Marlene Moster

Glaucoma in the Immediate Postoperative Period After Penetrating Keratoplasty

In a prospective study 155 consecutive patients undergoing penetrating keratoplasty were examined for postoperative increase in intraocular pressure to determine the frequency and duration of intraocular pressure spikes, risk factors, and response to treatment. Patients were maintained on preoperative glaucoma medications except miotics. Additional medications to lower intraocular pressure perioperatively were not given. Intraocular pressure was measured two to five hours, one day, and one week postoperatively. An intraocular pressure of 30 mm Hg or greater was considered an increase in pressure and was treated according to a standardized protocol. The results were analyzed by procedure as well as by variables commonly perceived to be associated with intraocular pressure increase (history of glaucoma, use of hyaluronate, lysis of the synechiae, or vitrectomy at the time of the operation). Overall, intraocular pressure increases in the early postoperative period occurred in 18 of 155 patients (12%). Pressure increases occurred in ten of 48 patients (21%) with a history of glaucoma; five of 24 patients (21%) undergoing combined penetrating keratoplasty, extracapsular cataract extraction, and posterior chamber intraocular lens implantation; and ten of 43 patients (23%) undergoing vitrectomy at the time of penetrating keratoplasty.

Color Doppler imaging in glaucoma patients with asymmetric optic cups.

To evaluate the color Doppler imaging (CDI) parameters of the retrobulbar circulation, we performed color Doppler imaging in both eyes of 29 glaucomatous patients with asymmetric cups [asymmetry >0.3 cup/disc ratio (C/D)] and asymmetric visual field loss. We used the QAD-1 Color Doppler unit (Quantum Medical Systems Inc.) with a 7.5-MHz linear-phased transducer to calculate the pulsatility index, and the peak systolic, end diastolic, and average blood-flow velocities in the ophthalmic, central retinal, nasal, and temporal short posterior ciliary arteries of each eye. In a second analysis, we compared the results of a randomly selected eye of age- and sex-matched controls. Paired t tests did not show any significant difference between the blood-flow velocities of the more damaged and less damaged eyes when the entire 29-patient group was considered together. The power was adequate to detect a 1.0 cm/s difference in most of the analyzed vessels. Thirteen of the 29 patients had primary open-angle glaucoma (POAG), and the remaining eyes had pseudoexfoliation and low tension, pigmentary, and chronic angle-closure glaucoma. When compared to age- and sex-matched controls, the less damaged eyes of patients with POAG displayed reduced systolic, diastolic, and mean velocities (p < 0.05) in the ophthalmic artery. In comparison, the more damaged eyes revealed statistically reduced velocities in the ophthalmic artery, temporal short posterior ciliary artery, and in all the parameters for the mean values of the short posterior ciliary arteries (p < 0.05). More advanced optic nerve damage in patients with POAG correlated with more severe reductions of CDI parameters of the retrobulbar circulation of patients with asymmetric disease. Further clinical color Doppler correlations are now mandatory to determine whether these vascular changes are pathogenetically important or epiphenomena.

Aqueous Humor Concentrations of Bimatoprost Free Acid, Bimatoprost and Travoprost Free Acid in Cataract Surgical Patients Administered Multiple Topical Ocular Doses of LUMIGAN® or TRAVATAN®

