Glaucomatous Eyes Research Articles

Influence of Refractive Error on Circumpapillary Structure-function vs. Vessel Density-function Relationships in Open-angle Glaucoma.

In Japanese OAG eyes correlation of 30-degree visual field MD and VFI with circumpapillary vessel density is systematically stronger than that with circumpapillary RNFLT, and is preserved in myopia and high myopia. To investigate the influence of refractive error on the relationship between circumpapillary retinal nerve fiber layer thickness (cpRNFLT) and circumpapillary vessel density (cpVD), respectively, and global visual field parameters in Japanese open-angle glaucoma (OAG) eyes. One eye of 81 Japanese OAG patients (spherical equivalent refractive error: +3.0 to -9.0 D) underwent 360-degree cpRNFLT and cpVD measurements with Cirrus HD 5000-AngioPlex optical coherence tomography and 30-2 Humphrey visual field testing for mean deviation [MD] and visual field index [VFI] within 1 month. Correlations were determined for the whole population and each refractive error subgroups, separately: emmetropia/hyperopia (n=24), mild (n=18), moderate (n=20), and high myopia (n=19). For the total population, significant strong to very strong correlations were found between MD, VFI, and both cpRNFLT and cpVD, respectively, with consistently higher r-values for cpVD (highest r-values: 0.532 for cpRNFLT, P<0.001; 0.722 for cpVD, P<0.001). Of the refractive subgroups, statistically significant correlations between cpRNFLT and the visual field parameters were maintained only in the hyperopia/emmetropia and moderate myopia groups. In contrast, statistically significant, strong to very strong correlations between cpVD and both MD and VFI, always exceeding the corresponding r-values found for cpRNFLT were found in all refractive subgroups, with r-values ranging between 0.548 (P=0.005) and 0.841 (P<0.001). Our results suggest that in Japanese OAG eyes the relationship of MD and VFI with cpVD is strong. It is systematically stronger than that with cpRNFLT, and preserved in each conventional refractive error category including high myopia.

Fluctuation of Intraocular Pressure and Vascular Factors Are Associated With the Development of Epiretinal Membrane in Glaucoma

To identify factors associated with the development of epiretinal membranes (ERM) in glaucoma patients. Multicenter, propensity-score matched, case-control study. One hundred ninety-two eyes of 192 patients with glaucoma from the Catholic Medical Center Glaucoma Suspect Cohort Study were analyzed. We identified 64 eyes who developed ERM from the cohort, and 128 eyes without ERM were selected by propensity score matching (1:2) according to baseline age and mean deviation (MD) of the visual field (VF). Demographic, systemic, and ocular characteristics were determined at baseline. Intraocular pressure (IOP) was measured, including baseline, mean IOP, and IOP fluctuation. Early-stage ERM, defined as translucent membrane with no underlying retinal distortion, was detected by fundus photography and optical coherence tomography. Central VF progression was considered when new VF defets developed in one either or both hemifields or when there was an increase of 3 or more abnormal points within 12 points of central 10° fixation. Autonomic nervous system status was evaluated by heart rate variability. Patients who developed ERM were more frequently receiving medication for systemic hypertension and had higher systolic blood pressure, greater IOP fluctuation, more frequent disc hemorrhage (DH), worse VF MD, and a higher rate of central VF progression than patients without ERM. Additionally, patients with early glaucoma who developed ERM had higher rate of autonomic imbalance while patients with moderate-to-advanced glaucoma who developed ERM had greater baseline and peak IOP and worse MD of the last follow-up VF (MD < 6.0 dB). Older age (P=.048), medication for systemic hypertension (P < .001), IOP fluctuation (P < .001), presence of DH (P < .001), and worse last MD of VF (P=.033) were significantly associated with ERM in Cox proportional hazard analysis. Early stage of ERMs in glaucomatous eyes are significantly associated with glaucoma progression, medication of systemic hypertension, presence of DH, and IOP fluctuation. These suggest that glaucoma patients who develop early stage of ERMs should be carefully monitored in terms of IOP fluctuation, vascular factors, and glaucoma progression.

