Debananda Padhy

Pattern of Pseudoexfoliation Deposits on the Lens and Their Clinical Correlation- Clinical Study and Review of Literature

Purpose To study the clinical correlates of pattern of deposits over the lens in patients with pseudoexfoliation syndrome (PXF) or pseudoexfoliation glaucoma. Methods This retrospective observational study screened 346 patients with PXF seen in glaucoma clinic of a tertiary hospital from 2011–2013. Details like pattern of deposits, location on the lens surface and pupillary abnormalities in slit lamp photographs and their correlation with clinical and demographic variables, were analysed. Results A total of 84 eyes of 42 patients with bilateral PXF were included for the study. Glaucoma was seen in 30 eyes with baseline IOP of 24+3.8 mm Hg. Comparing the type of deposits, namely classical (nu200a=u200a39 eyes), radial pigmentary (RP) form (nu200a=u200a39 eyes) and combined classical and radial pigmentary (CR) forms (nu200a=u200a6 eyes) of deposits, pupillary ruff atrophy was common in all forms while poor dilatation was rare in the RP type (nu200a=u200a5 vs nu200a=u200a25 in classical forms, p<0.001). Mean deviation (MD) was worse in the classical and CR form as compared to RP type with the latter presenting much earlier, 43±3.2 years vs 48±4.1 years in CR and 56±5.7 years in classical form, p<0.001. The baseline IOP in the RP group (18±2.3 mm Hg) was significantly lower than the other two forms (CR 20±3.2 mm Hg, classical 28±2.3 mm Hg), p<0.001, with only 2 eyes on anti-glaucoma drugs at presentation. Conclusion Pattern of exfoliation deposits may indicate the stage and severity of the disease process in evolution with the RP representing an earlier/less severe form of pseudoexfoliation syndrome.

Functional activity of matrix metalloproteinases 2 and 9 in tears of patients with glaucoma

PurposenTo evaluate the differential expression of tear matrix metalloproteinases (MMP) 2 and 9 in of patients with various forms of glaucoma.nnnMethodsnTear samples were collected with a Schirmers strip from 148 eyes of 113 patients (medically naïve patients with primary open-angle [POAG] or angle closure glaucoma [PACG] and those with pseudoexfoliation syndrome [PXF] or glaucoma [PXG]). These were compared to patients undergoing cataract surgery (controls) for this cross-sectional study. Functional activities of tear MMP-9 and MMP-2 were analyzed by gelatin zymography. Tenons capsules (n = 15) were harvested from the inferior quadrant in those undergoing cataract surgery and protein expression of MMP-9 was analyzed by immunohistochemistry (IHC). Hydrogen peroxide (H2O2) stress-induced effects on in vitro activities of MMP-9 in human trabecular meshwork (HTM) cells were analyzed.nnnResultsnThe MMP-9 activity in tears was increased significantly in POAG, (n = 27), PACG (n = 24), and PXF (n = 40) eyes compared to controls (n = 35), and was increased significantly in eyes with glaucoma compared to moderate/severe glaucoma (P < 0.001). The MMP-9 expression was significantly lower in PXG (n = 22) eyes. Immunohistochemistry of Tenons capsule revealed increased expression of MMP-9 in primary glaucoma eyes. Increased MMP-9 activity was seen in in vitro by gelatin zymography and was confirmed by Western and immunofluorescent assay on HTM upon 800 and 1000 μM H2O2-induced stress for 2 to 3 hours with approximately 80% cell death.nnnConclusionsnIncreased tear MMP-9 activity in early glaucoma and pseudoexfoliation syndrome suggesting activation of extracellular matrix (ECM) degradation can be used as a tear-based predictive biomarker. Decreased expression in advanced stages suggests exhaustion of the degradation response.

Unclassified Axenfeld-Rieger Syndrome: A CASE SERIES and Review of Literature.

ABSTRACT Purpose: To report anterior segment features in unclassified anterior segment dysgenesis with overlapping features of Axenfeld-Rieger syndrome and other developmental anomalies. Methods: This retrospective study included those with atypical or overlapping features in one or both eyes, which were identified as unclassified ASD. Typical ARS was defined as the presence of posterior embryotoxon with or without iris changes like stromal hypoplasia, corectopia, polycoria, or ectropion uvea with or without systemic features. Cases of ARS with overlapping features with other ASD, like aniridia (complete or incomplete absence of iris), iridocorneal endothelial (ICE) syndrome (beaten metal appearance of corneal endothelium), Peters anomaly, isolated trabeculodysgenesis (evidenced by Haab’s striae, buphthalmos, and epiphora) in one or both eyes with other typical ARS features in the same or other eye were included and screened. Results: Of 56 cases of ARS seen over 10 years, a total of 17 eyes of 11 cases (M:F=9:2, unilateral n=3) with unclassified ASD were identified with a median age of patients of 28.45±17.75 years (range 6–30 years). All cases of unclassified ASD had the presence of focal atypical strands of non-progressive anterior synechiae extending from the iris mid-periphery to the cornea with no attachments to the Schwalbe’s line in any case. Adjacent keratic precipitates or pigment were present in three eyes with focal beaten metal appearance in one eye. Three patients developed repeated episodes of anterior uveitis in one eye with stromal involvement seen in all cases, which responded to antiviral therapy. Conclusions: Atypical features like focal strands with differential corneal involvement and onset of viral uveitis in unclassified ARS suggest a possible viral etiology during different periods of eye development.

