Aqueous Suppressants Research Articles

Brimonidine tartrate for the treatment of glaucoma

ABSTRACTIntroduction: Brimonidine tartrate is a commonly used eyedrop for short- and long-term lowering of intraocular pressure. Its use has been popularized due to its effects on aqueous suppression and uveoscleral outflow, as well as the suggestion of neuroprotection. Although available with alternative preservative vehicles, brimonidine is associated with high rates of local allergy and is contraindicated in breastfeeding women, neonates, young children, and the elderly due to risk of central nervous system depression. Other topical agents with differing advantages have challenged brimonidine’s role in the treatment algorithm of ocular hypertension and glaucoma.Areas covered: The authors review the development of topical alpha-adrenergic agonists, with particular attention to the currently available formulations of brimonidine tartrate. Its mechanism of action, pharmacodynamics and safety, and clinical efficacy are analyzed.Expert opinion: Despite clinical familiarity with brimonidine after two decades of use, agents that offer daily dosing, nocturnal effect, and more favorable ocular and systemic side effect profiles have ultimately led to brimonidine’s adjunctive use in patients with elevated intraocular pressure or high- or low-tension glaucomas. Still, brimonidine may be advantageous in patients undergoing laser trabeculoplasty or iridotomy, in certain forms of glaucoma, or in pregnant individuals prior to the last trimester, underscoring its clinical importance.

Hypotony Maculopathy: A Silent Mimicker of Common Macular Diseases With Nonspecific Optical Coherence Tomography Findings

Purpose: To highlight the diagnostic challenge of eyes with hypotony maculopathy with concurrent macular diseases and to present optical coherence tomography (OCT) imaging findings in hypotony maculopathy. Methods: Retrospective review of 15 eyes of 12 patients with hypotony maculopathy at a single institution. Results: Low intraocular pressure (IOP) was caused by overfiltration from trabeculectomy in 9 eyes (of 15, 60%), overtreatment with topical aqueous suppressants after trabeculectomy in 3 eyes (of 15, 20%), bleb leak in 1 eye (of 15, 7%), and treatment with topical aqueous suppressants alone in 2 eyes (of 15, 13%). On OCT imaging, 7 eyes (of 15, 47%) had chorioretinal folds without intraretinal fluid (IRF) or subretinal fluid (SRF), 5 eyes (of 15, 33%) had either IRF or SRF with chorioretinal folds, and 3 eyes (of 15, 20%) had IRF or SRF without chorioretinal folds. The majority of eyes (11 of 15 eyes, 73%) had additional diagnoses apart from hypotony maculopathy that could have potentially caused IRF or SRF, which included epiretinal membrane, retinal vein occlusion, and age-related macular degeneration. Two eyes (of 15, 13%) were initially erroneously managed for a nonhypotony maculopathy pathology due to the diagnostic challenge in eyes with hypotony maculopathy. Conclusion: Hypotony maculopathy demonstrates nonspecific OCT findings such as IRF and SRF that are commonly seen in other macular diseases. In eyes with these macular diseases, diagnosing hypotony maculopathy may be challenging; thus, attention to past ocular history and IOP must always be part of evaluation.

