Mohamed S. Sayed

Green disease in optical coherence tomography diagnosis of glaucoma.

Purpose of review Optical coherence tomography (OCT) has become an integral component of modern glaucoma practice. Utilizing color codes, OCT analysis has rendered glaucoma diagnosis and follow-up simpler and faster for the busy clinician. However, green labeling of OCT parameters suggesting normal values may confer a false sense of security, potentially leading to missed diagnoses of glaucoma and/or glaucoma progression. Recent findings Conditions in which OCT color coding may be falsely negative (i.e., green disease) are identified. Early glaucoma in which retinal nerve fiber layer (RNFL) thickness and optic disc parameters, albeit labeled green, are asymmetric in both eyes may result in glaucoma being undetected. Progressively decreasing RNFL thickness may reveal the presence of progressive glaucoma that, because of green labeling, can be missed by the clinician. Other ocular conditions that can increase RNFL thickness can make the diagnosis of coexisting glaucoma difficult. Recently introduced progression analysis features of OCT may help detect green disease. Summary Recognition of green disease is of paramount importance in diagnosing and treating glaucoma. Understanding the limitations of imaging technologies coupled with evaluation of serial OCT analyses, prompt clinical examination, and structure–function correlation is important to avoid missing real glaucoma requiring treatment.

Current Management Approaches for Uveitic Glaucoma

Uveitic glaucoma is a term that encompasses a myriad of disease entities with different etiologies, mechanisms, and prognoses. The prevalence of glaucoma in inflammatory diseases of the eye ranges from 10% to 20% in non‐population-based studies. 1‐3 The mechanisms by which intraocular inflammation causes an elevation of intraocular pressure (IOP) and subsequent secondary glaucoma vary according to the specific uveitic etiology, ocular anatomic features, ocular physiology, and treatment modalities employed which can affect eye pressure. Aqueous outflow obstruction in uveitis may be either macroscopic (ie, with synechial seclusion of the pupil, secondary pupillary block and chronic synechial, and/or neovascular angle closure) or ultrastructural (ie, with open-angle glaucoma due to microanatomic changes to aqueous outflow pathways). In acute uveitis, decreased IOP may be observed due to reduced aqueous secretion by the inflamed ciliary body (cyclitis), 4 and theoretically, facilitation of aqueous uveoscleral outflow secondary to increased aqueous concentration of prostaglandins. 5,6 Eventually, IOP may paradoxically rise secondary to increased inflammatory mediators, cells and proteins, trabecular meshwork (TM) cell dysfunction and trabeculitis, with an associated increase in resistance to trabecular aqueous outflow. 7 In addition, the prolonged use of topical corticosteroids, a mainstay of uveitis treatment, and to a lesser extent, periocular or systemic corticosteroids, may result in trabecular damage and glycosaminoglycan deposition resulting in steroid-induced glaucoma. 8‐10 The use of corticosteroid intravitreal implants in the treatment of uveitic glaucoma has also been associated with a significant elevation of IOP. 11 The corticosteroid-induced IOP rise appears to be especially pronounced in eyes where damage to the

Safety and efficacy of a growth factor and cytokine-containing topical product in wound healing and incision scar management after upper eyelid blepharoplasty: a prospective split-face study

Purpose To evaluate the efficacy and safety of a topical product containing a mixture of growth factors and cytokines on the incision scar following upper eyelid blepharoplasty. Methods This is a prospective, single-blinded, and split-face study on patients who underwent bilateral upper eyelid blepharoplasty. Two weeks after surgery, one eye of each subject was randomized to receive Lumière Bio-Restorative Eye Cream on one eyelid incision for 12 weeks and no treatment on the other eyelid. Subjects returned at the postoperative weeks 6, 10, and 14. At each visit, patients and the investigator (who was blinded to the treated eyelid) evaluated the scar through specified questionnaires. Results A total of 20 subjects with a mean age of 66.3±9.2 years completed the study. Minor side effects were noted in three subjects. At all-time points, all subjects thought eyelids treated with Lumière had a better scar and overall appearance than fellow eyelids (P<0.5); and 60% of patients strongly encouraged others to use the product. The investigator assessment of erythema and pigmentation revealed less erythema and pigmentation in treated eyes at the weeks 6 and 10, although the difference was statistically insignificant. Investigator assessment also revealed a better scar appearance at week 10 in treated eyes (P=0.04). All evaluation parameters were similar in both eyes at the last visit. Conclusion Lumière eye cream shows an excellent safety profile and minimal effects on features of the incision scar following upper lid blepharoplasty. It may hasten the wound healing process considering the higher outcomes at the first weeks of application.