Outcomes of standalone ab interno trabeculotomy in the treatment of open-angle glaucoma in eyes with high myopia

BackgroundWe retrospectively evaluate the long-term efficacy and safety of trabeculotomy glaucoma surgery in treating open-angle glaucoma (OAG) in eyes with high myopia (HM).MethodsThis study included 20 eyes with HM (axial length ≥ 26.5 mm) and OAG; age, preoperative IOP (intraocular pressure), and sex-matched 20 non-HM eyes (axial length < 26.5 mm) served as controls. Each eye underwent standalone ab interno trabeculotomy using a Kahook dual blade. A follow-up examination was performed 36 months after surgery. The main outcome measure was the operative success rate (i.e., a ≥ 20% pre- to post-operative reduction in IOP with or without IOP-lowering medication). Kaplan–Meier analysis was employed as a measure of surgical success. The secondary outcome measures were postoperative IOP, the number of glaucoma medications, and postoperative complications.ResultsIOP and the number of glaucoma medications were statistically significantly reduced at all postoperative follow-up examinations. The Kaplan–Meier analysis demonstrated that the probability of postoperative success at 36 months was 45% and 65% for HM and non-HM eyes, respectively. In the HM group, the presence of pathological myopia was statistically significant risk factor for surgical failure. No critical postoperative complications were detected.ConclusionsIn our study, the long-term efficacy of ab interno trabeculotomy in HM eyes with OAG was inferior to that in non-HM eyes with OAG. Our findings suggest that surgical indications for trabeculotomy in HM should be determined based on the presence of pathological myopia.

Commentary: Innovation is the key to manage complications in rare ocular conditions like spherophakia.

Spherophakia is a rare diagnosis that is characterized by weak zonules encircling a more spherical, smaller, and thicker anteroposterior crystalline lens.[1] The eye is usually severely myopic. The lens zonules are abnormally weak and hypoplastic during development. It frequently coexists with lenticular myopia, lens subluxation, angle-closure glaucoma, and a shallow anterior chamber.[1] The crystalline lens in this situation has an increased anterior–posterior diameter and a smaller equatorial diameter.[2] Lens subluxation can cause pupillary block glaucoma[3] and can happen anteriorly, inferiorly, or posteriorly.[4] The indication of undergoing a lensectomy has already been mentioned for treating a displaced lens.[5] The surgeon and the patient’s characteristics play a significant role in the intraocular lens (IOL) selection. Both iris-fixated lenses[6] and angle-supported anterior chamber lenses (ACIOLs) are frequently used. Numerous case studies have also discussed posterior chamber IOLs (PCIOLs) and scleral-fixated IOLs (SFIOLs) – glued or sutured with/without capsule tension rings (CTR).[7,8] In 2008, Agarwal et al.[9] introduced the glued IOL technique, which was glued intrascleral haptic fixation of a PCIOL. Zonular weakness is frequently linked to ectopia lentis, congenital cataract with luxation, or traumatic cataract. A PCIOL (foldable or nonfoldable) is implanted in the eyes with a defective posterior capsule using a quick-acting surgical fibrin sealant. Glued IOL in various indications has shown very promising results. In nearly half of the cases of spherophakia, it is accompanied with subsequent glaucoma.[10] When the intraocular pressure (IOP) is uncontrolled, there is disagreement over the treatment to manage these eyes. Based on our previous experience and various studies, lens removal alone appears to help with IOP management in around 50% of the eyes, with the remainder perhaps handled with additional drugs. Glaucoma surgery is seldom required for IOP management.[11] Lensectomy, vitrectomy, and glued IOL have been done in eyes with spherophakia and secondary glaucoma in the current investigation. The findings of these procedures seem to be favorable in terms of the procedure’s safety and effectiveness. In one-third of the eyes, the IOP was managed without the use of Anti-Glaucoma Medications (AGM); the remaining eyes required AGM for IOP management. Lensectomy with glued IOL resulted in significant improvement in visual acuity and correction of refractive error to almost emmetropia in a majority of the eyes. Other factors associated with poor glaucoma control were also evaluated. Preoperative AGM, male gender, and low preoperative visual acuity were shown to be related to poor glaucoma management and the requirement for AGM or surgery to reduce IOP. Rao et al.[11] previously showed that younger age at presentation, higher IOP, and more disk injury at presentation were all substantially linked with increased failure after lensectomy. Muralidhar et al.[5] did report that lensectomy did not have any impact on IOP. Lensectomy was performed in 16 eyes in their study, but only four eyes had raised IOP before lensectomy. Hence, from four eyes, one cannot interpret that lensectomy is not effective in controlling IOP. In a study by Rao et al.,[11] following lensectomy, close to half of the patients had IOP control without AGM, while only one-third of the patients in this glued IOL cohort could achieve the same. The percentage of eyes needing surgical intervention for IOP control was similar (16%) either with lensectomy or with lensectomy with glued IOL surgery in eyes with spherophakia and secondary glaucoma. To the best of our knowledge, this was the first study to report on the results of lensectomy with glued IOL in spherophakia and glaucoma eyes.[12] Overall, IOP was managed well in 30% of the eyes after lensectomy and glued IOL without the need for AGM, 65% of the eyes required AGM for IOP management, and only 5% of the eyes required glaucoma surgery. The study’s shortcomings include a small sample size and a short postoperative follow-up period. The benefits of conducting lensectomy with glued IOL in eyes with spherophakia include not only improved IOP management, but also improved uncorrected and corrected visual acuity. There were no intraoperative or postoperative complications in this sample, indicating that the technique is safe. The authors would like to advocate lensectomy with glued IOL in spherophakic eyes with subluxated crystalline lens and increased IOP in the absence of syndromic disease due to these benefits and the shorter learning curve.[12] However, these individuals require regular monitoring of IOP; one-third of the eyes had well-controlled IOP, and almost two thirds required further antiglaucoma drugs or surgery for IOP management. Because this is a recent surgery, long-term results and complications must be investigated to determine the technique’s long-term effectiveness and safety.

