Pigmented Trabecular Meshwork Research Articles

Long-Term Efficacy of Selective Laser Trabeculoplasty in Primary Angle-Closure Disease After Laser Peripheral Iridotomy

ABSTRACT Purpose To evaluate the long-term efficacy of selective laser trabeculoplasty (SLT) in eyes with primary angle-closure (PAC) and primary angle-closure glaucoma (PACG) following a laser peripheral iridotomy (LPI). Method In this prospective cross-sectional study, 45 eyes of 34 patients with PAC/PACG diagnosis, uncontrolled intraocular pressure (IOP), and visible pigmented trabecular-meshwork (TM) at least 180° on gonioscopy following a LPI were recruited. Following a detailed baseline ophthalmic evaluation, all eligible eyes underwent SLT, and the patients were examined on day1, at 1 week, 1-, 3-, and 6-months, and 1-, 2-, 3-, 4-, and 5-year subsequently. The main outcomes measured were IOP, number of IOP-lowering agents, and complications. Results The mean age of the cohort was 57.80 ± 6.44 years, the male–female ratio was 8:26, and 17 eyes were PACG, and 28 were PAC. The baseline IOP was 23.81 ± 1.78 mm Hg, and was significantly declined at all follow-ups (p < .0001). The cumulative probability of overall success was 91% and 84% at 2-, and 5-year, respectively. At 5-year SLT provided drug-freedom in 80% of PAC and 23% of PACG eyes. Six eyes had IOP spike at 1-week and two patients underwent repeat SLT after 1-year. No other complications, such as pain/discomfort, inflammation, an increase in peripheral anterior synechiae and cystoid-macular-edema, were noted. Conclusions SLT appears a safe and cost-effective procedure in PAC/mild- moderate PACG eyes with uncontrolled IOP after laser iridotomy. The long-term effectiveness of SLT as adjuvant treatment was good, but need large sized randomized studies for more validation.

Effect of Preoperative Trabecular Meshwork Pigmentation and Other Eye Characteristics on Outcomes of Combined Phacoemulsification/Minimally Invasive Glaucoma Surgery

PurposeTo investigate associations between pigmentation of the trabecular meshwork (PTM) and other preoperative eye characteristics and outcomes of minimally invasive glaucoma surgery combined with phacoemulsification (Phaco/MIGS). DesignRetrospective interventional case series. ParticipantsAcademic glaucoma clinic patients with symptomatic cataract and glaucoma treated with combined Phaco/MIGS. MethodsAnalyzing preoperative PTM, intraocular pressure (IOP), IOP-lowering medications and visual acuity (VA) data in relation to Phaco/MIGS outcomes. Main Outcome MeasuresPTM and other preoperative eye characteristics in relation to Phaco/MIGS success defined as postoperative IOP between 5-21 mmHg and IOP reduction of ≥20% and/or a reduction of ≥1 IOP-medications compared to baseline, and final IOP, IOP-lowering medications and VA. Results265 eyes (172 patients, mean age, 73.5 [SD, 10.0], range 35-95 years, male 40.0%) were identified and categorized with high PTM (108 eyes, 40.8%) or low PTM (157 eyes, 59.2%). The high PTM group, compared with the low PTM group, demonstrated higher preoperative IOP (16.7 [SE 0.4] vs. 15.2 [0.4] mmHg, p=0.009), included more eyes with primary open-angle glaucoma (POAG, p=0.03), fewer eyes with normal-tension glaucoma (NTG, p=0.01), and fewer eyes with mild stage glaucoma (p=0.001). Compared to baseline, final IOP decreased by 6.5 [2.4]% and 13.4 [3.0]% (p=0.075) to 13.5 [0.3] mmHg and 13.6 [0.4] mmHg (p=0.77) in the low and high PTM groups, respectively, and IOP-lowering medications decreased by 34.6 [4.9]% (n=116) and 18.1 [7.3]% (n=85), respectively (p=0.062). Surgical success was 59.9% and 58.3%, respectively (p=0.87). It was positively associated with higher preoperative IOP (Hazard Ratio 1.08 [95% CI 1.04-1.12] p<0.0001) and higher number of preoperative IOP-medications (1.20 [1.05-1.37] p=0.007), negatively associated with history of Selective Laser Trabeculoplasty (SLT, 0.40 [0.23-0.68] p=0.0009) and longer axial length (0.87 [0.80-0.94], p=0.0006), but was not associated with PTM. ConclusionsHigher PTM was associated with POAG rather than NTG, with more severe glaucoma and higher preoperative IOP, but not with Phaco/MIGS success. Surgical success was positively associated with higher preoperative IOP and number of IOP-medications and negatively associated with history of SLT and longer axial length. These findings may help guide glaucoma surgeons in surgical planning and patient counselling.

