Ashish Agar

Pressure related apoptosis in neuronal cell lines

Pressure is a crucial component of the cellular environment, and can lead to pathology if it varies beyond its normal range. The increased intra‐ocular pressures in acute glaucoma are associated with the loss of neurons by apoptosis. Little is known regarding the interaction between pressure and apoptosis at the level of the cell. The model developed in this study examines the effects of elevated ambient hydrostatic pressure directly upon cultured neuronal lines. Conditions were selected to be within physiological limits: 100 mmHg over and above atmospheric pressure for a period of 2 hr, as seen clinically in acute glaucoma. This system can be used to investigate pressure relatively independently of other variables. Neuronal cell line cultures (B35 and PC12) were subjected to pressure conditions in specially designed pressure chambers. Controls were treated identically, except for the application of pressure, and positive controls were treated with a known apoptotic stimulus. Apoptosis was detected by cell morphology changes and by 2 specific apoptotic markers: TUNEL (Terminal transferase dUTP Nick‐End Labeling) and Annexin V. These fluorescent markers were detected and quantified by automated Laser Scanning Cytometry. All techniques showed that increased pressure was associated with a greater level of apoptosis compared to equivalent controls. Our results suggest that pressure alone may act as a stimulus for apoptosis in neuronal cell cultures. This raises the possibility of a more direct relationship at the cellular level between pressure and neuronal loss. J. Neurosci. Res. 60:495–503, 2000

Glaucoma filtration surgery following sustained elevation of intraocular pressure secondary to intravitreal anti-VEGF injections

BACKGROUND AND OBJECTIVE To document cases of sustained elevation of intraocular pressure (IOP) while receiving intravitreal anti-vascular endothelial growth factor (VEGF) agents and subsequent management. PATIENTS AND METHODS A retrospective series of all cases managed by the authors and colleagues was performed. RESULTS Six patients developed sustained elevated IOP; five received ranibizumab and one bevacizumab. Four received unilateral and two received bilateral injections. Two had preexisting primary open-angle glaucoma and one had pseudoexfoliative glaucoma, all with stable IOP prior to anti-VEGF treatment. Angles were open in all cases. Peak IOP averaged 43 mm Hg (range: 34 to 60 mm Hg). The mean number of injections preceding the IOP increase was 10 (range: 1 to 20). Four patients required trabeculectomy, one selective laser trabeculoplasty, and one multiple topical medications. CONCLUSION A sustained increase in IOP requiring glaucoma filtering surgery is a rare but important treatment complication for patients receiving intravitreal anti-VEGF therapy, especially those with preexisting glaucoma or glaucoma risk factors.

Clinical model assisting with the collaborative care of glaucoma patients and suspects

Optimizing patient management will reduce unnecessary vision loss in glaucoma through early detection. One method is the introduction of collaborative care schemes between optometrists and ophthalmologists.

Successful "medical" orbital decompression with adjunctive rituximab for severe visual loss in IgG4-related orbital inflammatory disease with orbital myositis.

IgG4-related disease (IgG4-RD) is an inflam matory condition of unknown etiology that can cause tumefactive lesions in a number of tissues and organs, including the orbit and ocular adnexa. Diagnostic criteria for IgG4-RD, including pathology and clinical features and pathology, have been recently proposed.1 This study presents the first case of unilateral acute visual loss secondary to IgG4-related orbital inflammatory disease with orbital myositis that was complicated by severe compressive optic neuropathy. After initial treatment with pulsed intravenous methylprednisolone, followed by rituximab and radiotherapy, there was a marked improvement in orbital inflammation and clinical and radiological improvement in the compressive optic neuropathy. After 9 months of follow up, the orbital inflammatory disease remained in remission.

Influence of education and diagnostic modes on glaucoma assessment by optometrists.

To evaluate the influence of different clinical examination techniques, including optic nerve head (ONH) photography, visual field tests, and adjunct imaging on the diagnosis of glaucoma by Australian and New Zealand optometrists. The effect of a short‐term, didactic teaching module on these is also explored.