Evolving Paradigms in Classification of Primary Angle Closure Glaucoma.

Abstract Purpose: To review the old and existing classification systems for primary angle closure disease. Methods: Literature review and new proposed classification system. Results: Existing classification systems have several shortcomings which cannot be applied in a clinical setting. This can be addressed by a proposed scoring system. Conclusion: A scoring system would be most appropriate for any clinical setting as well as for prognosticating primary angle closure disease.

Central Field Index Versus Visual Field Index for Central Visual Function in Stable Glaucoma.

Objective: To compare the variability of central field index (CFI) versus visual field index (VFI) in stable glaucoma with central fixation involvement. Materials and Methods: For this retrospective study, we identified multiple visual fields (VFs) of patients with repeatable central fixation involvement on Humphrey VFs (24-2 and 10-2 program) which were stable (clinically and on VFs) over a very short period of 2 to 3 months. The VFI and CFI were calculated as described in earlier reports. We graded the fields as early [mean deviation (MD)>−6 dB], moderate (−6.1 to −12 dB), and severe glaucoma (<−12 dB) based on MD on 24-2 program. The variability of CFI and VFI between visits and across different severity of glaucoma was compared. Relation of the divergence to field indices and clinical parameters were assessed. Results: The intervisit difference for VFI was greater than CFI ranging from −4% to 9% versus −1% to 8% in early (P=0.9), −13% to 18% versus −6% to 17% (P=0.056) in moderate, and −21% to 19% versus −9% to 9% (P<0.001) in severe glaucoma. The CFI within each group had narrower range than VFI with maximum range in severe glaucoma (33% to 95%). The divergence of CFI from VFI started at MD 24-2 beyond (worse) −10 dB. This difference between CFI and VFI was associated significantly with number of points with P<1% on 24-2 (R2=80.3%). Conclusions: CFI is less variable than VFI in stable eyes with fixation involvement especially in severe glaucoma indicating need for incorporating CFI calculation for monitoring advanced disease in eyes with central defects.

Serous retinal detachment after trabeculectomy in angle recession glaucoma

An 18-year-old male with 360 degree angle recession after blunt trauma in his right eye developed uncontrolled intraocular pressure (IOP) despite four antiglaucoma medications (AGM) with advancing disc damage. He underwent trabeculectomy with intraoperative mitomycin-c (MMC) application. There was an intraoperative vitreous prolapse which was managed accordingly. On post-surgery day 1, he had shallow choroidal detachment superiorly with non-recordable IOP. This was deteriorated 1 week postoperatively as choroidal detachment proceeded to serous retinal detachment. He was started with systemic steroid in addition to topical route. The serous effusions subsided within 2 weeks time. At the last follow up at 3 months, he was enjoying good visual acuity, deep anterior chamber, diffuse bleb, an IOP in low teens off any AGM and attached retina. This case highlights the rare occurrence of serous retinal detachment after surgical management of angle recession glaucoma.

Impact of Different Visual Field Instruction Strategies on Reliability Indices

ABSTRACT Purpose: To investigate and compare the visual field performance following three different types of visual field instruction strategies. Method: Ninety consecutive visual field-naïve glaucoma patients who can perform the test and understand instructions were imparted three forms of instructions prior to the visual field test. Patients with visual acuity <20/200, central corneal opacities, or anterior segment pathology and patients unable to understand general instructions/uncooperative were excluded. All forms of instructions were given by a trained optometrist in the patients’ own language as an instruction leaflet read out in 5 min for a verbal group (group1) and by a 5 min video created in house (group 2). Group 3 patients were shown the video first, followed by verbal instructions. We evaluated the reliability parameters in each group after visual field testing by an independent optometrist blinded to the form of instruction given. Results: Among the three groups, group 3 patients had the least number of repeat tests. Eyes with MD<–12Db had better reliability than that of the other groups. Mixed-model linear regression analysis shows that the duration of the test was significantly influenced by the severity of glaucoma in group 1, which is further predisposed by false negatives (FN; β = 0.06, p < 0.0001, R2 61.7%). Conclusion: The video with verbal instruction can minimize the number of repeated tests compared with only verbal or only video instruction medium. The video as well as the combined video/verbal instructions have a practical influence of obtaining more reliable fields compared with only verbal instruction.