Delivering active molecules to the eye; the concept of electrospinning as potent tool for drug delivery systems

Ocular drug delivery is a challenging but fascinating topical route of administration. Although the eye is easily accessible for common drug formulations such as drops, its complex structure presents main obstacles to successfully deliver drugs. Low ocular bioavailability due to pre-corneal fluid and gravity drainage limits the efficacy of the products. Therefore, researchers have proposed various drug delivery systems synthesized by biomaterials, mostly polymers, which can deliver active ingredients to the ocular surface and remain for longer period. Such systems as electrospun fibrous structures resembling the extracellular matrix can embed various therapeutic molecules aiming to target eye diseases. The electrospun matrices, which can be used as inserts or implants, offer biocompatibility, biodegradability, and good mechanical properties. At the same time, they can be molded into different shapes and textures, significant features for ocular delivery. Over the last decades, the electrospinning process has offered many advancements in tissue engineering and drug delivery fields; however, the clinical translation of the electrospun fibrous matrices is still in the embryonic stages. This review article focuses on the recent therapeutic applications of ocular fibrous systems as potent drug delivery tools. In addition, authors have categorized the electrospun matrices according to the target eye disease, such as glaucoma, ocular infections, and other eye diseases.

Detection Of Cataract, Diabetic Retinopathy and Glaucoma Eye Diseases with Deep Learning Approach

Eye diseases are one of the serious health problems affecting human life. Cataract, diabetic retinopathy and glaucoma eye diseases cause visual impairment and cause irreversible eye defects. Throughout human life; genetic, age and environmental factors affect people's eye health. Detection of the disease plays a critical role in order to apply the right diagnosis and therefore increase the quality of life of the patient. With the developing technology, artificial intelligence can detect eye defects and therefore whether there is a disease or not. This study aims to develop solutions for detecting an important health problem such as eye health by using deep learning models. In the related study, Convolutional Neural Networks models, one of the deep learning types are used. The data set used for disease detection includes a total of 2748 Retinal Fundus images taken from 1374 normal individuals and 1374 different disease groups. In order to compare the classification performances and to achieve better performance, a solution to the disease detection problem was sought by using a total of 5 different Convolutional Neural Networks architectures. These are DenseNet, EfficientNet, Xception, VGG, Resnet. For the validity of the approach, it was tested using the 10-fold cross-validation technique. Accuracy, Recall, Precision, F1-Score, and Matthews’s coefficient correlation metrics were used as performance evaluation criteria. When the classification performances were examined, the results obtained with the EfficientNet architecture were measured as 94.88%, 94.88%, 95.02%, 94.88%, 89.89% for Accuracy, Recall, Precision, F1-Score, and Matthews’s coefficient correlation metrics. In this context, the best classification performance was obtained with the EfficientNet architecture.

Progressive Macular Vessel Density Loss and Visual Field Progression in Open-angle Glaucoma Eyes with Central Visual Field Damage

To investigate the association between the longitudinal changes in both macular vessel density (mVD) and macular ganglion cell-inner plexiform layer thickness (mGCIPLT) and visual field (VF) progression (including central VF progression) in open-angle glaucoma (OAG) patients with central visual field (CVF) damage at different glaucoma stages. Retrospective longitudinal study. This study enrolled 223 OAG eyes with CVF loss at baseline classified as early-to-moderate (133 eyes) or advanced (90 eyes) stage based on the VF mean deviation (MD) (-10 dB). Serial mVDs at parafoveal and perifoveal sectors and mGCIPLT measurements were obtained using OCT angiography and OCT during a mean follow-up of 3.5 years. Visual field progression was determined using both the event- and trend-based analyses during follow-up. Linear mixed-effects models were used to compare the rates of change in each parameter between VF progressors and nonprogressors. Logistic regression analyses were performed to determine the risk factors for VF progression. In early-to-moderate stage, progressors showed significantly faster rates of change in the mGCIPLT (-1.02 vs.-0.47 μm/year), parafoveal (-1.12 vs.-0.40%/year), and perifoveal mVDs (-0.83 vs.-0.44%/year) than nonprogressors (all P<0.05). In advanced stage cases, only the rates of change in mVDs (parafoveal:-1.47 vs.-0.44%/year; perifoveal:-1.04 vs.-0.27%/year; all P<0.05) showed significant differences between the groups. By multivariable logistic regression analyses, the faster rate of mVD loss was a predictor of VF progression regardless of glaucoma stage, while the rate of mGCIPLT loss was significantly associated with VF progression only in early-to-moderate stage cases. Progressive mVD loss is significantly associated with VF progression (including central VF progression) in the OAG eyes with CVF loss regardless of the glaucoma stage. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Myopic Versus Glaucomatous Parapapillary Beta Zone in Myopic Eyes Versus Eyes With Secondary Angle-Closure Glaucoma.