Clinical spectrum and management of pseudoexfoliation syndrome: A cross-sectional study

Background: Pseudoexfoliation is one of the most common causes of secondary open-angle glaucoma worldwide. The current investigation is being carried out to investigate the clinical characteristics associated with pseudoexfoliation syndrome. Aims and Objectives: The current study was conducted with the goal of documenting the prevalence of the ocular clinical profile of patterns in patients with pseudo-exfoliative material attending a tertiarycare hospital’s general ophthalmology outpatient department. Materials and Methods: In the current study, 100 individuals were explored who were diagnosed with pseudoexfoliation and attended the outpatient department of ophthalmology, medical college, and hospital. The Snellen chart for visual acuity was used to test visual acuity. Pseudoexfoliation glaucomawas identified based on slit lamp examination of pseudoexfoliative material, intraocular pressure (IOP) &gt;21 mmHg, glaucomatous cupping on fundus examination, pigmentation of trabecular meshwork on gonioscopy, and glaucomatous field abnormalities on perimetry. Results: The age range of 61–70 years had the most cases of pseudoexfoliation, accounting for 23, followed by 51–60 years with 17 occurrences. The current study comprised 48 patients, 20 of whom had bilateral pseudoexfoliation and 28 of whom had unilateral pseudoexfoliation. Our findings revealed that 17 patients had high IOP. We discovered 15 cases of open-angle glaucoma and 2 cases of narrow-angle glaucoma after analyzing 48 patients. The sample of 15 individuals with open-angle glaucoma included 11 men and 4 women. Conclusion: Pseudoexfoliation becomes more common as people age, and it is often unilateral at first but progressively progresses to bilateral pseudoexfoliation, necessitating frequent follow-up in unilateral cases. Pseudoexfoliation is associated with an increased risk of glaucoma, and the majority of cases have open angles.

Lack of Correlation Between Segmental Trabecular Meshwork Pigmentation and Angiographically Determined Outflow in Ex Vivo Human Eyes.

Trabecular meshwork (TM) pigmentation is not correlated with angiographically determined aqueous humor outflow (AHO) in an ex vivo perfusion model using human eyes. To evaluate whether segmental TM pigmentation is correlated to segmental AHO in human eyes. Postmortem human eyes were acquired, and anterior segments were dissected. TM pigmentation was photographed 360-degrees around the eye. The anterior segments were then mounted onto a perfusion apparatus and perfused with Dulbecco's phosphate buffered saline (DPBS) until a stabile baseline outflow facility was achieved. Aqueous angiography (AHO angiography) was performed using fluorescein (2%), and segmental AHO was documented around the limbus using an angiographic camera (Spectralis HRA+OCT). Circumferential and nasal TM pigmentation were compared with respective angiographic outflow imaging using a Pearson correlation analysis. Segmental TM pigment distribution and segmental AHO were seen. TM pigment was statistically greatest in the inferior quadrant. AHO angiographic outflow was numerically greatest in the nasal quadrant, but this was not statistically significant. No statistically significant correlation was observed (r=-0.083, P =0.06) between segmental TM pigmentation and segmental AHO angiographic signal. Analyzing just the nasal quadrant, a significant weak negative correlation was found (r=-0.296, P =0.001). Segmental TM pigmentation circumferentially around the eye is not a good proxy for segmental AHO circumferentially around the eye and should not be used to guide trabecular minimally invasive glaucoma surgeries.

Assessment of the iridocorneal angle pigmentation and structures after the implantation of EVO+ Visian Implantable Collamer Lens.

To evaluate the effect of EVO+ Visian Implantable Collamer Lens (ICL) implantation on the iridocorneal angle pigmentation and structures. Myopic refractive surgery candidates who underwent posterior chamber EVO+ ICL implantation were evaluated preoperatively and 3 and 6months postoperatively. High-resolution images of the iridocorneal angle (nasal, superior, temporal and inferior quadrants) were acquired during gonioscopy. A masked observer, blinded to study visits and patients' information, evaluated the angle width, apparent iris root insertion, iris configuration, and trabecular meshwork pigmentation according to the Spaeth scale in two different occasions. The intra-rater reliability was estimated using the weighted Gwet's Agreement Coefficient (AC2). Differences between visits were analyzed using the Cochran Q test or the Friedman test. Twenty-one patients (13 females and 8 males) aging 31.3 ± 6.3years old were recruited. The intra-rater reliability of gonioscopy assessment was excellent for every parameter assessed (AC2 ≥ 0.97). No significant differences were found among the study visits for any quadrant in the angle width (p ≥ 0.74), apparent iris root insertion (p ≥ 0.22), iris configuration (p ≥ 0.21) and trabecular meshwork pigmentation (p ≥ 0.24). Mean pigmentation of trabecular meshwork for the four quadrants did not vary either among visits (p = 0.25). The EVO+ ICL implantation after uneventful procedures appears not to clinically affect the iridocorneal angle pigmentation and/or structures during a short-medium follow-up using gonioscopy assessment. The intra-rater reliability of glaucoma specialists assessing iridocorneal angle structures using gonioscopy images is very high.