Blood-ocular barrier disruption in patients with acute stroke

Prompted by the unexpected finding of gadolinium leakage into ocular structures (GLOS) in acute stroke patients, we studied the frequency and nature of this finding in 167 patients. Patients were selected who had an MRI with gadolinium at baseline and another MRI with fluid-attenuated inversion recovery (FLAIR) imaging at 2 and/or 24 hours later. GLOS was detected as lack of vitreous and/or aqueous fluid suppression on postcontrast FLAIR images. GLOS, evident on postcontrast FLAIR MRI, occurred in 127/167 (76%) patients: 86/109 (79%) patients treated with tissue plasminogen activator and 41/58 (71%) who were untreated. At 2 hours after administration of the contrast, GLOS was more common in the aqueous chamber alone, occurring in 67% of patients, compared to the vitreous chamber alone, seen in 6% of patients; it occurred in both chambers in 27% of patients. At 24 hours, GLOS was present in 121/162 (75%) patients, always involving the vitreous chamber, but also affecting the aqueous chamber in 6% of cases. Vitreous GLOS at 24 hours was associated with increasing age (p = 0.002) and a higher burden of cerebral white matter hyperintensities (p = 0.017). Patients with rapid diffuse GLOS, defined as GLOS involving both chambers at 2 hours, had larger infarcts (p = 0.022) and a higher degree of blood-brain barrier permeability (p = 0.025). We found GLOS to be common in patients with acute stroke; delayed GLOS was a marker for chronic vascular disease. The mechanism for acute GLOS remains uncertain but may be a remote effect of acute cerebral injury on the blood-ocular barrier.

Aqueous Flow Measured by Fluorophotometry in the Mouse.

PurposeA fluorophotometer designed to measure aqueous flow in murine eyes was tested with artificial fluorescein chambers and in live mice with different anesthesia regimens, aqueous flow suppressants, and an anterior chamber cannulation method.MethodsTwo hours following topical fluorescein application, one group of CD-1 mice was anesthetized with ketamine/xylazine, 2,2,2-tribromoethanol, or ketamine alone. Cornea and anterior chamber fluorescein concentrations were measured periodically for 60 to 90 minutes by fluorophotometric scans to calculate aqueous flow. Later, a subgroup of mice underwent aqueous flow measurement by anterior chamber cannulation. A third group was treated with timolol, dorzolamide, and vehicle in a crossover manner 1 hour prior to fluorophotometric scans.ResultsAqueous flow with ketamine/xylazine anesthesia (0.09 ± 0.05 μL/min, mean ± SD, n = 24) was slower than with tribromoethanol or ketamine alone (P < 0.001). Timolol reduced aqueous flow from 0.20 ± 0.07 μL/min to 0.07 ± 0.03 μL/min (P = 0.001) under tribromoethanol anesthesia and from 0.14 ± 0.03 μL/min to 0.10 ± 0.02 μL/min (P = 0.004) under ketamine anesthesia but not under ketamine/xylazine anesthesia. Dorzolamide reduced aqueous flow from 0.09 ± 0.03 to 0.06 ± 0.03 μL/min (P = 0.04) under ketamine/xylazine anesthesia. Aqueous flow by anterior chamber cannulation (0.20 ± 0.13 μL/min) was greater (P = 0.05) than by fluorophotometry (0.09 ± 0.07 μL/min).ConclusionsA new noninvasive fluorophotometric method detected effects of general anesthesia and known aqueous suppressants on aqueous flow in mice. Aqueous flow measured by fluorophotometry was slower than by cannulation, and was technically easier with less variability. The mouse fluorophotometer is useful for repeated measurements of aqueous flow in the murine eye making crossover and longitudinal studies possible.

Reversing the Rubeotic Rampage – Current Approaches in the Management of Neovascular Glaucoma

Neovascular glaucoma is a sight-threatening condition, and can rapidly progress from rubeosis with normal intraocular pressure (IOP), to secondary open-angle glaucoma with raised IOP and finally secondary angle-closure glaucoma with uncontrolled IOP. Early detection and aggressive management with panretinal photocoagulation, intravitreal anti-vascular endothelial growth factor (VEGF), topical aqueous suppressants and valved glaucoma drainage surgery can reduce risk of significant visual loss secondary to neovascular glaucoma. This editorial explores some simple measures that can increase surgical success rates and minimise complications.

Bilateral, Simultaneous, Acute Angle Closure Glaucoma in Pseudophakia Induced by Chlorthalidone.