Acute intraoperative rock-hard eye syndrome and its management

Purpose To evaluate the use of pars plana needle aspiration of retrolenticular fluid in the immediate management of an acute intraoperative rock‐hard eye syndrome (AIRES). Setting Private practice, Sydney, Australia. Design Retrospective case series. Methods Data over an 18‐month period were collected to evaluate efficacy, complications, and visual outcomes in patients who had pars plana needle aspiration for management of AIRES, which is an acute intraoperative shallowing of the anterior chamber and a marked increase in intraocular pressure (IOP) during phacoemulsification cataract surgery but without evidence of a choroidal hemorrhage. Preoperative and postoperative (1 day, 1 week, and 1 month) data were evaluated. Resolution of AIRES and postoperative posterior segment status, IOP, and corrected distance visual acuity (CDVA) were the main outcome measures. Results Acute intraoperative rock‐hard eye syndrome occurred in 6 (1.45%) of 413 surgeries. All 6 patients were women with a mean age of 81 years. Four patients had dense nuclear cataracts. In each case, the anterior chamber depth and IOP normalized immediately after pars plana needle aspiration and the procedure concluded uneventfully. Mild vitreous hemorrhage was observed in 1 patient postoperatively. At 1 month, the IOP was normal in 5 of 6 cases, while the CDVA was 20/12 in 5 of 6 cases. Conclusion Although the etiology of AIRES is iatrogenic, immediate resolution was achieved uneventfully with pars plana needle aspiration, which appears to be a safe management technique with satisfactory outcomes. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Comparison of macular morphology between femtosecond laser–assisted and traditional cataract surgery

Comparison of macular morphology between femtosecond laser–assisted and traditional cataract surgery After reading the article by Nagy et al. on femtosecond laser–assisted cataract surgery technology, we have significant methodological concerns about the risk for postoperative cystoid macular edema (CME). These render the conclusions drawn by the authors difficult to support. The incidence of CME following cataract surgery is variable. Differing definitions of CME make it difficult to determine accurately its incidence; a recent review reported the incidence as 0.1% to 2.5%. It is essential to differentiate clinical CME, in which visual impairment is present, from angiographic or subclinical macular edema, in which visual acuity is not impaired. Flach identified 20 factors that could affect the reported incidence of postoperative CME. These factors relate to the patient (underlying vascular diseases such as diabetes mellitus, hypertension, and chronic kidney disease), research methodology, and surgical technique. The numerous shortcomings we find in the Nagy et al. study methodology are as follows. 1. Relevance of subclinical macular edema. The authors state that the incidence of subclinical macular edema after uneventful cataract surgery has become an issue of safety. This is in fact not the case. Subclinical macular edema is defined and diagnosed using fundus fluorescein angiography. It is considered a precursor process that might predispose to CME. The major objective outcome parameter after cataract surgery remains corrected distance visual acuity (CDVA). While macular edema is a critical determinant of surgical success, it is only so when it is clinically significant and results in an adverse effect on CDVA. The authors suggest that the mean CDVA was similar in the traditional phacoemulsification group and the femtosecond laser–assisted cataract surgery group, but no statistical analysis was performed. 2. Methodological bias. Specific patient factors such as age, sex, and refractive error were accounted for, but systemic illnesses (cited above) known to affect the risk for CME were not documented. Despite the study being documented as a prospective case-control series, the criteria for allocation to the traditional phacoemulsification cohort versus the femtosecond laser–assisted cataract surgery cohort were not addressed. There was no record of masking the observers during follow-up and optical coherence tomography (OCT). The mean follow-up was stated to be similar in the 2 cohorts, but there was no statistical

Technique to exclude temporal lash incursion in phacoemulsification surgery

&NA; We describe the use of a Steri‐Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Materials in the vitreous during cataract surgery: nature and incidence, with two cases of histological confirmation.

To identify and classify materials in the vitreous observed during phacoemulsification cataract surgery (phaco).

Utilisation of a Novel Test to Measure Severity and Treatment Efficacy of Posterior Blepharitis.

Background. This study evaluated the effectiveness of managing posterior blepharitis (PB) using a novel Posterior Blepharitis Management Protocol (PBMP). Design. Prospective, consecutive case series with 100% followup to one month. Participants. 27 patients (54 eyes) with PB from an Ophthalmology practice in Sydney, Australia. Methods. Each patients PB was assessed by grading the nature and expressibility of the central lower lid tarsal gland secretions on Compression Of The Eyelid (COTE). Patients were then instructed in detail to undertake daily PB management sessions at home using our modified PBMP. Main Outcome Measures. On a subjective scale, patients compared their symptoms at one month with baseline. COTE scores were reevaluated to assess the objective effectiveness of each individuals PBMP. COTE scoring was described as grades 1 (clear oil), 2 (pus, liquid), 3 (toothpaste-like secretions), and 4 (complete tarsal gland obstruction). Results. Patients reported a mean 77.8% ± 13.5% subjective improvement in symptoms. There was a trend towards improvement in COTE grading at one month compared with baseline: grades 1 (0 to 7.4%), 2a (22.2 to 16.6%), 2b (7.4 to 3.7%), 3 (18.5 to 27.7%), and 4 (51.8 to 44%). Conclusions. PBMP provided a rapid, inexpensive, simple, effective, and safe method of treating PB.