Use of Digital Methods to Optimize Visualization during Surgical Gonioscopy.

Purpose: The aim of this study was to evaluate the efficacy of digital visualization for enhancing the visualization of iridocorneal structures during surgical gonioscopy. Methods: This was a prospective, single-center study on a series of 26 cases of trabecular stent implantation performed by the same surgeon. Images were recorded during surgical gonioscopy, and before stent implantation, with standard colors and with the optimization of various settings, principally color saturation and temperature and the use of the cyan color filter. Subjective analyses were performed by two glaucoma surgeons, and objective contrast measurements were made on iridocorneal structure images. Results: The surgeons evaluating the images considered the optimized digital settings to produce enhanced tissue visibility for both trabecular meshwork pigmentation and Schlemm's canal in more than 65% of cases. The mean difference in the standard deviation of the pixel intensity values was 37.87 (±4.61) for the optimized filter images and 32.37 (±3.51) for the standard-color images (p < 0.001). The use of a cyan filter provided a good level of contrast for the visualization of trabecular meshwork pigmentation. Increasing the color temperature highlighted the red appearance of Schlemm's canal. Conclusions: We report here the utility of optimized digital settings including the cyan filter and a warmer color for enhancing the visualization of iridocorneal structures during surgical gonioscopy. These settings could be used in surgical practice to enhance the visualization of the trabecular meshwork and Schlemm's canal during minimally invasive glaucoma surgery.

Surgical decisions in the setting of zonulopathy.

An 85-year-old man with a history of type 2 diabetes, pseudoexfoliation (PXF) in both eyes, and tamsulosin use was referred for the evaluation of a dense cataract in the right eye and a subluxated intraocular lens (IOL) in the left eye. Unfortunately, his surgery in the left eye was complicated by diffuse zonulopathy. The referring surgeon placed a 3-piece IOL in the sulcus. However, the passively fixated 3-piece IOL moved inferiorly causing monocular diplopia for over a year. Because the patient was pleased with the IOL immediately postoperatively, a refixation procedure was performed in the form of sulcus placement with iris suture fixation in the left eye. Fortunately, the iris-fixated IOL in the left eye has remained well centered and stable without cystoid macular edema (CME) or chronic inflammation for over 8 months. The patient is on no ocular medications and has no family history of glaucoma. He now needs cataract surgery in the right eye and is extremely apprehensive because of his difficult course in the left eye. The corrected distance visual acuity is 20/70 in the right eye and 20/25 in the left eye. Intraocular pressures (IOPs) measure 20 mm Hg in the right eye and 14 mm Hg in the left eye by Goldmann tonometry. Pachymetry is 536 µm in the right eye and 543 µm in the left eye. Pupils are round with minimal reactivity and without a relative afferent pupillary defect. Extraocular motility is normal in both eyes, and confrontation visual fields is full in both eyes. Gonioscopy reveals an angle open to the pigmented trabecular meshwork (PTM) in the right eye and the ciliary body in the left eye with 1+ PTM and without peripheral anterior synechia in both eyes. The retinal nerve fiber layer and macular optical coherence tomography are normal in both eyes. On slitlamp examination, pertinent findings include pseudoexfoliative changes at the pupillary margin with poor dilation of 3.5 mm in both eyes; the anterior chamber (AC) is shallow but adequate in the right eye and deep and quiet with rare pigmented cells in the left eye. There is a 5+ nuclear sclerotic cataract with pseudoexfoliative changes on the anterior capsule and no obvious phacodonesis in the right eye and a 3-piece posterior chamber IOL in the sulcus fixated to the iris with 10-0 polypropylene sutures at 6 and 12 o'clock without pseudophacodonesis in the left eye. Dilated fundus examination reveals a cup-to-disc ratio of 0.4 with healthy neuroretinal rims in both eyes, posterior vitreous detachments in both eyes, and no evidence of diabetic retinopathy in both eyes. All other findings are unremarkable. How would you counsel this patient regarding his risk factors for surgery in the right eye? What surgical maneuvers would you use to remove the cataract safely? How would you stabilize the IOL if the capsule bag becomes compromised due to zonulopathy?

