Kamran Rahmatnejad

Surgical Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Patients with Open-angle Glaucoma

Purpose: To evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with open-angle glaucoma. Participants and Methods: A retrospective chart review of adult patients who underwent GATT due to inadequately controlled intraocular pressure (IOP) or intolerance to medication. Main outcome measures were success rate, IOP, and number of glaucoma medications. Success was defined as IOP reduction >20% from baseline or IOP between 5 to 21 mm Hg, and no need for further glaucoma surgery. When success criteria were not met for any postoperative visit >3 months after surgery, failure was determined. Results: In total, 66 patients, average age 62.9±14.9 years (50.8% female) were included in the analysis. Average follow-up was 11.9 months (range, 3 to 30 mo) and overall success rate was 63.0%. Mean IOP was 26.1±9.9 mm Hg preoperatively and 14.6±4.7 mm Hg at 12 months (44% IOP decrease; P<0.001). Mean number of medications decreased from 3.1±1.1 preoperatively to 1.2±0.9 at 12 months (P<0.001). No significant differences between patients with primary open-angle glaucoma and other types of glaucoma were found. The rate of hyphema at 1 week and 1 month postoperatively was 38% and 6%, respectively. Overall GATT success rate among white and black patients was 69% and 42%, respectively, which was statistically significant (P<0.05). Conclusions: The future of GATT as a minimally invasive glaucoma surgery in adults seems promising. This position is supported by its low rate of long-term complications and the conjunctiva-sparing nature of the surgery.

Efficacy of Wavefront‑guided Photorefractive Keratectomy with Iris Registration for Management of Moderate to High Astigmatism by Advanced Personalized Treatment Nomogram

Purpose: To evaluate the efficacy of photorefractive keratectomy (PRK) using the advanced personalized treatment (APT) nomogram for correction of moderate to high astigmatism. Methods: This prospective interventional case series included 60 consecutive eyes of 30 patients undergoing wavefront-guided PRK (Zyoptix 217 Z100 excimer laser, Bausch & Lomb, Munich, Germany) using the APT nomogram and iris registration for myopic astigmatism. Mitomycin-C was applied intraoperatively in all eyes. Ophthalmic examination was performed preoperatively and 1, 3 and 6 months postoperatively. Results: Preoperatively, mean sphere was -1.68 ± 2.08 diopters (D), mean refractive astigmatism was -3.04 ± 1.05 D and mean spherical equivalent (SE) was -3.12 ± 1.77 D. Six months postoperatively, mean sphere was + 0.60 ± 0.64 D (P < 0.005), mean cylinder was -0.43 ± 0.46 D (P < 0.005) and mean SE was + 0.28 ± 0.48 D (P < 0.005). Hyperopic overcorrection (≥ +1.0 D) occurred in 3 (5%) eyes. Postoperatively, root mean square (RMS) of higher order aberrations (HOAs) was significantly increased (P = 0.041). RMS of spherical aberration (Z [4, 0]) showed no significant change after surgery (P = 0.972). Conclusion: Considering the acceptable residual refractive error, low rate of hyperopic overcorrection, acceptable uncorrected visual acuity, and low risk of postoperative corneal haze, PRK using the APT nomogram with iris registration and mitomycin-C use is a safe and effective modality for treatment of moderate to high astigmatism.

Factors Associated with Patient Satisfaction in an Outpatient Glaucoma Population

ABSTRACT Purpose: To determine what metrics might impact satisfaction survey responses. Methods: A 37-question survey was administered to 249 participants. Responses were correlated to demographics, clinical factors, weather conditions, and examination timing. Results: Sample consists of 55.4% female and 73.9% white, and mean age was 65.1 years. Participants were assigned to: completely satisfied (77.9%) or not completely satisfied (22.1%) groups based on their rating of glaucoma specialist on a scale of 1–10, while 10 considered “completely satisfied” and less than 10 “not completely satisfied.” Complete satisfaction was associated with ability to schedule appointments early, phone calls answered/returned same day, shorter perceived wait time, and better communication skills of ophthalmologist (p < 0.05). Completely satisfied participants reported their ophthalmologist spent enough time with them, listened carefully, and communicated in an understandable way (p < 0.05). Conclusions: The majority of factors found to be associated with patient satisfaction were related to characteristics of the ophthalmologists and their office.

Visual field changes in professional wind versus non-wind musical instrument players in the Philadelphia orchestra

Purpose: We compare the prevalence of glaucoma in professional wind versus non-wind instrument players in the Philadelphia Orchestra. Visual field changes in individuals with glaucoma and glaucoma suspects were evaluated, and the results were correlated with cumulative practice time. Methods: In this cross-sectional, observational study, fifty-one Philadelphia Orchestra musicians were enrolled and categorized as wind or non-wind instrument players. All study participants underwent screening fundus photography. Participants with optic discs suspicious for glaucoma underwent further evaluation, including standard automated visual field perimetry and a comprehensive eye examination by a glaucoma specialist. Results: Of the 51 musicians enrolled, 9 of the 21 wind instrument players (43%) and 8 of the 30 non-wind instrument players (27%) were suspected of developing glaucoma in at least one eye (P = 0.25), with examinations performed on 12 of the 17 returning musicians (71%) for further confirmation. Wind instrument players exhibited significantly higher Octopus visual field mean defect scores (1.08 ± 1.5 dB) than non-wind instrument players (−0.43 ± 0.7 dB; P < 0.001). There was a significant association between cumulative hours playing wind instruments and visual field mean defect (P < 0.001). Conclusion: Among members of the Philadelphia Orchestra, the difference in prevalence of glaucoma suspicious optic discs between wind and non-wind instrument players was not significant. The clinical significance of the greater visual field mean defect found in wind instrument players, and the association between the degree of visual field mean defect and the cumulative practice-time of playing wind instruments, needs further investigation.