Purpose. To report two persons with acute, bilateral, and simultaneous angle closure glaucoma in pseudophakia secondary to uveal effusions induced by administration of chlorthalidone. Methods. Case reports. Results. Bilateral shallow anterior chambers and high intraocular pressure with decline in visual acuity were reported in two patients within days of intake of chlorthalidone for systemic hypertension. Gonioscopy confirmed appositional angle closure while choroidal detachment and ciliochoroidal detachment were revealed on ultrasonographic studies. Discontinuing chlorthalidone and institution of aqueous suppressants to reduce IOP and cycloplegics reversed angle closure and glaucoma. Conclusions. Reports of angle closure glaucoma in pseudophakic eyes induced by idiosyncratic reaction to chlorthalidone confirms that osmotic changes in the crystalline lens has no role in the pathogenesis of drug induced glaucoma and reaffirms that glaucoma is secondary to ciliochoroidal detachment and ciliary body rotation and edema.

Standardised antibacterial Manuka honey in the management of persistent post‐operative corneal oedema: a case series

BackgroundCorneal oedema is a common post‐operative problem that delays or prevents visual recovery from ocular surgery. Honey is a supersaturated solution of sugars with an acidic pH, high osmolarity and low water content. These characteristics inhibit the growth of micro‐organisms, reduce oedema and promote epithelialisation. This clinical case series describes the use of a regulatory approved Leptospermum species honey ophthalmic product, in the management of post‐operative corneal oedema and bullous keratopathy.MethodsA retrospective review of 18 consecutive cases (30 eyes) with corneal oedema persisting beyond one month after single or multiple ocular surgical procedures (phacoemulsification cataract surgery and additional procedures) treated with Optimel Antibacterial Manuka Eye Drops twice to three times daily as an adjunctive therapy to conventional topical management with corticosteroid, aqueous suppressants, hypertonic sodium chloride five per cent, eyelid hygiene and artificial tears. Visual acuity and central corneal thickness were measured before and at the conclusion of Optimel treatment.ResultsA temporary reduction in corneal epithelial oedema lasting up to several hours was observed after the initial Optimel instillation and was associated with a reduction in central corneal thickness, resolution of epithelial microcysts, collapse of epithelial bullae, improved corneal clarity, improved visualisation of the intraocular structures and improved visual acuity. Additionally, with chronic use, reduction in punctate epitheliopathy, reduction in central corneal thickness and improvement in visual acuity were achieved. Temporary stinging after Optimel instillation was experienced. No adverse infectious or inflammatory events occurred during treatment with Optimel.ConclusionsOptimel was a safe and effective adjunctive therapeutic strategy in the management of persistent post‐operative corneal oedema and warrants further investigation in clinical trials.

Magnetic Resonance Imaging Study on Blebs Morphology of Ahmed Valves.

ABSTRACTPurpose: To determine the morphometric parameters of filtration blebs of a valved aqueous humor drainage device.Materials and methods: Orbital magnetic resonances imaging (MRI) was taken after implantation of an Ahmed valve (FP7 model). Outcomes of the analysis were intraocular pressure (IOP) and the bleb’s morphometric analysis (volume, height, major and minor axis). Associations between IOP and the imaging-related study variables were explored by Spearman’s correlation test.Results: Eleven patients underwent orbital MRI examination. Recordings were taken after a mean of 2.7 months (1-6 months) after surgery. IOP was significantly lower than its preoperative values (17.6 ± 6.4 mm Hg vs 36.1 ± 6.4 mm Hg, p < 0.01). Mean bleb volume was 856.9 ± 261 mm3 and its height, major and minor axis were 5.77 ± 1.9, 14.8 ± 2.9 and 8.14 ± 3.6 mm, respectively. A positive correlation was detected between IOP and mean height (r = 0.77, p = 0.048) and major axis (r = 0.83, p = 0.03). Interestingly, the overall bleb volume was related to IOP levels immediately prior to surgery (r = 0.75, p < 0.01). Additionally, the posterior part of the plate was found to be displaced from the scleral surface in five cases (45%).Conclusion: Ahmed valve’s bleb morphology seems to correlate with both the pre- and postoperative IOP, which might suggest a clinical benefit of administering aqueous suppressants pre- as well as postoperatively. The plate of the device may show a significant dislocation from its initial surgical implantation site.How to cite this article: Ferreira J, Fernandes F, Patricio M, Brás A, Rios C, Stalmans I, Pinto LA. Magnetic Resonance Imaging Study on Blebs Morphology of Ahmed Valves. J Curr Glaucoma Pract 2015;9(1):1-5.

