirrus, and gonioscopy, respectively. The scleral spur was identified in 56% and 50% of quadrants with Visante and Cirrus OCT, respectively. Visante and Cirrus OCT showed moderate agreement in detecting angle closure (K=0.42 light, K=0.53 dark) but slight-to-fair agreement with gonioscopy (Visante K=0.25, Cirrus K=0.15). Gonioscopy demonstrated substantial agreement in angle closure (K=0.65 to 0.68) and angle-closure risk assessment (W=0.83) among 3 examiners. CONCLUSIONS Visante and Cirrus OCT imaging may have limited ability to identify angle closure because of difficulty identifying angle structures. Gonioscopy by well-trained clinicians had remarkably consistent agreement for identifying angle-closure risk.

Reconsidering trabeculectomy's strengths and weaknesses.

The trabeculectomy, a guarded filtration procedure, has long been regarded as the primary modality for the surgical management of glaucoma. However, the reported success rate and complications vary widely in the literature with limited longer-term studies. As newer surgical options are considered, it is important that these are viewed in perspective to current trabeculectomy outcomes. Lusthaus and associates in this issue present a retrospective analysis of the intermediate term safety and efficacy of primary trabeculectomy expanding upon the current body of literature. This report has several strengths. The foremost is that surgical technique was relatively standardized for the entire fairly sizeable cohort, including the concentration, duration and method of application of anti-metabolite. The results were good: at three years, about 77% of eyes achieved pressures between 6 and 18 mmHg with a 20% intraocular pressure (IOP) reduction. However, most eyes required medication, and the results were not good for normal tension glaucoma eyes. Low incidences of avascular and of cystic blebs were observed, with a majority demonstrating a diffuse, elevated bleb at 3 years. Serious early and late complications were infrequent, although 4 of 48 patients lost two to five lines of vision. Surgical factors and patient selection may play a substantial role in the success and complication rates of any procedure. It is important to note that this study was primarily of Caucasian patients. Also notable is that this single surgeon achieved very good results, with low complications and few interventions, although he would be considered a relatively low volume glaucoma surgeon (albeit not in a referral setting which might include a greater percentage of higher risk patients). But what fundamentally constitutes a surgical success and a complication is ambiguous territory in the current literature, and this undoubtedly impacts how we perceive surgical results. Glaucoma surgical success has been largely defined using IOP as a surrogate marker, with the relationship of IOP to glaucomatous progression firmly established through large prospective randomized controlled trials. There is a great deal of variability among studies in precisely how IOP is used to define success. Astoundingly, nearly as many definitions of success have been used as articles produced on the subject for a 5-year period. With different definitions of success for a surgical procedure, it follows that very different success rates can be the result. A meaningful comparison of surgical outcomes across studies with different definitions of success then becomes a murky task, whether comparing trabeculectomy studies to each other or to non-trabeculectomy glaucoma surgeries. One wonders whether the field of cardiology could have made the progress it has in the last two decades if the clinical definition of myocardial infarction had not been established. There is a general movement, not yet a consensus, towards the use of IOP of 6 to 18 mmHg, with a 20% or greater reduction from preoperative levels, as a success criterion. Although not perfect, this benchmark would still serve the field well if widely adopted. Similarly, how complications are defined and weighed can also influence the resultant rates and clinician perceptions. Not all complications portend the same implications for shortor long-term morbidity. Comparing numbers of complications is thus often not helpful. The most feared complications beyond the immediate postoperative period of trabeculectomy surgery centre largely around bleb related concerns. Late bleb leaks, hypotony, blebitis, endophthalmitis are potentially sight threatening concerns in the antimetabolite era of guarded filtration procedures. With a high incidence in some (but not all) studies, it has been suggested that the risks may even outweigh the benefits of the procedure. However, certain modifications have been offered to promote safer surgery and bleb morphologies that are less prone to long-term complications. The findings of this retrospective analysis are favourable for trabeculectomy with mitomycin-C in the intermediate term, and the long-term follow-up of this cohort will be of great interest. There are now multiple studies showing reasonable safety and efficacy for primary trabeculectomy, as well as multiple studies showing significant risks and limited outcomes. Based on this diverse body of literature, one might expect some consensus on which patients are better candidates, and an understanding that some surgeons and centres have found ways to achieve better outcomes. However, trabeculectomy’s devastating complications in some patients have had a profound effect on how the procedure is widely viewed, with many clinicians and patients assuming the worst for all. This has created fertile ground for the development and promotion of newer, less studied procedures. An improved glaucoma surgery with similar efficacy and reduced risk should be embraced by all. However, new surgeries must be submitted to the same exacting evaluations as trabeculectomy. Further, until the strengths and limitations Clinical and Experimental Ophthalmology 2010; 38: 827–828 doi: 10.1111/j.1442-9071.2010.02433.x

