Nariman Nassiri

Subconjunctival Bevacizumab Versus Mitomycin C Adjunctive to Trabeculectomy

PURPOSE To compare the outcome of trabeculectomy with subconjunctival bevacizumab with that of trabeculectomy with mitomycin C (MMC). DESIGN Prospective, randomized, comparative study. METHODS Thirty-six eyes from 34 patients with uncontrolled glaucoma were enrolled. Eighteen eyes underwent trabeculectomy with subconjunctival bevacizumab injection (2.5 mg/0.1 mL), and 18 eyes underwent trabeculectomy with MMC (0.02% for 3 minutes). The outcome measures were the best-corrected visual acuity, intraocular pressure (IOP), number of IOP-lowering medications, complications, and bleb morphologic features (based on the Indiana Bleb Appearance Grading Scale). RESULTS The mean follow-up times for the MMC and bevacizumab groups were 7.8 ± 2.2 months and 7.4 ± 24 months, respectively (P = .62). The mean preoperative IOP in the bevacizumab group improved from 21.9 ± 7.9 mm Hg with 2.7 ± 0.8 antiglaucoma medications to 13.6 ± 3.2 mm Hg with 0.2 ± 0.5 antiglaucoma medications at the last visit (P < .001 and P < .001, respectively). The mean preoperative IOP in the MMC group improved from 23.3 ± 4.9 mm Hg with 2.6 ± 0.7 antiglaucoma medications to 9.6 ± 2.7 mm Hg with no antiglaucoma medications at the final visit (P < .001 and P < .001, respectively). There was a statistically significant difference in the IOP between the 2 groups at the last visit (P < .001). The cumulative probabilities of total success at the last follow-up according to Kaplan-Meier analysis were 100% and 94.4% in bevacizumab and MMC groups, respectively (P = .32, log-rank test). CONCLUSIONS Adjunctive subconjunctival bevacizumab with trabeculectomy is effective in controlling the IOP profile; however, its effect is less prominent than that of MMC.

Corneal endothelial cell injury induced by mitomycin-C in photorefractive keratectomy: Nonrandomized controlled trial

PURPOSE: To evaluate the effect of intraoperative use of mitomycin‐C (MMC) on the corneal endothelium during excimer laser photorefractive keratectomy (PRK). SETTING: Vanak Eye Surgery Center, Tehran, Iran. METHODS: This nonrandomized trial comprised 81 patients (162 eyes) with bilateral low to moderate myopia and adequate corneal thickness to allow PRK (estimated postoperative residual stromal thickness >350 μm without considering epithelial thickness). The indication for intraoperative application of MMC 0.02% (0.2 mg/mL) was an ablation depth of 75 μm or more. Patients were divided into 3 groups: bilateral (both eyes treated with MMC), unilateral (only 1 eye treated with MMC), and untreated (no eye treated with MMC). Visual acuity, refraction, endothelial cell density (ECD), and corneal thickness were measured preoperatively as well as 1 week and 1, 3, and 6 months postoperatively. RESULTS: Overall, 76 eyes were treated with MMC. Eyes treated with MMC and untreated eyes were comparable in postoperative visual acuity and refraction. Preoperative to postoperative changes in ECD were statistically significantly greater in the treated eyes (−14.8%) than in untreated eyes (−5.1%) 6 months after PRK (P<.001). Longer MMC contact time (P<.001) and male sex (P= .04) were the only factors independently associated with greater endothelial cell loss. CONCLUSIONS: The prophylactic use of diluted intraoperative MMC 0.02% solution caused corneal endothelial cell loss. The rate of cell loss was correlated with the duration of MMC exposure.

Structure-function relationships between spectral-domain OCT and standard achromatic perimetry.

PURPOSE To explore structure-function relationships in early glaucoma with spectral-domain optical coherence tomography (SD-OCT) and standard achromatic perimetry. METHODS One hundred thirty-six eyes of 97 patients with suspected or early glaucoma were enrolled from the clinical database at UCLAs Glaucoma Division. All patients had good-quality peripapillary retinal nerve fiber layer (RNFL)/optic disc measurements and a reliable 24-2 SITA-Standard Humphrey visual field (VF) within a 6-month period. Correlations of global and sectoral RNFL thickness and rim area (RA) measurements, with corresponding global and regional VF sensitivities (both in logarithmic [dB] and 1/Lambert scales [1/L]), were investigated with components of variance models. RESULTS The average RNFL thickness, RA, and mean deviation (MD) were 85.6 ± 5.7 μ, 1.0 ± 0.3 mm(2), and -1.3 ± 1.9 dB, respectively. Global RA demonstrated a stronger correlation with MD compared to average RNFL thickness (P = 0.002). The highest correlations were observed between superonasal VF cluster (in dB scale) and inferotemporal RA (R(2) = 0.26, 95% CI: 0.15-0.40) or inferotemporal RNFL thickness (R(2) = 0.24, 95% CI: 0.13-0.37). In glaucoma suspects, the highest correlations were seen between superonasal VF cluster and inferotemporal RA (R(2) = 0.16) in dB scale or RNFL thickness (R(2) = 0.10) in 1/L scale. Correlations were slightly greater with dB scale than 1/L scale and tended to be linear with both scales. CONCLUSIONS Structure-function relationships can be detected in early glaucoma with SD-OCT. Correlations of RA with VF thresholds tended to be higher compared to those of RNFL. Structure-function relationships were well described with a linear model.