Endoscopic cyclophotocoagulation.

In recent years, many new procedures and implants have been introduced as safer alternatives for the surgical treatment of glaucoma. The majority of these advances are implant-based with a goal of increased aqueous drainage to achieve lower intraocular pressure (IOP). In contrast, endoscopic cyclophotocoagulation (ECP) lowers IOP through aqueous suppression. Although ciliary body ablation is a well-established method of aqueous suppression, the novel endoscopic approach presents a significant evolution of this treatment with marked improvement in safety. The endoscope couples a light source, video imaging, and diode laser to achieve direct visualization of the ciliary processes during controlled laser application. The result is an efficient and safe procedure that can achieve a meaningful reduction in IOP and eliminate or reduce glaucoma medication use. From its initial use in refractory glaucoma, the indications for ECP have expanded broadly to include many forms of glaucoma across the spectrum of disease severity. The minimally-invasive nature of ECP allows for easy pairing with phacoemulsification in patients with coexisting cataract. In addition, the procedure avoids implant or device-related complications associated with newer surgical treatments. In this review, we illustrate the differences between ECP and traditional cyclophotocoagulation, then describe the instrumentation, patient selection, and technique for ECP. Finally, we summarize the available clinical evidence regarding the efficacy and safety of this procedure.

Effect of topical aqueous suppression on intraocular gas duration after pure perfluoropropane injection in nonvitrectomized eyes with retinal detachment.

To determine whether topical aqueous suppressants affect the duration of pure expansile intraocular gas in nonvitrectomized eyes. A prospective randomized controlled trial was performed on nonvitrectomized patients undergoing retinal detachment repair with scleral buckle or pneumatic retinopexy using 0.3 mL of 100% perfluoropropane (C3F8) gas tamponade. Eyes were randomly assigned to receive topical dorzolamide 2% and timolol 0.5% twice daily postoperatively until gas dissolution or to observation. Twenty-one patients met all inclusion and exclusion criteria. Twelve were randomized to the control group and nine to the dorzolamide-timolol group. In the dorzolamide-timolol group, mean intraocular pressure was 17.4 on postoperative Day 1 and 12.5 on postoperative Week 1 (P = 0.03). In the control group, mean intraocular pressure was 14.5 on postoperative Day 1 and 15.1 on postoperative Week 1 (P = 0.73). The mean duration of C3F8 was 37.8 days in the dorzolamide-timolol group and 40.4 days in the control group (P = 0.70). Topical aqueous suppression does not seem to have a significant effect on the duration of pure expansile intraocular C3F8 in nonvitrectomized eyes after pneumatic retinopexy or scleral buckling.

Suppression of Intraocular Vascular Endothelial Growth Factor During Aflibercept Treatment of Age-Related Macular Degeneration

To determine the duration of suppression of aqueous humor concentrations of vascular endothelial growth factor (VEGF) in eyes with neovascular age-related macular degeneration (AMD) treated with aflibercept. Nonrandomized prospective clinical study. Twenty-seven eyes of 27 neovascular AMD patients receiving intravitreal aflibercept injections on a pro re nata regimen driven by spectral-domain optical coherence tomography (SD OCT) were included in this study. A total of 132 aqueous humor specimens were collected before intravitreal aflibercept injections and their VEGF-A concentrations assayed by multiplex bead analysis. Mean aqueous humor VEGF concentrations before treatment initiation were 90.6 ± 37.1 pg/mL (range 23.4-190.3 pg/mL). Intravitreal injection of aflibercept suppressed the aqueous VEGF concentrations to below the lower limit of quantification (<4 pg/mL) in all patients. The mean duration of VEGF suppression below the lower limit of quantification was >71 ± 18 days. The earliest time after injection at which the VEGF concentration recovered to above the lower limit of quantification was 55 days in 1 patient and >56 days, the recommended aflibercept treatment interval, in 20 patients. The aqueous VEGF recovery status of 6 patients was uncertain after 56 days. On average, VEGF concentrations in the aqueous humor were suppressed below the lower limit of quantification after intravitreal aflibercept injections for about 10 weeks. This aqueous suppression time suggests durable VEGF inhibition for most patients dosed with aflibercept every 8 weeks.

