Faculty Bibliography

Purpose: The relative efficacies of new ab interno surgical approaches to intraocular pressure (IOP) reduction in the treatment of primary open-angle glaucoma (POAG) are unclear. We performed a retrospective case-controlled study comparing outcomes between ab interno canaloplasty with viscoanalastomy using the Sight Sciences VISCO360 Viscosurgical System and excision of trabecular meshwork using New World Medical's Kahook Dual Blade (K

Purpose: Glaucoma patients who undergo cataract and microincisional glaucoma surgery (MIGS) are burdened with eye drop requirements. Intravitreal delivery of triamcinolone/moxifloxacin (TriMoxi) potentially eliminates the need for postoperative anti-inflammatory and antibiotic topical medications, but raises concern for increased steroid-related intraocular pressure (IOP). This study retrospectively compared IOP outcomes and glaucoma medication requirements in MIGS patients who received topical medications (Group 1) or TriMoxi injections (Group 2). Methods: Fifty patients who underwent MIGS, using the VISCO360 instrument, from 2015 to 2016 were selected. Twenty-five patients received post-operative topical drops, including prednisolone acetate 1% and an antibiotic, and 25 patients received a TriMoxi intravitreal injection during surgery. Age and baseline IOP were matched between groups. IOP's were collected from baseline to 6 months after surgery. The two groups were analyzed for differences in post-operative IOP and glaucoma medication drops. Results: The mean patient age was 66.3+/-8 years for Group 1 and 68.3+/-9.5 years for Group 2 (p >.05). The mean baseline IOP was 16.4 +/- 3.4mmHg for Group 1 and 16.8+/-3.1mmHg for Group 2 (p >.05). There were no significant differences in postoperative IOP's at day 1, month 1, month 2, month 3, and month 6 between Group 1 (13.6+/-6.5, 15.2+/-4.5, 14.8+/-2.7, 14.3+/-4.3, 15.2+/-2.8mmHg) and Group 2 (12.4+/-5.3, 15+/-3.2, 14.9 +/-3.9, 15+/-3, 14.4+/-4mmHg; p>.05 for all). Group 2 had lower IOP's at week 1 (17.84+/-8 vs. 13.75+/-4.3 mmHg, p<.05). There were no significant differences in glaucoma treatment eye drops taken at baseline or follow-up at week 1, month 1, month 2, month 3, and month 6 between Group 1 (1.28+/-0.74, 1.16+/-0.75, 1.05+/-0.80, 1+/-0.76, 0.89+/-0.78, 1.05+/-0.78) and Group 2 (1.24+/-1.42, 0.75+/-0.74, 0.67+/-0.82, 0.8+/-0.63, 0.8+/-0.84, 0.63+/-0.83; p>.05 for all). When considering total eye drop usage (including steroid and antibiotics), Group 2 used significantly fewer drops at week 1 (3.16+/-0.75 vs. 0.75+/-0.74, p<.05). Conclusions: The use of intravitreal TriMoxi was not associated with IOP elevations or increased glaucoma medication requirements when compared to postoperative topical agents, but it did decrease total drop usage. TriMoxi injections may alleviate compliance issues with antibiotic and anti-inflammatory medications and potentially minimize burden on post-operative patients

PURPOSE: To create a multivariable predictive model for glaucoma in an exclusively African American population and to compare the performance of the model with individual structural parameters derived from SD-OCT. PATIENTS AND METHODS: A total of 103 healthy eyes and 118 glaucomatous eyes of African American patients underwent SD-OCT optic disc and macular scanning. Twenty-seven optic nerve head, retinal nerve fiber layer (RNFL), and ganglion cell parameters were collected. A multivariable model was derived using a backward elimination variable selection procedure. Areas under the curve were used to measure the diagnostic performance of the individual parameters and the multivariable model. RESULTS: The best performing parameters for glaucoma patients included inferior quadrant thickness (AUC=0.9239), average RNFL thickness (AUC=0.9209), sup2 RNFL thickness (AUC=0.9157), superior quadrant thickness (AUC=0.8906), and vertical CDR (AUC=0.8640). The best performing parameters for early glaucoma patients were sup2 RNFL thickness (AUC=0.8680), inferior quadrant thickness (AUC=0.8571), average RNFL thickness (AUC=0.8550), superior quadrant thickness (AUC=0.8420), and inf2 RNFL thickness (AUC=0.8420). The AUC of the multivariable model was 0.8918 for early glaucoma and 0.9744 for moderate/advanced glaucoma. There was some variability in the performance of the model based on disc size. CONCLUSIONS: These findings confirm that several individual RNFL, ONH, and GCA parameters have excellent diagnostic performance in differentiating glaucomatous patients from healthy patients in African American population. A multivariable model was developed and validated with high diagnostic accuracy.