To search for histologic differences in the beta zone between myopic eyes versus eyes with secondary angle-closure glaucoma. The histomorphometric study consisted of human eyes enucleated due to uveal melanomas or secondary angle-closure glaucoma. The study included 100 eyes (age: 62.1 ± 15.1 years; axial length: 25.6 ± 3.1 mm; range: 20.0-35.0 mm). In non-highly myopic glaucomatous eyes compared with non-highly myopic nonglaucomatous eyes, the parapapillary alpha zone was longer (223 ± 168 µm vs. 125 ± 128 µm; P = 0.03), beta zone prevalence (15/20 vs. 6/41; P < 0.001) and length (277 ± 245 µm vs. 44 ± 150 µm; P = 0.001) were higher, and RPE cell density in the alpha zone and alpha zone border was lower (all P < 0.05). In highly myopic nonglaucomatous eyes compared with non-highly myopic glaucomatous eyes, parapapillary RPE drusen prevalence (2/19 vs. 10/10; P = 0.01) and alpha zone prevalence (2/19 vs. 16/20; P < 0.001) and length (23 ± 68 µm vs. 223 ± 168 µm; P < 0.001) were lower. In non-highly myopic glaucomatous eyes, Bruch's membrane (BM) thickness decreased (P < 0.001) from the beta zone (6.0 ± 3.1 µm) to the alpha zone (5.1 ± 4.3 µm) and peripheral to it (3.0 ± 0.9 µm). In highly myopic nonglaucomatous eyes, BM thickness did not differ (P > 0.10) between all three regions. In the total study population, RPE cell density in the alpha zone (24.5 ± 9.3 cells/240 µm) was higher than at the alpha zone border (19.2 ± 4.8 cells/240 µm; P < 0.001) or peripheral to it (19.0 ± 3.6 cells/240 µm; P < 0.001). The glaucomatous beta zone in eyes with chronic angle-closure glaucoma (with the alpha zone, parapapillary RPE drusen, thickened BM, and higher RPE cell count in the adjacent alpha zone) differs histologically from the myopic beta zone (characterized by the absence of the alpha zone and parapapillary RPE drusen, unremarkable BM thickness, and unremarkable parapapillary RPE). The differences suggest different etiologies of the glaucomatous versus myopic beta zone.

Evaluation of optic nerve head and retinal layers in affected and fellow eyes of pediatric glaucoma

ObjectivePediatric glaucoma is a rare disease that is potentially more severe than adult glaucoma because it is more challenging to diagnose and more difficult to treat. The segmented retinal layer has been shown to have excellent capability in assessing adult glaucoma. However, there is limited information regarding the benefits of spectral domain-optical coherence tomography (SD-OCT) in children. Thus, our study aims to investigate the role of circumpapillary (cp) OCT analysis in examining pediatric glaucoma and characterizing the changes in the fellow eyes of glaucomatous children. MethodsSD-OCT was used to investigate the optic nerve head (ONH) and retinal morphology of 18 patients with pediatric glaucoma and 14 matched healthy controls. ResultsAs predicted, pediatric patients with glaucoma had a wider disk diameter, cup diameter, and cup-to-disk ratio (CDR). Pediatric glaucoma also resulted in a thinner retinal nerve fiber layer (RNFL), ganglion cell layer – inner plexiform layer (GCL-IPL), photoreceptor layer – retinal pigment epithelium (PRL-RPE), and total retinal layer (TRL). Similarly, these observations were found in the fellow eyes of glaucomatous children. Our finding also indicated that cpRNFL, GC-IPL, and PRL-RPE thickness were useful for the early identification of pediatric glaucoma. ConclusionIn conclusion, SD-OCT could be implemented in managing glaucoma in young children. Moreover, retinal layer damage at the corresponding locations of the fellow eye is similarly detected in the glaucomatous eye.