Effect of Early Treatment with Aqueous Suppressants on Ahmed Glaucoma Valve Implantation Outcomes

To evaluate the effect of early aqueous suppressant treatment on Ahmed glaucoma valve (AGV) surgery outcomes. Randomized clinical trial. Ninety-four eyes of 94 patients with refractory glaucoma. After AGV implantation, 47 cases (group 1) received topical timolol-dorzolamide fixed-combination drops twice daily when intraocular pressure (IOP) exceeded 10 mmHg, whereas 47 controls (group 2) received conventional stepwise treatment when IOP exceeded target pressure. Main outcome measures included IOP and success rate (6 mmHg < IOP < 15 mmHg and IOP reduction of at least 30% from baseline). Other outcome measures included best-corrected visual acuity, complications, and hypertensive phase frequency. Groups 1 and 2 were both followed up for a mean of 45±11.6 and 47.2±7.4 weeks, respectively (P = 0.74). Mixed model analysis revealed a significantly greater IOP reduction in group 1 at all intervals (P<0.001). At 1 year, the cases exhibited a significantly higher success rate (63.2% vs. 33.3%; P = 0.008) and reduced hypertensive phase frequency (23.4% vs. 66.0%; P<0.001). Early aqueous suppressant treatment may improve AGV implantation outcomes in terms of IOP reduction, success rate, and hypertensive phase frequency.

Persistent Leak After Glaucoma Aqueous Shunt Implantation

To present 4 cases of persistent leak attributed to subconjunctival fistula formation after glaucoma aqueous shunt implantation. Our preferred method for management is also described. Retrospective noncomparative case series. Four cases of persistent leak after glaucoma aqueous shunt surgery are described. Three patients had an underlying diagnosis of iridocorneal endothelial syndrome and 1 patient had a diagnosis of chronic panuveitis. Three patients had prior trabeculectomy with adjunctive periocular application of antiproliferative agents (mitomycin C and/or 5-fluorouracil). One patient had aqueous shunt implantation as a primary glaucoma procedure. Implantation of the Molteno (1 patient), Ahmed (2 patients), and Baerveldt (1 patient) aqueous shunts was uneventful in all cases. Early onset of the leak, between postoperative months 1 and 2, was typical. The use of aqueous suppressants, bandage contact lens, conjunctival photocoagulation, sutures, tissue adhesives, conjunctival autografts, and scleral patch grafts were unsuccessful in the described cases. Resolution of the leak occurred after removal of the aqueous shunt and elimination of the causative subconjunctival fistula. Histologic support for fistulization was obtained in 3 cases. Severe complications including endophthalmitis (1 patient), hypotony (4 patients), suprachoroidal hemorrhage (2 patients), and corneal decompensation (3 patients) occurred because of the persistent leaks. Persistent leak is a rare but important complication after glaucoma aqueous shunt implantation. Early consideration for the presence of a subconjunctival fistula, especially in patients with iridocorneal endothelial syndrome or chronic uveitis, can spare many ineffective efforts to repair the leak and prevent severe vision threatening complications.