Measurement of the Optic Disc Vertical Tilt Angle With Spectral-Domain Optical Coherence Tomography and Influencing Factors

PURPOSE To report a novel method for measuring the vertical tilt angle of the optic nerve (ON) head and to investigate the associated factors. DESIGN Cross-sectional diagnostic study. METHODS One hundred and twelve normal, glaucomatous, and glaucoma suspect eyes (99 patients) were enrolled in this study. Subjects underwent a full eye examination, biometry, and spectral-domain optical coherence tomography (SDOCT). The vertical tilt angle was measured on high-resolution cross-sectional SDOCT images passing through the ON head and foveal centers using the inner edges of the Bruch membrane opening as the reference plane. The correlation between the vertical tilt angle with the ovality index and the potential associated factors was estimated with univariate and multivariate linear regression analyses. RESULTS The median (interquartile range, [IQR]) axial length and visual field mean deviation were 24.5 (23.8-25.3) mm and -0.9 (-2.76 to 0.26) dB. The median (IQR) tilt angle was 3.5 (1.2-11.2) degrees. There was a moderate correlation between the ovality index and tilt angle (Spearman ρ = 0.351; P < .001). In univariate analyses, axial length, spherical equivalent, and mean deviation were correlated with the tilt angle (P = .002, P = .011, and P = .013, respectively). Axial length, mean deviation, and their interaction showed a statistically significant correlation with the tilt angle in multivariate analyses (P = .044 for axial length, P = .039 for mean deviation, and P = .028 for their interaction). CONCLUSIONS We describe a new method for measuring the ON head vertical tilt angle with high-resolution SDOCT imaging. The ovality index demonstrated only a moderate correlation with the tilt angle measurements and hence is not a good proxy measure for the vertical ON head tilt angle. Axial length and visual field mean deviation are the main factors associated with the ON head vertical tilt angle. The underlying basis for the relationship of vertical tilt angle and glaucoma severity should be further explored.

Detection of visual field progression in glaucoma with standard achromatic perimetry: A review and practical implications

Detection of visual field progression remains a challenging task despite the recent advances for better handling of longitudinal visual field data, some of which are incorporated in currently available perimeters. Standard achromatic perimetry remains the gold standard for detection of visual field progression. The authors present a practical and clinically relevant review of the main issues involved in detection of early glaucoma as well as detection of visual field progression in eyes with pre-existing glaucomatous damage. After discussing some basic concepts in perimetry, the authors present evidence-based recommendations for criteria to detect earliest evidence of glaucomatous damage with perimetry. The authors will review different event- and trend-based criteria and present data with regard to comparative performance of such criteria. Relevance of using absolute versus corrected threshold data with regard to different criteria is also addressed. At the end, the authors provide practical guidelines for detection of visual field progression in a clinical setting and review issues related to clinical trials.

Retinal nerve fiber thickness is reduced in sleep apnea syndrome

OBJECTIVE To investigate the prevalence of glaucoma, visual field abnormalities, as well as changes in retinal nerve fiber layer in patients with obstructive sleep apnea syndrome (OSAS). METHODS In this cross-sectional study, 51 patients with OSAS were included. Based on apnea hypopnea index (AHI), there were 26, 6 and 19 cases of severe (AHI⩾30), moderate (15⩽AHI<30), and mild (5⩽AHI<15) OSAS, respectively. The control group was matched for age, sex and body mass index. Prevalence of glaucoma and ocular hypertension as well as the following values were assessed and compared between two groups: best-corrected visual acuity, intraocular pressure, central corneal thickness (CCT), cup:disk ratio, mean deviation (MD), pattern standard deviation, and retinal nerve fiber layer (RNFL) parameters using glaucoma diagnosis measurement (GDx). RESULTS Seven eyes (6.7%) had intraocular pressure (IOP)>21mmHg; of these, four eyes (3.9%) had glaucoma. No significant difference was detected in CCT between the two groups. IOP was significantly higher in the OSAS group before (p<0.001) and after (p<0.001) correcting for CCT. There was a significant difference between groups in MD and most GDx parameters including DISK (temporal-superior-nasal-inferior-temporal) average (p=0.002), superior average (p=0.05) and nerve fiber indicator (NFI) (p=0.03), where those in the patient group showed lower values. There was a significant positive correlation between AHI and both IOP and NFI. CONCLUSIONS OSAS patients had a higher prevalence of glaucoma and ocular hypertension. OSAS patients also had higher IOP, worse visual field indices, and lower RNFL parameters compared with the control group.