PURPOSEnTo quantify the aqueous humor (AH) concentrations of bimatoprost (amide), travoprost (isopropyl ester), and their hydrolysis products, bimatoprost free acid (BFA) and travoprost free acid (TFA), after multiple topical ocular doses of LUMIGAN and TRAVATAN, respectively, in patients awaiting cataract surgery.nnnMETHODSnIn 2 separate open-label, sparse-sampling trials, glaucoma patients with cataracts received LUMIGAN (bimatoprost ophthalmic solution, 0.03%) or TRAVATAN (travoprost ophthalmic solution, 0.004%) bilaterally once daily for at least 21 days prior to cataract surgery. Anterior chamber paracentesis was performed at selected times up to 5 h after the last dose and an AH sample was collected. AH samples were assayed by an independent bioanalytical laboratory using a sensitive and validated tandem LC-MS/MS method. The assay lower limits of quantitation were 0.59 nM for bimatoprost, 0.29 nM for BFA, and 0.44 nM for TFA.nnnRESULTSnAH concentrations of BFA (17-phenyl-trinor PGF(2alpha)) were quantifiable in all but one sample at 0.5 h. The maximum concentration achieved (C(max)) of BFA was 30.9 + or - 16.41 nM (n =5), observed at 2 h postdose. AH concentrations of bimatoprost amide were lower than BFA at all time points, with a C(max) of 6.81 + or - 1.36 nM (n = 7) at 1 h postdose. For TFA, measurable AH concentrations were obtained at all time points with a TFA C(max) of 3.91 + or - 2.27 nM (n = 5), which was observed at 3 h after the dose (all data are mean + or - SEM).nnnCONCLUSIONSnOnce daily topical ocular administration of LUMIGAN or TRAVATAN for 3 weeks resulted in significant concentrations of BFA and TFA in the AH. Quantifiable levels of bimatoprost amide were also measured. Maximum concentrations of BFA (30.9 nM) and TFA (3.91 nM) in the anterior chamber are sufficient to fully activate the FP prostanoid receptors in the target cells of the ciliary muscle and trabecular meshwork. Both bimatoprost in LUMIGAN and travoprost in TRAVATAN are essentially prodrugs that are rapidly hydrolyzed to their respective free acids that induce the IOP-lowering effect observed with both drugs in vivo.

Evaluation of Risk Factors for Glaucoma Drainage Device-related Erosions: A Retrospective Case-Control Study.

Purpose:To identify risk factors for glaucoma drainage device (GDD) erosions. Patients and Methods:In a retrospective comparative case series, medical records of 1013 patients who underwent GDD surgery performed by 5 surgeons between 2006 and 2011 were reviewed. The outcome measures assessed included age, race, sex, contact lens wear, seasonal allergies, medical comorbidities, glaucoma diagnosis, preoperative oral and topical medications, type and number of preoperative surgeries and lasers, concomitant surgeries, tube type and position, patch graft material, and intraoperative use of Avastin, mitomycin-C, or Triescence. The association of variables with erosion status was evaluated using the Fisher exact test for categorical variables and the exact Wilcoxon rank-sum test for continuous variables. Results:Charts were included from 339 eyes that had complete data sets and at least 6 months of follow-up. Twenty-eight eyes (8.3%) developed conjunctival erosions. The median follow-up time was 2.03 years for the erosion group and 1.71 years for nonerosion group. Erosion was only associated with the presence of concomitant surgical procedures at the time of GDD implantation (35.7% erosion group vs. 17.4% nonerosion group, P=0.02, OR=2.64). The majority of concomitant surgeries were composed of pars plana vitrectomy (35.0%) and cataract surgery (32.0%). Variables that were suggestive of association with erosion (P<0.20) included smoking (OR=2.14), pseudoexfoliation glaucoma (OR=2.71), and history of dry eye syndrome (OR=2.22). Conclusion:History of concomitant intraocular surgery with GDD implantation may be a potential risk factor for future erosions.

Effectiveness of nonocclusive ligature and fenestration used in Baerveldt aqueous shunts for early postoperative intraocular pressure control.

PurposeThe authors determined the effectiveness of two different methods of modification of Baerveldt aqueous shunts in the control of early postoperative intraocular pressure. MethodsThe authors retrospectively reviewed charts of 122 eyes of 113 patients who underwent a Baerveldt 350-mm2 modified with tube fenestration and charts of 129 eyes of 122 patients who underwent a Baerveldt 350-mm2 modified with a nonocclusive ligature to examine early postoperative intraocular pressure control. In the fenestration group, the tube was modified with a 4–0 intraluminal suture and an occlusive 6–0 external polyglactin ligature before ocular placement. After ocular placement, the tube was further modified with one to three perforating fenestrations. In the nonocclusive-ligature group, the tube was modified with a 4–0 nylon intraluminal suture with a nonocclusive 6–0 external polyglactin ligature before ocular placement. ResultsA total of 94 eyes (77%) achieved adequate intraocular pressure control with or without adjunctive medications and. A total of 28 eyes (23%) had postoperative hypertension or hypotony in the fenestration group versus 81 (62.8%) and 48 (37.2%) eyes in the nonocclusive-ligature group (P = 0.014), respectively. The mean change in intraocular pressure preoperatively and 3 months postoperatively was 18.2 mm Hg versus 21.0 mm Hg (P = 0.11) in the fenestration and nonocclusive-ligature groups, respectively. ConclusionsBoth the nonocclusive ligature and the fenestration methods provide desirable decreases in intraocular pressure in the immediate postoperative period and 3 months postoperatively; however, the fenestration modification may achieve adequate intraocular pressure control more often in the early postoperative period.