Pharmacological management of ocular hypertension: current approaches and future prospective

Elevated eye pressure is the main risk factor for glaucoma, and intraocular pressure rises when the balance between aqueous humor formation and outflow resistance is compromised. In a normal eye there is a precise tune of aqueous outflow under the fine control of ciliary body and trabecular meshwork. Current pharmacological therapies for lowering the intraocular pressure in glaucoma include increasing aqueous humor outflow and suppression of aqueous humor production. However, most of antiglaucoma drugs currently on the market do not target the trabecular meshwork that represents the site of the pathology. This review focuses on pharmacological management of ocular hypertension with a particular attention to the future pharmacotherapy scenario.

Microbead-Induced Ocular Hypertensive Mouse Model for Screening and Testing of Aqueous Production Suppressants for Glaucoma

To characterize the microbead-induced ocular hypertension (OHT) mouse model and investigate its potential use for preclinical screening and evaluation of ocular hypotensive agents, we tested the model's responses to major antiglaucoma drugs. Adult C57BL/6J mice were induced to develop OHT unilaterally by intracameral injection of microbeads. The effects of the most commonly used ocular hypotensive drugs, including timolol, brimonidine, brinzolamide, pilocarpine, and latanoprost, on IOP and glaucomatous neural damage were evaluated. Degeneration of retinal ganglion cells (RGCs) and optic nerve axons were quantitatively assessed using immunofluorescence labeling and histochemistry. Thickness of the ganglion cell complex (GCC) was also assessed with spectral-domain optical coherence tomography (SD-OCT). A microbead-induced OHT model promptly responded to drugs, such as timolol, brimonidine, and brinzolamide, that lower IOP through suppressing aqueous humor production and showed improved RGC and axon survival as compared to vehicle controls. Accordingly, SD-OCT detected significantly less reduction of GCC thickness in mice treated with all three aqueous production suppressants as compared to the vehicle contol-treated group. In contrast, drugs that increase aqueous outflow, such as pilocarpine and latanoprost, failed to decrease IOP in the microbead-induced OHT mice. Microbead-induced OHT mice carry dysfunctional aqueous outflow facility and therefore offer a unique model that allows selective screening of aqueous production suppressant antiglaucoma drugs or for studying the mechanisms regulating aqueous humor production. Our data set the stage for using GCC thickness assessed by SD-OCT as an imaging biomarker for noninvasive tracking of neuronal benefits of glaucoma therapy in this model.

Diurnal and Nocturnal Variations in Aqueous Humor Dynamics of Patients With Ocular Hypertension Undergoing Medical Therapy

To evaluate the interaction of intraocular pressure(IOP)–lowering medications with physiologic day and night changes in aqueous humor dynamics in participants with ocular hypertension. Thirty participants were enrolled in thisdouble-masked, randomized, crossover study. Each participant underwent aqueous humor dynamics measurements at baseline and at 2 weeks of dosing in random order with latanoprost in the evening and placebo in the morning, timolol maleate twice daily, and dorzolamide hydrochloride twice daily. Measurements included central corneal thickness by ultrasound pachymetry, anterior chamber depth by A-scan, seated and habitual IOP by pneumatonometry, blood pressure by sphygmomanometry,episcleral venous pressure by venomanometry,and aqueous flow by fluorophotometry. Outflow facility was assessed by fluorophotometry and by tonography. Uveoscleral outflow was mathematically calculated using the Goldmann equation. Latanoprost use significantly decreased IOP during the day and night. It increased daytime uveoscleral outflow by a mean (SD) of 0.90 (1.46) μL/min (P=.048), but a nighttime increase of 0.26 (1.10) μL/min (P=.47)did not reach statistical significance. Timolol use decreased IOP during the day by reducing aqueous flow by 25%. Dorzolamide use lowered IOP only at the noon measurement and reduced daytime aqueous flow by 16%. Neither dorzolamide nor timolol use added to the physiologic 47% reduction in nighttime aqueous flow. The daytime IOP-lowering effects of latanoprost are mediated by an increase in uveoscleral outflow,and those of timolol and dorzolamide are mediated by aqueous flow suppression. Nighttime physiologic changes in uveoscleral outflow limit the nighttime pharmacodynamic efficacy of latanoprost. Aqueous flow suppression with timolol and dorzolamide was ineffective in obtaining IOP lowering at night.

