Srishti Raj

Postural and diurnal fluctuations in intraocular pressure across the spectrum of glaucoma

Aims To evaluate postural fluctuations (PFs) and diurnal variation (DV) of intraocular pressure (IOP) in patients with untreated glaucoma, glaucoma suspects and healthy volunteers, and study their relationship, if any, to the extent of glaucomatous damage. Methods This prospective, observational cross-sectional study was carried out in a tertiary care referral institution. The patient population included five groups of patients comprising the following: 19 with ocular hypertension (OHT), 26 with optic discs suspicious for glaucoma (DS), 18 with normal tension glaucoma (NTG), 19 with primary open angle glaucoma (POAG) and 20 normal subjects. The IOP was measured at four time periods using Perkins tonometer, in sitting and supine positions. The main outcome measures were change in IOP with posture, the DV in both postures and the relationship between PF, DV and the extent of visual field damage. Results The supine IOP was significantly higher than the sitting IOP, at all time points of the day, in all groups (p<0.001). The PF at 04:30 was significantly higher in POAG, OHT and NTG. The PF at 09:00 correlated significantly with the mean deviation (MD) on visual fields in the NTG group (r=0.735; p=0.001). The DV did not correlate with the MD in any of the five groups studied. Conclusions The significantly higher supine IOP is frequently missed in routine glaucoma practice. An early morning supine IOP measurement may reveal a peak IOP hitherto not picked up during routine office IOP measurements, and may be a useful measurement in unexplained progressive glaucoma.

Outcome of Ocular Steroid Hypertensive Response in Children.

Purpose:The aim of our study was to analyze the epidemiological profile and outcome of steroid-induced ocular hypertension in children below 12 years of age in a tertiary eye center. Methods:Hospital records of patients attending the pediatric glaucoma clinic from July 2005 to December 2012 at our center were retrospectively reviewed. Steroid-induced ocular hypertension was defined as intraocular pressures (IOP)>21 mm Hg (or an increase of>6 mm from baseline) with or without associated glaucomatous optic neuropathy after intake of steroids in any form. Demographic data, management details and IOP, anterior segment, and posterior segment findings were recorded. The main outcome measure was the control of IOP after treatment. Results:Of the acquired pediatric glaucoma patients, 24% were steroid-induced ocular hypertensives (36 of 150 patients) (mean age group 9.2±2.4 y). We studied 57 eyes of 36 patients that had an IOP>21 mm Hg after steroid intake. Of the 36 patients, 22 had bilateral steroid hypertensive response. Of all the patients, 15 (41.6%) received steroids because of vernal conjunctivitis, 16 (22 eyes) could be managed by withdrawing steroids only, 13 (25 eyes) were controlled by medical therapy, and 7 (10 eyes) needed surgery. Favorable outcome (defined as<21 mm of Hg with/without topical antiglaucoma medications) was achieved in 80.5% at the last follow-up (mean 17.4±23.47 mo; range 4 mo to 8 y). Conclusions:Our paper emphasizes on the ocular hypertensive side effects of steroids in children. There are many instances where one can avoid the use of steroids and consider nonsteroidal/anti-inflammatory alternatives. Withdrawal of steroids and antiglaucoma medicines are effective in controlling IOP in majority (80.5%).

Safety and efficacy of a low-cost glaucoma drainage device for refractory childhood glaucoma

Background To evaluate the safety and efficacy of a low-cost glaucoma drainage device (GDD), Aurolab aqueous drainage implant (AADI), similar in design to the Baerveldt glaucoma implant (BGI), in refractory childhood glaucoma. Methods This prospective interventional study was conducted in a tertiary care postgraduate teaching institute. Children aged <16 years with uncontrolled intraocular pressure (IOP) refractory to medical treatment and considered at high risk of failure following trabeculectomy were recruited. Eligible children were implanted with the AADI. Those completing minimum 6-month follow-up were included. Main outcome measures were IOP reduction from preoperative values and postoperative complications. Results 34 eyes of 31 patients were analysed. Average follow-up was 18.3±6.9 months. Mean IOP reduced from 27.4±7.5 mm Hg on maximum medication to 14.6±10.74 mm Hg, 13.8±7.5 mm Hg, 12.8±5.6 mm Hg and 14.7±5.8 mm Hg at 1 week, 6 months, 1 year (32 eyes of 29 children) and 2 years (25 eyes of 22 children) postoperatively, respectively (p<0.001). The cumulative probability of success was 91.18% at 6 months and 81.7% at 18–24 months. Mean number of topical medications decreased from 3.1±0.6 to 1.8±1.3 at 6 months and 1.6±1.1 at 24 months (p<0.001). Preoperatively, 25 patients required systemic acetazolamide, decreasing to three patients at 2 years. There was no tube erosion or infection. One eye developed retinal detachment. Conclusion The AADI appears to be a viable low-cost GDD with effectiveness and safety profile comparable with published reports of the BGI and Ahmed glaucoma valve implant in children.