Development of a deep learning system to detect glaucoma using macular vertical optical coherence tomography scans of myopic eyes

Myopia is one of the risk factors for glaucoma, making accurate diagnosis of glaucoma in myopic eyes particularly important. However, diagnosis of glaucoma in myopic eyes is challenging due to the frequent associations of distorted optic disc and distorted parapapillary and macular structures. Macular vertical scan has been suggested as a useful tool to detect glaucomatous retinal nerve fiber layer loss even in highly myopic eyes. The present study was performed to develop and validate a deep learning (DL) system to detect glaucoma in myopic eyes using macular vertical optical coherence tomography (OCT) scans and compare its diagnostic power with that of circumpapillary OCT scans. The study included a training set of 1416 eyes, a validation set of 471 eyes, a test set of 471 eyes, and an external test set of 249 eyes. The ability to diagnose glaucoma in eyes with large myopic parapapillary atrophy was greater with the vertical than the circumpapillary OCT scans, with areas under the receiver operating characteristic curves of 0.976 and 0.914, respectively. These findings suggest that DL artificial intelligence based on macular vertical scans may be a promising tool for diagnosis of glaucoma in myopic eyes.

Characteristics of Henle's fiber layer in healthy and glaucoma eyes assessed by polarization-sensitive optical coherence tomography.

Using conventional optical coherence tomography (OCT), it is difficult to image Henle fibers (HF) due to their low backscattering potential. However, fibrous structures exhibit form birefringence, which can be exploited to visualize the presence of HF by polarization-sensitive (PS) OCT. We found a slight asymmetry in the retardation pattern of HF in the fovea region that can be associated with the asymmetric decrease of cone density with eccentricity from the fovea. We introduce a new measure based on a PS-OCT assessment of optic axis orientation to estimate the presence of HF at various eccentricities from the fovea in a large cohort of 150 healthy subjects. By comparing a healthy age-matched sub-group (N = 87) to a cohort of 64 early-stage glaucoma patients, we found no significant difference in HF extension but a slightly decreased retardation at about 2° to 7.5° eccentricity from the fovea in the glaucoma patients. This potentially indicates that glaucoma affects this neuronal tissue at an early state.

Quantification of vascular morphology in optical coherence tomography angiography in primary open angle glaucoma

PurposeTo quantitatively measure and compare the vascular morphology in healthy eyes and eyes with primary open-angle glaucoma (POAG) using optical coherence tomography angiography (OCTA) scans. MethodsThis is a retrospective and cross-sectional study which include healthy individuals and individuals with POAG that underwent OCTA imaging at an academic center's glaucoma clinic. We analyzed OCTA scans of the macula and optic nerve head (ONH) of one eye from each subject to quantitatively measure vessel density (VD), vessel length density (VLD), and branchpoint density (BPD). We compared these 3 parameters between the healthy and POAG groups and used logistic regression classification models to determine their diagnostic value in differentiating healthy and glaucomatous eyes. ResultsWe included 49 healthy subjects and 49 subjects with POAG. After age-adjusted analysis, the parameters of VD, VLD, and BPD were significantly reduced in eyes with POAG (P ​< ​0.001) in all scan layers and most significantly around the ONH. The parameter with the best performances were radial peripapillary capillary (RPC) VD [AUC (areas under the curve): 0.939 (0.891, 0.987)] which had statistically higher performances (P ​< ​0.05) than parameters in the superficial or deep layers. All 3 parameters in the RPC layer had statistically similar performances. ConclusionsWe found that VD, VLD, and BPD were reduced in glaucomatous eyes. The morphologic parameters of VLD and BPD had similar performances to the traditional parameter of VD in RPC layers. Our results suggest that vascular morphology parameters may provide additional value in the diagnosis and evaluation of glaucoma.

Intermediate Outcomes of the Novel 63-μm Gelatin Microstent versus the Conventional 45-μm Gelatin Microstent