Diplopia and Symblepharon Following Mueller’s Muscle Conjunctival Resection in Patients on Long-term Multiple Antiglaucoma Medications

To report the occurrence of diplopia and symblepharon following conjunctival Muellerectomy for ptosis repair in 3 patients under chronic antiglaucoma treatment. In this retrospective observational case series, 3 patients were identified who were being treated chronically with multiple antiglaucoma agents and concurrently underwent Muellers muscle conjunctival resection (MMCR) for the management of ptosis. These patients developed conjunctival scarring and symblepharon extending from the operative site to the bulbar conjunctiva postoperatively. All 3 patients reported diplopia after surgery. Two of the patients were treated with prismatic correction and one underwent surgical correction. All patients were closely monitored postoperatively and 1 out of the 3 required symblepharon lysis and mucous membrane graft for ocular surface reconstruction with a consequent improvement in symptoms. Long-term use of topical antiglaucoma medications may alter the integrity of the conjunctiva, rendering conjunctival procedures more prone to postoperative scarring. In patients treated with multiple antiglaucoma medications who are in need of ptosis repair surgery, consideration should be given to an external approach to avoid the potential for postoperative symblepharon and diplopia.

Anterior segment trauma

Mechanical ocular trauma involving the anterior segment may result in damage to the conjunctiva, cornea, limbus, anterior chamber angle, iris, lens, and ciliary body. The mechanism of trauma (closed or open, blunt, penetrating, or perforating), force and extent of trauma, and whether a foreign body is involved determine the pathophysiologic consequence of injury to the various anterior segment structures. The treatment modalities employed and the final visual outcome are also dependent upon these trauma variables. Thorough history taking and careful clinical examination are crucial in the proper assessment and management of anterior segment trauma.

Correlation of echographic and photographic assessment of optic nerve head cupping in children

PURPOSE To determine the diagnostic value of B-scan echography in optic nerve head (ONH) cupping estimation in children. METHODS The medical records of pediatric patients who had previously undergone examination under anesthesia and for whom both adequate B-scan echography images and optic nerve head (ONH) photographs and were available were reviewed retrospectively. The cup:disk ratio was estimated with a grading scale of 0-1.0 and rounded to the nearest tenth; degree of cupping was estimated from B-scan echography (small, medium, or large) by 5 masked graders (3 glaucoma specialists and 2 ophthalmic sonographers) on 2 separate occasions. Inter- and intraobserver agreement in echographic and photographic cupping assessment by the masked graders as well as correlation of echographic and photographic cup size estimation was evaluated. RESULTS A total of 36 children were included. Glaucoma specialists reliably assessed cup:disk ratio with moderately good consistency across specialists (average intraclass correlation coefficient [ICC] for intraobserver agreement, 0.86; average ICC for interobserver agreement, 0.71). Sonographers were extremely reliable in assessment of cup size when examining echographic images (ICC for both inter- and intrarater variability, 1.0). Echographic estimate of cup size correlated poorly with cup:disk ratio (ICC, 0.34). CONCLUSIONS B-scan echography is a reliable and consistent diagnostic tool in estimating the degree of ONH cupping in children and can be very useful in patients in whom direct visualization is not feasible. Failure to account for disk size may have contributed to the poor correlation between echographic cup size and photographic cup:disk ratio.