PURPOSE: Corneal hysteresis (CH) is lower in glaucomatous eyes. The aim of this study was to determine and compare the change in CH over time between normal, open angle glaucoma (POAG) and diabetic subjects. METHODS: We retrospectively analysed records of patients undergoing assessment with the Ocular Response Analyzer (Reichert, Corp., New York, NY, USA). Right eyes with at least 7 measurements were included. Patients with ocular pathology other than POAG were excluded. Two-sample t-tests, chi-squared and logistic regression were used to analyse data. RESULTS: A total of 1418 normal and 322 POAG patients were included. Patients with POAG were significantly older (70.73 +/- 11.33 vs. 61.59 +/- 16.56 years; p < 0.001), had a longer follow-up (4.14 +/- 1.34 vs. 2.72 +/- 1.49 years; p < 0.001) and had lower CH (9.58 +/- 2.17 vs. 9.95 +/- 2.19 mmHg p = 0.01), but there were no gender differences between groups (61.5 vs. 57.7% female; p = 0.21). We observed a significantly greater decrease in CH among patients with POAG (-0.11 +/- 0.73 vs. 0.07 +/- 2.31 mm Hg/year; p = 0.02). The relation between CH/year and diagnosis persisted after adjusting for age and follow-up time (OR 0.90; 95% CI 0.82, 0.99; p = 0.03). We found CH to be higher in diabetics vs. non-diabetics (10.34 +/- 2.04 vs. 9.88 +/- 2.19; p = 0.02), but CH/year was not different (0.07 +/- 1.27 vs. 0.03 +/- 2.10; p = 0.77). CONCLUSIONS: Patients with POAG in this study had a significantly greater rate of CH decline compared to normal. There was no significant difference in rate of CH change in diabetic and non-diabetic patients.

PURPOSE: The purpose of this study was to provide the practicing clinical ophthalmologist with an update on relevant glaucoma literature published from 2013 to 2014. DESIGN: This study is a literature review. METHODS: The authors conducted a 1-year (October 1, 2013, to September 30, 2014) English-language glaucoma literature search on PubMed of articles containing "glaucoma" or "glaucomatous" with title/abstract as a filter. Medical subject headings filtered searching was not performed because of the newness of the reviewed material. RESULTS: Literature search yielded 2314 articles, after which we excluded reviews and letters to the editor. We highlighted articles featuring new or updated approaches to the pathophysiology, diagnosis, or treatment of glaucoma and gave preference to human research. CONCLUSIONS: This review features literature that is of interest to ophthalmologists in practice and also highlights studies that may provide insight on future developments applicable to clinical ophthalmology.

PURPOSE: To evaluate the relationship between baseline corneal hysteresis (CH) and the change in intraocular pressure (IOP) before and after cataract extraction in patients without glaucoma. SETTING: Private practice, New York City, New York, USA. DESIGN: Retrospective cohort study. METHODS: Charts of consecutive patients who had phacoemulsification cataract extraction with posterior chamber intraocular lens implantation were analyzed. All included patients had preoperative and postoperative measurements with the Ocular Response Analyzer 2 to 4 months and 10 to 12 months postoperatively. Data collected included age, baseline CH, baseline central corneal thickness (CCT), and IOP. RESULTS: Thirty nine (65 eyes) of the 230 patients met the inclusion criteria. The mean patient age was 70.8 years +/- 8.6 (SD). The mean preoperative, 2- to 4-month and 10- to 12- month postoperative IOP values were 14.8 +/- 3.5 mm Hg, 11.9 +/- 3.4 mm Hg, and 12.6 +/- 3.1 mm Hg, respectively (P < .05 for comparisons with preoperative IOP). The baseline CH was not predictive of the IOP reduction at 2 to 4 months (beta = -0.3; 95% confidence interval [CI], -0.7 to 0.01; P = .06). However, the baseline CH (but not the baseline CCT) was statistically associated with the magnitude of IOP reduction at 10 to 12 months when controlling for patient age (beta = -0.5; 95% CI, -0.8 to -0.1; P = .01). CONCLUSION: A low baseline CH was associated with a larger magnitude of IOP reduction after cataract extraction. FINANCIAL DISCLOSURE: Dr. Radcliffe is a consultant to Reichert Technologies and Glaukos Corp.; a consultant to and speaker for Allergan, Inc., Alcon Laboratories, Inc., Iridex Corp., Merge Healthcare, Carl Zeiss Meditec AG; and a speaker for Merck Pharmaceuticals. No other author has a financial or proprietary interest in any material or method mentioned.

PURPOSE OF REVIEW: Glaucoma is a leading cause of irreversible blindness worldwide. It is estimated that roughly 60.5 million people had glaucoma in 2010 and that this number is increasing. Many patients continue to lose vision despite apparent disease control according to traditional risk factors. The purpose of this review is to discuss the recent findings with regard to corneal hysteresis, a variable that is thought to be associated with the risk and progression of glaucoma. RECENT FINDINGS: Low corneal hysteresis is associated with optic nerve and visual field damage in glaucoma and the risk of structural and functional glaucoma progression. In addition, hysteresis may enhance intraocular pressure (IOP) interpretation: low corneal hysteresis is associated with a larger magnitude of IOP reduction following various glaucoma therapies. Corneal hysteresis is dynamic and may increase in eyes after IOP-lowering interventions are implemented. SUMMARY: It is widely accepted that central corneal thickness is a predictive factor for the risk of glaucoma progression. Recent evidence shows that corneal hysteresis also provides valuable information for several aspects of glaucoma management. In fact, corneal hysteresis may be more strongly associated with glaucoma presence, risk of progression, and effectiveness of glaucoma treatments than central corneal thickness.

This is a case-based approach to the diagnosis and management of angle closure glaucoma of a variety of causative factors, with a special emphasis on the use of advanced anterior segment imaging including ultrasound biomicroscopy and anterior segment optical coherence tomography. Although all angle closure is caused by iridotrabecular contact, the cause of angle closure glaucoma is classified based on the site of primary blockage of aqueous movement from anterior to posterior: pupillary block, plateau iris, lens-related, and posterior causative factors. Although gonioscopy is traditionally used to visualize the angle structures and estimate the angle width, objective and reproducible measurement of the anterior chamber angle can best be obtained with advanced anterior segment imaging. In this review article, we demonstrate the utility of anterior advanced imaging to identify underlying mechanisms in cases of angle closure glaucoma in guiding directed management.