To determine intermediate intraocular pressure (IOP)-lowering and adverse event profile of the 63-μm gelatin microstent (Xen63) with mitomycin C (MMC) compared with the 45-μm gelatin microstent (Xen45) with MMC. Single center, consecutive, retrospective cohort study. Eighty-four glaucomatous eyes (42 63-μm gelatin microstent and 42 45-μm gelatin microstent) with or without previous subconjunctival glaucoma surgery. Consecutive eyes that underwent 63-μm gelatin microstent implantation with MMC from February 2020 to June 2021 were compared with eyes that underwent 45-μm gelatin microstent implantation with MMC. Standalone and combined cases with phacoemulsification were included. Primary outcome was the hazard ratio of failure of 45-μm gelatin microstent vs. 63-μm gelatin microstent eyes at 12 months, with failure defined as 2 consecutive IOPs, (1) >17 mmHg, (2) <6 mmHg with 2 lines of vision loss, or (3) <20% reduction from baseline IOP, without (complete) or with (qualified) glaucoma medications. Secondary outcomes included IOP thresholds of 14 mmHg and 21 mmHg, postoperative IOP, medications, adverse events, interventions, and reoperations. The complete success rate was higher in the 63-μm gelatin microstent group (59.5% vs. 28.6%, P=0.009) at the primary IOP threshold of 6 to 17 mmHg but did not differ significantly for qualified success (66.7% vs. 45.2%, P= 0.08). The crude hazard ratio of failure of 45-μm gelatin microstent relative to 63-μm gelatin microstent was 2.28 (95% confidence interval [CI], 1.21-4.32), and the adjusted hazard ratio was 7.90 (95% CI, 2.12-29.43). 63-μm gelatin microstent eyes had significantly lower mean IOP (12.7 ± 4.8 vs. 15.5 ± 5.1 mmHg, P= 0.001) and fewer medication classes (0.6 ± 1.1 vs. 1.7 ± 1.6 medications, P= 0.0005), with the degree of reduction in IOP and medication count being significantly greater in 63-μm gelatin microstent eyes. There were 28 and 21 distinct interventions in 63-μm gelatin microstent and 45-μm gelatin microstent eyes respectively, with 11.9% of eyes undergoing needling in each group. There were 34 and 19 distinct adverse events, in 63-μm gelatin microstent and 45-μm gelatin microstent eyes, respectively, most of which were early and transient. Nine Xen63 eyes (21.4%) and 6 45-μm gelatin microstent eyes (14.3%) underwent reoperation. 63-μm gelatin microstent resulted in higher surgical success rates and fewer medications compared with 45-μm gelatin microstent. This was tempered by more postoperative interventions and adverse events, although most were transient. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Glaucoma in Uveitic Eyes: Long-Term Clinical Course and Management Measures

ABSTRACT Background The management of glaucoma in uveitis is challenging. A meticulous combination of anti-glaucoma and anti-inflammatory agents is often needed to control the intraocular pressure (IOP) and preserve the visual status in an otherwise blinding disease. Aim To study the clinical course and management of glaucoma in uveitic eyes. Methods A retrospective study analyzing the case records of patients over 12 years, referred for the management of uveitic glaucoma in the last two decades. Results The analysis of 582 uveitic glaucoma eyes of 389 patients was done, and the mean IOP at baseline was 25.89 (±13.1) mmHg. Non-granulomatous uveitis (102 eyes) was the most common diagnosis. Granulomatous uveitis was the most common diagnosis among the treatment failure eyes and in eyes requiring more than one surgical intervention for glaucoma. Conclusion An appropriate and adequate combination of anti-inflammatory and IOP-lowering therapy will lead to better clinical outcomes.

Simvastatin Attenuates Glucocorticoid-Induced Human Trabecular Meshwork Cell Dysfunction via YAP/TAZ Inactivation

Purpose Impairment of the trabecular meshwork (TM) is the principal cause of increased outflow resistance in the glaucomatous eye. Yes-associated protein (YAP) and transcriptional coactivator with PDZ binding motif (TAZ) are emerging as potential mediators of TM cell/tissue dysfunction. Furthermore, YAP/TAZ activity was recently found to be controlled by the mevalonate pathway in non-ocular cells. Clinically used statins block the mevalonate cascade and were shown to improve TM cell pathobiology; yet, the link to YAP/TAZ signaling was not investigated. In this study, we hypothesized that simvastatin attenuates glucocorticoid-induced human TM (HTM) cell dysfunction via YAP/TAZ inactivation. Methods Primary HTM cells were seeded atop or encapsulated within bioengineered extracellular matrix (ECM) hydrogels. Dexamethasone was used to induce a pathologic phenotype in HTM cells in the absence or presence of simvastatin. Changes in YAP/TAZ activity, actin cytoskeletal organization, phospho-myosin light chain levels, hydrogel contraction/stiffness, and fibronectin deposition were assessed. Results Simvastatin potently blocked pathologic YAP/TAZ nuclear localization/activity, actin stress fiber formation, and myosin light chain phosphorylation in HTM cells. Importantly, simvastatin co-treatment significantly attenuated dexamethasone-induced ECM contraction/stiffening and fibronectin mRNA and protein levels. Sequential treatment was similarly effective but did not match clinically-used Rho kinase inhibition. Conclusions YAP/TAZ inactivation with simvastatin attenuates HTM cell pathobiology in a tissue-mimetic ECM microenvironment. Our data may help explain the association of statin use with a reduced risk of developing glaucoma via indirect YAP/TAZ inhibition as a proposed regulatory mechanism.