Histopathology of Neodymium:YAG Laser Iridectomy in Humans

Fifteen peripheral iridectomy specimens were obtained, with informed consent, from patients with primary narrow angle glaucoma, after previous neodymium:YAG (Nd:YAG) laser iridectomy. The iridectomies were performed three hours to ten weeks after laser application. Iridectomy specimens were examined by scanning and/or transmission electron microscopy. Early effects of the Nd:YAG laser on the iris were mild hemorrhage and fibrinous aggregates. There were no inflammatory cell infiltrates. At later time intervals (up to 2 months post-laser treatment) the holes showed irregular thickness of iris pigment epithelium at the margins, and tissue atrophy limited to the immediate margins of the hole. Elsewhere the iris was structurally intact. The diameter of the holes varied from 60 to 500 microns. The larger holes corresponded to cases that had received more application shots.

The Wills Eye Glaucoma App: Interest of Patients and Their Caregivers in a Smartphone-based and Tablet-based Glaucoma Application.

Purpose:To evaluate the interest of glaucoma patients and their caregivers in a smartphone-based and tablet-based glaucoma application (App), developed by the Wills Eye Glaucoma Research Center in collaboration with Drexel University. Materials and Methods:Cross-sectional survey of patients with glaucoma and their caregivers. Main outcome measures are answers to survey questions regarding how receptive participants are to using the Glaucoma App. Results:Fifty subjects completed the survey. The mean age (SD) was 59.5 (±17.3) years. A total of 88.6% of the participants lived in a household with access to a smartphone or tablet. The majority (72.3%) of participants would consider downloading the Glaucoma App, and younger participants (<65 y) were more likely to do so compared with their older (≥65 y) counterparts, P=0.025. Participants were more likely to download the App if it was free of charge, compared with a version that costs

Initial Experience With the New Ahmed Glaucoma Valve Model M4: Short-term Results.

3, P=0.018. Although only about one third (37.8%) of participants used eye drop reminders, nearly 3 of 4 (72.9%) participants were receptive to using the automated reminder feature of the Glaucoma App. Conclusions:Glaucoma patients and their caregivers were very interested in using a Glaucoma App; however, many were not willing to spend

A prospective study of consecutive patients undergoing full-thickness conjunctival/scleral hypotony sutures for clinical ocular hypotony.

3 for an App they seem to value. The free Wills Eye Glaucoma App currently available on the Apple store, includes educational videos, eye drop and appointment reminders, medical and ocular data storage, visual field tutorial, and intraocular pressure tracker. These features aim to increase patients’ level of knowledge about glaucoma and improve their adherence to medication and follow-up appointment recommendations.

Glaucoma Filtering Surgery

Purpose:To evaluate the clinical outcomes of the new Ahmed glaucoma valve (AGV) model M4. The device consists of a porous polyethylene shell designed for improved tissue integration and reduced encapsulation of the plate for better intraocular pressure (IOP) control. Methods:Medical records of patients with an AGV M4 implantation between December 1, 2012 and December 31, 2013 were reviewed. The main outcome measure was surgical failure, defined as either (1) IOP<5 mm Hg or >21 mm Hg and/or <20% reduction of IOP at last follow-up visit, (2) a reoperation for glaucoma, and/or (3) loss of light perception. Results:Seventy-five eyes of 73 patients were included. Postoperative IOP at all follow-up visits significantly decreased from a baseline IOP of 31.2 mm Hg (P<0.01). However, IOP increased significantly at 3 months (20.4 mm Hg), 6 months (19.3 mm Hg), and 12 months (20.3 mm Hg) compared with 1 month (13.8 mm Hg) postoperatively (P<0.05). At 6 months and 1 year, the cumulative probability of failure was 32% and 72%, respectively. Conclusions:The AGV M4 effectively reduced IOP in the first postoperative month, but IOP steadily increased thereafter. Consequently, failure rates were high after 1 year of follow-up.