Viscoless Manual Small Incision Cataract Surgery with Trabeculectomy

ABSTRACT Purpose: To compare the efficacy of combined manual small incision cataract and glaucoma surgery with anterior chamber maintainer (ACM) alone versus that with intraoperative viscoelastics. Methods: Hospital electronic medical records of patients who underwent small incision cataract and trabeculectomy and intraocular lens implantation without Mitomycin-C from 2014 to 2016 were identified from the hospital operation theater database for this retrospective, hospital-based comparative study. All MSICS surgeries were performed by a single surgeon under peribulbar block. Data retrieved from all patients undergoing surgery with viscoelastic (group 2) or under AC maintainer without viscoelastic (group 1) included preoperative visual acuity, preoperative treated intraocular pressure, number of anti-glaucoma medications before surgery, total surgical time, intraoperative complications, postoperative best-corrected visual acuity and IOP at one week and one month, need for additional procedures, and corneal clarity. Differences in surgical time and postoperative course in both groups were compared. Results: Of 268 manual combined cataract and glaucoma surgeries done from 2014–2016, we identified 147 eyes of 130 age-matched patients, which included 51 PACG, 50 POAG, 12 NTG, and 24 PXG eyes with a mean age of 66 ±11.2 years and 64± 10.8 years in group 2 (n=74) and group 1 (n=73), respectively; p=0.9. The surgical time was significantly lower in group 1 (16±4.8 minutes compared to 44±14.6 minutes for group 2; p<0.001) with transient edema seen <1 week after surgery in 24 eyes of group 2 and seven eyes of group 1; p=0.02. The postoperative IOP at all postoperative visits dropped to >50% in both groups with 11 eyes (PXG n=6, PACG n=5) requiring medications for rise in intraocular pressure at a median time of 1.2 months (r=0.2–3 months). The final visual acuity improved >4 snellen lines in all cases with two patients with advanced damage having 1 line improvement in Snellen acuity at final follow-up. Conclusion: The ACM can help completely avoid the use of viscoelastic during surgery, which can be an effective technique for MSICS with trabeculectomy in low resource stings. Training for such procedures should be incorporated into residency training programs.

Tear biomarkers in latanoprost and bimatoprost treated eyes

Purpose Prostaglandin analogues (PGA’s) are the mainstay and first line of treatment in current glaucoma practise. Though latanoprost and bimatoprost are the most commonly used PGA’s with minimal side effects at lower concentrations like bimaotoprost 0.01%, direct comparison of their cytokine/MMP profile in tears has not been evaluated earlier. The study intends to ascribe PGA to the upregulation of MMPs, Cytokines and Chemokines mediating varied pathways to result in side effects of the drugs. Methods Tear sample collection was done from outer canthus of 30 eyes of 30 patients (primary open angle glaucoma (n = 26 and n’ = 20), normal tension glaucoma (n = 4 and n’ = 10), in latanoprost (n) 0.005% and bimatoprost (n’) 0.01% group respectively, with a mean age of 62±10.5 years) on >6 months of PGA use using Tear floTM Schirmer filter strip. Tear samples from 30 eyes of 30 cataract patients without drug treatment were used as the control. Gelatinolytic activity of MMP-9 and MMP-2 were examined by substrate gelatine zymography MMP-1 and TIMP-1 concentrations from tears samples with PGAs were evaluated by ELISA while cytokine concentration in the eluted tears was evaluated using a convenient bioplex kit assay (Milliplex MAP kit, HCYTMAG-60K-PX41, Millipore, Massachusetts, United States). The mean duration of use of PGA in both groups did not differ significantly (median 1.3 years in bimatoprost and 1.1 years in latanoprost eyes, p = 0.6). Results The tear MMP-9 expression was higher in eyes receiving latanoprost while the MMP-2 expression was higher in eyes receiving bimatoprost with MMP1 protein levels being higher in the former. Latanoprost treated eyes had marginally elevated tear cytokines involved in tissue remodelling while bimatoprost eyes showed elevated cytokines regulating allergic pathways. Conclusion Differential cytokine and MMP expression indicates differential signalling pathways mediating different cellular effects (evident as clinical and side effects) with the two drugs which can be explored further.

Automated retinal nerve fiber layer defect detection using fundus imaging in glaucoma

Retinal nerve fiber layer defect (RNFLD) provides an early objective evidence of structural changes in glaucoma. RNFLD detection is currently carried out using imaging modalities like OCT and GDx which are expensive for routine practice. In this regard, we propose a novel automatic method for RNFLD detection and angular width quantification using cost effective redfree fundus images to be practically useful for computer-assisted glaucoma risk assessment. After blood vessel inpainting and CLAHE based contrast enhancement, the initial boundary pixels are identified by local minima analysis of the 1-D intensity profiles on concentric circles. The true boundary pixels are classified using random forest trained by newly proposed cumulative zero count local binary pattern (CZC-LBP) and directional differential energy (DDE) along with Shannon, Tsallis entropy and intensity features. Finally, the RNFLD angular width is obtained by random sample consensus (RANSAC) line fitting on the detected set of boundary pixels. The proposed method is found to achieve high RNFLD detection performance on a newly created dataset with sensitivity (SN) of 0.7821 at 0.2727 false positives per image (FPI) and the area under curve (AUC) value is obtained as 0.8733.