Association of superficial macular vessel density with visual field progression in open-angle glaucoma with central visual field damage

Identifying the clinical relevance of superficial versus deep layer macular vessel density (mVD) in glaucoma is important for monitoring glaucoma patients. Our current retrospective longitudinal study investigated the association of superficial and deep layer mVD parameters with glaucomatous visual field (VF) progression in mild to moderate open-angle glaucoma (OAG) eyes with central visual field (CVF) damage. Serial optical coherence tomography (OCT) angiography-derived mVD measurements were obtained in 182 mild to moderate OAG eyes (mean deviation ≥ -10 decibels). Forty-eight eyes (26.4%) showed VF progression during a mean follow-up of 3.5 years. The parafoveal and perifoveal mVDs of both superficial and deep layers showed significantly faster reduction rates in the VF progressors than in the non-progressors according to linear mixed effects models (P < 0.05). Cox and linear regression analyses showed that greater reduction rates of both the superficial layer parafoveal and perifoveal mVDs, but not their deep layer counterparts, were significant predictors of VF progression and faster VF loss (P < 0.05). In conclusion, faster rates of change in superficial but not deep layer mVD parameters are significantly associated with subsequent VF progression and faster VF deterioration in mild to moderate OAG eyes with CVF damage.

Commentary: The impact of yoga practice on glaucoma.

Yoga is the most popular form of complementary therapy being practiced to maintain one’s physical and mental wellbeing. While yoga traditionally comprises advice for ethical lifestyle and spiritual practice, it is most often associated with physical postures (asanas), breathing techniques (pranayama), and meditation (dhyana). While these exercises are routinely safe, there are risks involved for certain patients including those suffering from or at risk of glaucoma. The effects of yoga on intraocular pressure (IOP) have been found to be bidirectional, and the exact mechanisms are not yet fully understood. The authors have reviewed literature to study the effect of yoga on IOP and glaucoma. They have observed a reduction of IOP in patients of glaucoma through Jyoti tratak (candle meditation) and slow yoga breathing exercises and a rapid increase in IOP immediately after head-down posture yoga.[1] Tratak kriya is said to lead to contraction and relaxation of ciliary muscles, which may possibly increase the aqueous humor outflow and subsequently decrease the IOP.[2] Dada et al.[3] have evaluated the effect of yoga and meditation on IOP, quality of life, stress markers, neurotrophins, and gene expression in patients with primary open-angle glaucoma and found an improvement in all parameters. On the other hand, progressive glaucomatous optic neuropathy and field loss in patients who regularly practiced Sirsasana (Headstand) has also been identified.[1,4,5] Four yogasanas [Adho Mukha Savasana (downward-facing dog), Uttanasana (standing forward bend), Halasana (plough pose), and Viparita Karani (legs-up-the-wall)] showed a 20–73.7% increase in IOP in all study subjects.[1] Yoga with head-down positions was associated with a rapid rise in IOP in glaucoma and healthy eyes and with the body vertical, with a doubling of the IOP, remaining elevated as long as the position was maintained.[1] Mani Baskaran et al.[6] observed a twofold increase in IOP during Sirsasana, which was maintained during the posture in all age groups irrespective of their ocular characteristics. Valsalva maneuver is known to affect IOP; so it is expected that breath-holding yogic exercises are likely to cause IOP elevation. Forced unilateral nostril breathing has also been observed to affect IOP significantly.[7] Rakstyte et al.[8] studied an impact on IOP before, during, and after Matsyasana (fish yoga pose) and found an increased IOP in head- down position which returns to the initial value shortly after. A case series by Mehrdad Malihi et al.[9] to study the effect of different body and head positions on IOP shows a lower measurement while sitting with a neutral neck position and a rise in IOP in all other positions. Acute angle-closure glaucoma attacks often precipitated by prone-position yoga exercises suggest that this position probably increases pupillary block in “at risk” eyes by causing the lens to fall onto the iris, which has been the principle of the prone provocative test for decades. Certain questions, however, remain unanswered. It is unclear whether yoga has any sustained effects on the IOP and optic nerve. Further research is needed to fully comprehend the mechanisms by which yoga exerts its effects and determine the types, optimal duration, and frequency of yoga practice for glaucoma patients. Future studies are also warranted to ascertain whether yoga-associated IOP changes are associated with parallel changes in perimetry and nerve fiber thickness and changes in cerebrospinal fluid pressure, blood pressure in lamina cribrosa capillaries, and the ocular blood flow. It is difficult to establish direct causality between different yogic postures and glaucomatous progression, but in patients with pre-existing glaucomatous optic neuropathy, dramatic changes in IOP can definitely be harmful. Inquiring about the practice of yoga in cases of unexplained progression despite an apparently well-controlled IOP can, therefore, be an important consideration. Relaxation and meditative aspects of yoga may help to reduce stress and improve the overall well-being of an individual which can be indirectly beneficial. The key is to “keep the head above the heart at all times.” It is also important to note that yoga should not replace traditional glaucoma treatment but rather be practiced/advised as a complementary therapy and glaucoma patients should consult their healthcare provider before beginning any new exercise or relaxation program, including yoga.