Evolution of cyclophotocoagulation

Cyclodestructive techniques have been a treatment option for refractory glaucoma since its first use in the 1930s. Over the past nine decades, cyclodestruction has advanced from the initial cyclodiathermy to micropulse transscleral cyclophotocoagulation (MP-TSCPC) which is the current treatment available. Complications associated with cyclodestruction including pain, hyphema, vision loss, hypotony and phthisis have led ophthalmologists to shy away from these techniques when other glaucoma treatment options are available. Recent studies have shown encouraging clinical results with fewer complications following cyclophotocoagulation, contributing greatly to the current increase in the use of cyclophotocoagulation as primary treatment for glaucoma. We performed our literature search on Google Scholar Database, Pubmed, Web of Sciences and Cochrane Library databases published prior to September 2017 using keywords relevant to cyclodestruction, cyclophotocoagulation and treatment of refractory glaucoma.

Validation of the structure–function correlation report from the heidelberg edge perimeter and spectral-domain optical coherence tomography

AbstractPurpose To compare the diagnostic assessment of glaucoma specialists with an automated structure–function correlation report combining visual field (VF) and spectral-domain optical coherence tomography (SD-OCT) imagining in subjects with glaucoma.MethodsThis prospective, cross-sectional study was conducted at Wills Eye Hospital, Philadelphia, PA, USA. Subjects with glaucoma received ophthalmic examination, VF testing, and SD-OCT imaging. An automated report was generated describing structure–function correlations between the two structural elements [retinal nerve fiber layer (RNFL) and Bruch’s membrane opening-minimum rim width (MRW)] and VF sectors. Three glaucoma specialists masked to the automated report and to each other identified clinically significant structure–function correlations between the VF and SD-OCT reports. Raw agreement and chance-corrected agreement (kappa statistics) between the automated report and the clinical assessments were compared.ResultsA total of 53 eyes from 45 subjects with glaucoma were included in this study. The overall agreement between the automated report and clinical assessment comparing MRW and VF was good at 74.8% with a kappa of 0.62 (95% CI 0.55–0.69). Agreements for the six different MRW sections were moderate to good with kappa values ranging from 0.54 to 0.69. For mean RNFL thickness and VF comparisons, agreement between the automated report and clinical assessment was 75.4% with a kappa of 0.62 (95% CI 0.54–0.70). For different RNFL sectors, kappa values ranged from 0.47 (moderate agreement) to 0.80 (good agreement).ConclusionsThis study suggests that the automated structure–function report combining results from the SD-OCT and the HEP may assist in the evaluation and management of glaucoma.

Laser Trabeculoplasty and Aqueous Dynamics

For the past four decades, laser trabeculoplasty has been a staple in the treatment armamentarium against glaucoma. Although the exact mechanism of laser trabeculoplasty has not been fully elucidated, its clinical utility in lowering intraocular pressure has been well established. Aqueous dynamic studies uniformly reveal an increase in aqueous outflow facility at the trabecular meshwork. Accumulating evidence suggests that the mechanism is the result of complex cellular and biochemical processes. Histopathological studies of the trabecular meshwork tissue after argon laser suggest an additional mechanical role. The traditional treatment algorithm for glaucoma placed laser trabeculoplasty as an intermediary between medical therapy and incisional surgery. However, because of the safety profile of selective laser trabeculoplasty, recent studies have challenged this treatment paradigm. One such study was a multicenter trial headed by our department that compared laser trabeculoplasty and medical therapy as initial treatment for glaucoma. We showed a similar efficacy between the two modalities, reinforcing the possibility of using laser as the initial treatment in the right clinical setting.

Non-Invasive Electrical Stimulation for Vision Restoration: Dream or Reality?

In 1873, Henri Dor performed one of the earliest experiments using electrical stimulation for the treatment of eye diseases, including amblyopia, retinochoroiditis, glaucoma, and optic atrophy [1]. His experiments however, remained unnoticed until the 20th century, when seminal studies like those conducted by Nitsche and Paulus demonstrated the viability of non-invasive electrical stimulation therapy (EST) [2]. EST has been investigated for treating numerous ophthalmological and neurologic diseases and employs a low current (in the range of μA) stimulus to activate injured nerves. There are three proposed mechanisms for the restorative effects of EST: first, its ability to facilitate mechanisms of plasticity in higher brain areas [3]; second, its neuroprotective abilities early after the lesion; and third, its ability to reactivate surviving neurons post-trauma [4,5]. It has been shown that neurons are able to respond to externally applied electrical current and synchronize themselves with each other and the related brain area which receives the stimulus and also form more neurites with their growth directed along the external electrical field [6,7]. Furthermore, EST has shown to selectively activate Müller cells by upregulating insulin-like growth factor 1 production within the cells and increasing secretion of the antioxidant glutamine synthetase [8–10]. EST can be delivered via direct current (DC) or alternating current (AC). DC stimulation modulates spontaneous neuronal activity in a polarity-dependent fashion with site-specific effects that are perpetuated throughout the brain via interneuronal networks, whereas AC stimulation directly interferes with ongoing oscillations in the brain by forcing neurons to fire [11–13]. For ophthalmological diseases, EST is applied via 3 different routes, detailed below.