5-year disease progression of patients across the glaucoma spectrum assessed by structural and functional tools

Background Assessment of spectral-domain optical coherence tomography (SD-OCT) compared with visual fields, to detect progression across the glaucoma spectrum. Methods In this study, adult glaucoma suspects and patients, with baseline retinal nerve fibre layer (RNFL) thickness on SD-OCT and reliable visual field (VF) tests on Humphrey Field Analyser (HFA) prior to March 2010, were recruited. Functional and structural progression over at least 5 years was compared using Glaucoma Progression Analysis (GPA) and VF index (VFI) on HFA and Guided Progression Analysis (GPA-OCT) on SD-OCT, respectively. Agreement of progression detection between the two modalities was computed using κ statistics. Results 122 subjects (63 glaucoma suspects; 59 glaucoma patients) were enrolled. Of 18 suspects who progressed to glaucoma, 13 showed progression by GPA-OCT, 4 by GPA, 7 by VFI and 2 were concordant. In the 14 glaucoma patients who progressed, GPA-OCT detected progression in 6, GPA in five and VFI in six. GPA-OCT had poor agreement with GPA in glaucoma suspects (Kappa 0.15; p=0.13) and patients (Kappa 0.10; p=0.45). VFI had better agreement with GPA-OCT in glaucoma suspects (Kappa 0.34; p=0.01) than glaucoma patients (Kappa 0.12; p=0.36). Progressors by VF in both groups had similar percentage change from baseline RNFL thickness (−9.9% vs −8.6% p=0.46), even though the absolute change was significantly greater in suspects(−8.75µ vs−6.4µ p=0.03). Conclusion Structural change appears to be more useful to detect progression in glaucoma suspects, while functional change is a better indicator as the disease progresses. Percentage change from baseline RNFL thickness was a better measure than absolute change in RNFL.

Cobbler's Technique for Iridodialysis Repair.

We describe a novel “Cobblers technique” for iridodialysis repair in the right eye of a patient aged 18 years, with a traumatic iridodialysis secondary to open globe injury with an iron rod. Our technique is simple with easy surgical maneuvers, that is, effective for repairing iridodialysis. The “Cobblers technique” allows a maximally functional and cosmetic result for iridodialysis.

Pediatric cataract surgery in buphthalmos

Purpose The pediatric eye offers many inherent surgical difficulties and when associated with a large buphthalmic eyeball, acts as a challenging ground for cataract surgeons. The purpose of our study is to describe the surgical outcome of cataract surgery in 6 children with buphthalmos. Methods Eight eyes of 6 children with congenital glaucoma (buphthalmos) underwent phacoaspiration with or without intraocular lens (IOL) implantation. Demographic data, history of glaucoma surgery, intraocular pressure, biometry, surgical steps, and intraoperative and surgical outcome were noted for all patients from medical records. Postoperative outcome in terms of IOL stability, centration, visual acuity, and intraocular pressure were evaluated. Results Pediatric cataract surgery was performed in 8 eyes with buphthalmos. Implantation of IOL was possible in 7/8 eyes. Primary posterior capsulorhexis (PPC) was done in 2/8 eyes. The IOL was implanted in the bag in 3 eyes and captured in 4 eyes. Decentration of IOL occurred in 100% of eyes where PPC was performed. Membranectomy for visual axis obscuration was done in 3 eyes. Conclusions Standard IOLs remain stable and centered with endocapsular implantation or rhexis fixation of IOL after pediatric cataract surgery in buphthalmos. However, PPC should not be attempted in the same sitting, as it leads to decentration.

Glaucoma Secondary to Uveitis in Children in a Tertiary Care Referral Center

ABSTRACT Purpose: To study outcome of secondary glaucoma in pediatric uveitis patients. Methods: Retrospective analysis of records of uveitis patients ≤16 years. Results: Of 182 pediatric uveitis patients, secondary glaucoma was seen in 48 patients (75 eyes, 26.23%) with female preponderance (F:M-29:19) . JIA was the most common etiology (35.71%). BCVA of ≥20/40 was seen in 22 eyes at presentation and in 38 eyes at final follow up (p<0.001). Twenty eight children (66.67%) received systemic antiglaucoma therapy while 17 children (21 eyes) required surgery (60.71%). Logistic regression showed pseudophakia could predict the higher use of oral antiglaucoma medication (p=0.03) while anatomical site of involvement was predictive of higher chances of surgery (p=0.003). Overall success was seen in 82.10% and 71.64% using IOP limit of 21 and 18 mmHg respectively at mean follow-up of 3.9 years. Conclusion: Pediatric uveitic glaucoma though require multitude of therapies, can be managed effectively with appropriate therapy.