Clinical outcomes and complications following intraocular lens exchange in the setting of an open or intact posterior capsule

To assess whether there are added risks when performing intraocular lens (IOL) exchange in the setting of an open posterior capsule (OPC) when compared with a closed posterior capsule (CPC) IOL exchange. Private practice, Los Angeles, California. Nonrandomized and unmasked retrospective chart review. Eyes undergoing IOL exchange solely to relieve optical symptoms, with open or intact posterior capsules, were included. Eyes undergoing IOL exchange due to IOL malposition or dislocation were excluded. Eyes with preexisting, uncontrolled glaucoma and inflammation and eyes with a visual potential worse than 20/40 (Snellen) were also excluded. The main outcome measures were the postoperative complications compared between the OPC and CPC groups. 90 eyes of 75 patients undergoing IOL exchange were included in this study; 38/90 eyes had an OPC, and 52/90 eyes had a CPC. 3/38 in the OPC group and 2/52 in the CPC group experienced worsening intraocular pressure control. 1/38 in the OPC group experienced chronic inflammation. 2/38 in the OPC group and 2/52 in the CPC group experienced cystoid macular edema. 1/52 in the CPC group experienced a retinal tear. Statistically or clinically significant differences in postoperative complications between the OPC and CPC groups were not found. In the hands of an experienced surgeon, IOL exchange with an OPC appear red to be just as safe as IOL exchange with a CPC; when deemed necessary, experienced surgeons may perform an IOL exchange safely in the presence of an OPC.

Relatively anterior lens position in primary angle-closure glaucoma eyes with long axial length.

To evaluate the refractive status and ocular biometric parameters in primary angle-closure glaucoma (PACG) eyes with different axial lengths (ALs). In total, 742 Chinese PACG subjects with complete ophthalmic examinations were enrolled. The refractive status was categorized as myopia (spherical equivalent [SE] ≤-0.5 D), emmetropia (-0.5 D < SE < +0.5 D), and hyperopia (SE ≥+0.5 D), whereas the AL was divided into short (AL <22.5 mm), regular (22.5 ≤ AL <23.5 mm), and long (AL ≥23.5 mm). The refractive status and ocular biometric parameters were compared among different AL groups. The mean AL of the PACG eyes was 22.53 ± 0.84 mm (range: 19.68-25.57 mm). The refractive status was significantly different among different AL groups (P < 0.001). Also, 92.6% of hyperopic PACG eyes showed AL <23.5 mm, and 19.0% of myopic PACG eyes showed AL ≥23.5 mm. The SE showed significant differences among different AL groups only in the hyperopic subjects (P = 0.012). The AL was significantly longer in myopic eyes (P < 0.001). The PACG eyes with longer AL exhibited lower keratometry, longer central anterior chamber depth and corneal diameter, and lens position and relative lens position closer to the anterior (P < 0.001). Axial hyperopia was common in PACG eyes, and axial myopia was not uncommon. Relatively anterior lens position could explain the occurrence of PACG in the eyes with long AL.

RISK FACTORS FOR DEVELOPMENT OF PHACOMORPHIC GLAUCOMA IN MATURE CATARACT - A HOSPITAL BASED STUDY, JHANSI

Aim:To study the roles of axial length and anterior chamber depth as risk factors for the development of phacomorphic glaucoma in eyes with mature cataract. Material and Methods: This is a prospective case-control study done in the year 2023 at Department of Ophthalmology, MLB Medical College, Jhansi. Phacomorphic glaucoma was diagnosed by Intraocular Pressure of more than 21 mmHg, intumescent cataract with signs and symptoms of phacomorphic glaucoma, axial length and anterior chamber depth.All patients examined by slit lamp examination . Results: The Mean Intra ocular pressure of phacomorphic glaucoma was 49±8 mmHg and of mature cataract was 15±6 mmHg. Vision was Light perception in phacomorhic glaucoma and Hand movement observed was mature cataract. The mean axial length was 23.08±0.32mmHg among phacomorphic glaucoma, shorter than mature cataract, where the mean axial length was 23.71±0.78mm. Conclusion:Patients with shorter axial lengths are at increased risk for phacomorphic glaucoma.