TOPICAL AQUEOUS SUPPRESSION DOES NOT SIGNIFICANTLY AFFECT DURATION OF INTRAOCULAR GAS TAMPONADE AFTER VITRECTOMY

To determine if topical aqueous suppression affects the duration of intraocular sulfur hexafluoride (SF6) gas tamponade after pars plana vitrectomy. A prospective randomized controlled trial was conducted on patients undergoing 23-gauge sutured pars plana vitrectomy with air-fluid exchange and 20% SF6 gas tamponade. Eyes were randomly assigned to receive either postoperative topical dorzolamide 2%-timolol 0.5% twice a day or no additional drops (control group). Standard postoperative topical antibiotics and corticosteroids were used by all patients. A total of 21 patients were recruited for the study. Four were excluded because of noncompliance with use of dorzolamide-timolol. In the remaining 17 patients, 8 were randomly assigned to the dorzolamide-timolol group and 9 to the control group. Topical dorzolamide-timolol drops twice a day did not affect the duration of SF6 gas tamponade after pars plana vitrectomy (17.1 vs. 18.1 days with no drops, P = 0.35). The difference in mean gas duration was -1.0 days with a 95% confidence interval of -3.2 days to 1.2 days. Secondary analyses did not reveal a difference in SF6 duration based on lens status, presence of diabetes or hypertension, vitrectomy versus combined buckle with vitrectomy, or patient age. Topical aqueous suppression with dorzolamide-timolol does not have a large effect on duration of SF6 gas tamponade after pars plana vitrectomy.

Severe Intraocular Pressure Fluctuation After Intravitreal Anti-Vascular Endothelial Growth Factor Injection

A 65-year-old man with unilateral exudative age-related macular degeneration presented initially with hypotony and a shallow choroidal detachment 5 days after an intravitreal ranibizumab injection. This was followed by an acute increase in intraocular pressure (IOP) to 60 mm Hg despite open angles, no evidence of intraocular inflammation, and no corticosteroid use. Ultrasound biomicroscopy showed a focal atrophic area in the ciliary body from the 7- to 9-o'clock positions, corresponding to the site of intravitreal injection. The IOP elevation was successfully treated with aqueous suppressants and resolved spontaneously after 48 hours. This report describes a patient with a rare case of labile IOP secondary to angle changes following ranibizumab injection. Injury to angle structures following intravitreal ranibizumab injection is a rare but potentially severe complication. Ultrasound biomicroscopy may be helpful in elucidating angle changes in the setting of labile IOP following intravitreal ranibizumab injection.

Painless Progression to Legal Blindness

Phacomorphic glaucoma is a lens-induced secondary angle closure glaucoma that may occur as a result of mature cataract formation. A patient with markedly asymmetric cataract and anterior chamber depth was referred after the development of significant eye pain and elevated intraocular pressure that did not respond to topical antiglaucoma medications. The presence of an asymmetric mature lens, angle closure, and intraocular pressure elevation in the affected eye led to the diagnosis of phacomorphic glaucoma. Because the patient was systemically ill, physically frail, and had poor vision in the affected eye since birth, secondary to strabismic amblyopia, initial therapy was medically directed toward pain management. Cycloplegia, corticosteroids, and aqueous suppressants successfully ameliorated the patient’s intraocular pressure and adequately controlled pain. However, progression to phacolysis and subsequent failure of pain management necessitated referral for lens extraction. The diagnosis and mechanism of phacomorphic glaucoma is discussed along with a review of current treatment modalities.

Compression sutures with autologous blood injection for leaking trabeculectomy blebs

Leaks may follow trabeculectomy surgery, particularly where antimetabolite useage has resulted in thin or avascular filtration blebs. Leaking blebs are associated with endophthalmitis, low intraocular pressure (IOP), hypotony maculopathy and...