Evaluation of macular ganglion cell analysis compared to retinal nerve fiber layer thickness for preperimetric glaucoma diagnosis

Purpose: To compare the diagnostic ability of the ganglion cell analysis (GCA) and retinal nerve fiber layer (RNFL) protocol on optical coherence tomography (OCT), to diagnose preperimetric glaucoma. Methods: A prospective, cross-sectional study of 275 adult patients including 47 early glaucoma (mean deviation better than -6.0 D), 150 glaucoma suspects (106 with suspicious discs and 44 ocular hypertensive (OHT), and 78 normal controls was done. Eligible participants were scanned with the spectral domain CirrusTM OCT (Carl Zeiss Meditec, Dublin, CA). Average peripapillary RNFL thickness and GCA measurements were obtained. Area under receiver operating characteristic (AROC) curves were used to evaluate discriminant value of both protocols to diagnose likely preperimetric glaucoma among glaucoma suspects. Results: Average RNFL and GCA were significantly thinner in glaucoma patients compared to glaucoma suspects and normal controls (P < 0.001). The RNFL was 92.26 ± 8.8 μ in normal controls, 87.9 ± 12.12 μ in glaucoma suspects and significantly thinner in POAG (70.29 ± 10.18 μ; P < 0.001). The GCA was 81.94 ± 6.17 μ in normal controls, 77.69 ± 9.03 μ in glaucoma suspects, and significantly thinner in POAG (69.36 ± 11.06 μ; P < 0.001). AROCs for discriminating glaucoma suspects from normal were modest, with no difference in AROC of average RNFL or GCA measurements (DeLong; P = 0.93). Average RNFL thickness had significantly greater AROC values than average GCA for discriminating glaucoma suspects (both suspicious discs and OHT) from glaucoma (P = 0.03 and 0.05, respectively. AROC for diagnosing glaucoma was significantly better (P = 0.02) for RNFL (0.88 ± 0.03) than GCA (0.77 ± 0.04). Conclusion: In the present time, GCA measurements, as provided by the SD-OCT, do not appear to outperform RNFL measurements in the diagnosis of preperimetric glaucoma.

Efficacy of selective laser trabeculoplasty in primary angle closure disease

BackgroundTo study the role of selective laser trabeculoplasty (SLT) in intraocular pressure (IOP) reduction in post-laser iridotomy primary angle-closure disease patients with inadequately controlled IOP.MethodsIn this prospective cross-sectional study, 34 patients with primary angle-closure disease with post-laser iridotomy open angles up to at least 180° were recruited. Following SLT, patients were examined at 1 day, 1 week, 1 and 3 months, 6 months and 1 year post SLT.ResultsData of 34 patients (34 eyes; 8 males and 26 females), with a mean age of 57.80 ± 6.44 years, were analysed. The reduction in IOP at each follow-up visit was significant (p < 0.001). The maximum reduction in IOP was noticed on post-laser day 1 and the least reduction was noticed 1 week post laser. Post-SLT range of IOP reduction varied from 9 to 46% at 1 year, which indicates the variability of a response to SLT. Mean IOP in both primary angle closure (PAC) and primary angle closure glaucoma (PACG) groups was comparable at all visits except at post-SLT week 1 when IOP in the PACG group was significantly higher than that in the PAC group (p = 0.035). None of the patients complained of pain and/or discomfort or had any clinically significant anterior segment inflammation on any of the follow-up visits. None of the patients underwent repeat SLT or surgery. The mean pre-SLT and post-SLT visual field index at 1-year follow-up was 95.47 ± 3.58 and 95.90 ± 4.13, respectively, which was not significant (p = 0.84).ConclusionsHigh baseline IOP significantly correlated with reduction in IOP. Our results suggest that SLT is a safe, cost-effective modality for reducing IOP in primary angle-closure disease with patent laser iridotomy with a visible trabecular meshwork.

Lack of association between lysyl oxidase-like 1 polymorphism in pseudoexfoliation syndrome and pseudoexfoliation glaucoma in North Indian population

Introduction: Pseudoexfoliation syndrome is commonly associated with pseudoexfoliation glaucoma. The two nonsynonymous single-nucleotide polymorphisms rs1048661 (R141L) and rs3825942 (G153D) within exon 1 of LOXL1 gene have been found to confer risk of pseudoexfoliation syndrome and pseudoexfoliation glaucoma in different geographical populations. This study aims to find association between two nonsynonymous single-nucleotide polymorphisms with pseudoexfoliation syndrome and pseudoexfoliation glaucoma in North Indian population. Methods: North Indian subjects clinically diagnosed with pseudoexfoliation syndrome/pseudoexfoliation glaucoma and normal age-matched control were enrolled in the study. Genomic DNA was extracted and the two single-nucleotide polymorphisms of LOXL1 gene were genotyped by polymerase chain reaction and sequencing. The association between single-nucleotide polymorphisms with pseudoexfoliation syndrome/pseudoexfoliation glaucoma was evaluated by chi-square test. Results: A total of 30 pseudoexfoliation glaucoma, 27 pseudoexfoliation syndrome and 61 control subjects were enrolled in the study. Patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma did not show any genetic association with either single-nucleotide polymorphism rs1048661 or rs3825942. Conclusion: The study shows lack of association between LOXL1 single-nucleotide polymorphisms and pseudoexfoliation in North Indian population.