Patient considerations in ocular hypertension: role of bimatoprost ophthalmic solution

Glaucoma is a leading cause of irreversible blindness worldwide. The reduction of intraocular pressure has been well established as an effective treatment to prevent both the development and the progression of all forms of glaucoma. Bimatoprost 0.03% ophthalmic solution, introduced in 2001, is a synthetic prostamide with the unique mechanism of improving both uveoscleral and trabecular outflow. Comparative studies with other pharmacotherapies have shown favorable results for bimatoprost as a potent ocular hypotensive agent that is generally well tolerated. Common side effects include conjunctival hyperemia, eyelash growth, iris pigmentation and periorbital changes. Hyperemia rates were reduced following the introduction of bimatoprost 0.01%. Bimatoprost should be used with caution in those with higher risk of developing ocular inflammation and macular edema. However, the perceived risk of bimatoprost in these patient populations is likely greater than the actual risk observed in practice. Bimatoprost is currently in the center of several clinical trials including its use for dermatologic applications and sustained-release therapies for the treatment of ocular hypertension and glaucoma.

Steady-state pattern electroretinogram and short-duration transient visual evoked potentials in glaucomatous and healthy eyes

This study evaluates two rapid electrophysiological glaucoma diagnostic tests that may add a functional perspective to glaucoma diagnosis.

Adherence to Follow-up Recommendations Among Individuals in the Philadelphia Glaucoma Detection and Treatment Project

Purpose: To evaluate rates of adherence to free follow-up eye exam appointments among participants in the Philadelphia Glaucoma Detection and Treatment Project. Patients and Methods: Ophthalmologists and testing equipment were brought directly to participants at risk for glaucoma at 43 community sites in Philadelphia. Those diagnosed with glaucoma-related pathology were recommended to return for follow-up to be reexamined on site. Rates of adherence and clinical and demographic risk factors for adherence were evaluated. Results: Five hundred thirty-one participants were diagnosed with glaucoma-related conditions and recommended to attend community-based follow-up exams. Follow-up adherence rate was 61.2% (n=325/531). Significant factors associated with greater eye exam appointment adherence, based on our univariable analysis, included final diagnosis of glaucoma (risk ratio [RR]=1.33; 95% confidence interval [CI], 1.13-1.57), male sex (RR=1.19; 95% CI, 1.04-1.36), white race (RR=1.26; 95% CI, 1.08-1.48), age (RR=1.17; 95% CI, 1.00-1.37) recommendation for glaucoma medication (RR=1.52; 95% CI, 1.35-1.71), recommendation for laser peripheral iridotomy (RR=1.18; 95% CI, 1.02-1.35), diagnosis of age-related macular degeneration (RR=1.42; 95% CI, 1.13-1.77) and an increased intraocular pressure (>22 mm Hg in the worse eye) (RR=1.23; 95% CI, 1.06-1.42). On the basis of our multivariable model, diagnosis, sex, and recommended glaucoma medications were significantly associated with follow-up adherence. Conclusions: This study demonstrates that individuals living in underserved urban communities would take advantage of free eye exams in community sites and return for follow-up eye exams in these same settings. Future studies could investigate interventions to improve eye exam appointment adherence in community-based settings to detect glaucoma-eye conditions.

Inadvertent implantation of an iStent in the supraciliary space identified by ultrasound biomicroscopy

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Topiramate as Treatment for Alcohol Dependence

To the Editor: In their clinical trial of topiramate for treating alcohol dependence, Dr Johnson and colleagues concluded that topiramate is a safe and efficacious medication. However, it is important to note that the use of topiramate has been associated with acute angle-closure glaucoma among patients with no previous history of ocular disease and no predisposition to glaucoma. Unless appropriately recognized and treated, the angle closure may result in loss of sight. For those affected, blindness is no less of a problem than alcohol dependence.