Effect of intravitreal bevacizumab on retrobulbar blood flow in injected and uninjected fellow eyes of patients with neovascular age-related macular degeneration.

Background: To determine the effect of intravitreal administration of bevacizumab (1.25 mg/0.05 mL) on retrobulbar circulation of the injected and the fellow (uninjected) eyes in patients with neovascular age-related macular degeneration. Methods: In this prospective study, the retrobulbar hemodynamics of 43 patients with neovascular age-related macular degeneration was examined by color Doppler ultrasonography. Peak systolic velocity, end-diastolic velocity, and resistive index values in the central retinal artery and short posterior ciliary artery in both injected and uninjected fellow eyes were measured at baseline and 7 days after a single intravitreal injection of bevacizumab. Results: At baseline, the peak systolic velocity, end-diastolic velocity, and the resistive index in the central retinal artery and short posterior ciliary artery of the injected eye were not significantly different compared with the fellow uninjected eye (P > 0.05 for all). However, intravitreal bevacizumab induced a significant reduction in the peak systolic velocity and end-diastolic velocity and a significant rise in the resistive index of the central retinal artery and short posterior ciliary artery of the injected eye (P ⩽ 0.006 for all). Peak systolic velocity and end-diastolic velocity decreased in the central retinal artery (P = 0.023 and P = 0.030) and the short posterior ciliary artery (P = 0.001 and P < 0.000) in the uninjected eye while the resistive index did not significantly change in central retinal artery (P = 0.114) and short posterior ciliary artery (P = 0.082) of the fellow eyes. Conclusion: Intravitreal injection of bevacizumab significantly affects ocular hemodynamic parameters of both the injected and the uninjected fellow eyes with neovascular age-related macular degeneration.

National Eye Institute Visual Function Questionnaire: usefulness in glaucoma.

ABSTRACT The National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25) is the most commonly used patient-reported outcome measure to assess vision-related quality of life in patients with glaucoma. Glaucoma negatively affects the composite and several NEI-VFQ subscale scores; this effect is correlated with the severity of glaucomatous visual field loss. Contrast sensitivity, glare, and dark adaptation are potential items that could be added to the NEI-VFQ to make it more responsive to changes in vision-related quality of life in patients with glaucoma.

Ahmed glaucoma valve and single-plate Molteno implants in treatment of refractory glaucoma: a comparative study.

PURPOSE To report 2-year follow-up data after Ahmed valve implantation (New World Medical, Inc) and Molteno single-plate implantation surgical treatment of refractory glaucoma. DESIGN Prospective, randomized, comparative study. METHODS Patients with refractory glaucoma, defined as uncontrolled intraocular pressure (IOP) of more than 21 mm Hg despite maximal antiglaucoma medication, previously failed nonseton surgical treatment, or a combination thereof were included. Ninety-two patients were allocated randomly to each of the study groups and underwent implantation of either the Ahmed valve implant (model FP7; 184 mm(2) surface area) or Molteno single-plate implant (134 mm(2) surface area) and were followed up for 24 months. Main outcome measures were IOP and surgical success rate. Other outcome measures were changes in visual acuity, number of ant-glaucoma medications, mean deviation of visual field, and rate of intraoperative and postoperative complications. RESULTS Those who successfully completed the trial (28 in the Molteno group and 29 in the Ahmed group) achieved significantly less IOP and fewer glaucoma medications, but worse visual acuity 24 months after surgery. The Molteno group, compared with the Ahmed group, achieved significantly lower IOPs after the early postoperative period until the end of the study. Both groups reasonably maintained visual field during the follow-up. The rate of surgical failure was comparable in both groups. Median survival time was 24 months for both groups. There were no devastating intraoperative or postoperative complications in either group. CONCLUSIONS Both Ahmed and Molteno implants successfully preserved visual field, although IOP control was more pronounced in the Molteno implant group.

Limbal allograft transplantation using fibrin glue.

Limbal transplantation is now widely accepted as the treatment of advanced limbal stem cell deficiency. Herein, we describe a technique for harvesting thin limbal grafts from cadaveric corneoscleral rims and a sutureless method to secure the grafts to the recipient eye using fibrin glue. We report the results of fibrin glue-assisted keratolimbal allograft in 19 eyes of 16 patients, with the outcome measures being ocular surface stability, visual acuity, and postoperative complications. The results indicate that limbal allograft transplantation can be performed safely and successfully using only fibrin glue to secure the grafts. This can potentially improve surgical efficiency and patient comfort postoperatively.