A Case of Optic Disc Pigmentation in a Nevus of Ota Patient

Purpose: To report a case of optic disc pigmentation in a nevus of Ota patient.Case summary: A 56-year-old female was referred to our clinic with suspected glaucoma in the left eye. She had no previous history of ocular surgery or treatment. The best corrected visual acuity and intraocular pressure were 0.7 and 15 mmHg in both eyes, respectively. Slit lamp microscopy demonstrated nevus of Ota in the right sclera and increased iris pigmentation. Gonioscopy demonstrated increased trabecular meshwork pigmentation in the right eye. Fundus examination showed pigmentation of the choroid and optic disc in the right eye; choroidal thickness of the right eye was greater than that of the left eye on optical coherence tomography. However, there were no glaucomatous changes in the right eye. There were no specific findings in the left eye.Conclusions: To the best of our knowledge, this was the first reported case of optic disc pigmentation in a Korean nevus of Ota patient.

Morphological changes in the iridocorneal angle and their relationship with intraocular pressure after infantile cataract surgery.

To evaluate morphological changes in the iridocorneal angle after pediatric cataract surgery. Children who underwent primary infantile cataract surgery were included and 64 eyes from 41 children, including 18 with unilateral cataracts (18 eyes) and 23 with bilateral cataracts (46 eyes) were examined. All patients underwent two gonioscopic examinations to evaluate the iridocorneal angle, before the primary lens removal and before the secondary intraocular lens implantation. The anatomical changes in the iridocorneal angle and the relationship between intraocular pressure (IOP) and iridocorneal angle changes were also analyzed. The iridocorneal angle was wide in 64 eyes before and after surgery. The trabecular meshwork pigmentation, number of iris processes in every quadrant of the iridocorneal angle, and the width of the ciliary body band in the superior and inferior quadrants at the second gonioscopic examination were significantly increased compared to those at the first examination (P<0.001, P<0.05, P<0.05, and P<0.05, respectively). IOP gradually increased at 1mo after operation, and returned to the preoperative level at 3mo. However, IOP still increased significantly at 6 and 12mo. The main changes after pediatric cataract surgery include an increase in trabecular meshwork pigmentation and number of iris processes, IOP gradually increase and has positive correlation with trabecular meshwork pigmentation and anterior insertion of iris process.

Energy Dose-Response in Selective Laser Trabeculoplasty: A Review.

Précis:A literature review of selective laser trabeculoplasty (SLT) energy dose-response found no definitive relationship between intraocular pressure (IOP) reduction with respect to total or pulse energy, race, pigmentation, or application pattern.Purpose:SLT is a safe and effective treatment for lowering IOP. Although evidence is mounting for the advantage of its use as a first-line treatment for IOP reduction, the SLT procedures in use vary widely. The purpose of this literature review was to investigate whether there were any relationships between SLT energy and efficacy for lowering IOP in the published literature.Methods:A literature review was undertaken that included studies in which energy levels required for successful SLT treatment were investigated: in general, with respect to angle pigmentation, race or ethnicity, and treatment arc extent.Results:There was no indication that higher (or lower) energy used in the treatment leads to greater (or less) IOP reduction. Similar results were obtained regarding the level of trabecular meshwork pigmentation. Race was not found to be associated with altered dose response in SLT. There were indications that treating the full 360 degrees, as opposed to smaller arcs, could be beneficial for more IOP reduction. IOP reduction from SLT was found to be similar to that provided by topical medications.Conclusions:The optimal energy level of SLT needed for IOP reduction has not yet been definitively established, with all reported pulse energies resulting in similar IOP reduction. Furthermore, similar lack of conclusive findings exists regarding optimal SLT energy dosage for use in different races and degrees of trabecular meshwork pigmentation. This parameter and each of the abovementioned factors requires further research.

Optimal number and orientation of anterior segment OCT images to measure ocular biometric parameters in angle closure eyes: the Chinese American Eye Study

PurposeTo assess the optimal number and orientation of anterior segment optical coherence tomography (AS-OCT) images for accurately measuring ocular biometric parameters in angle closure eyes.MethodsSubjects with angle closure, defined as...

Pseudoexfoliation Glaucoma and its Systemic Association: A Clinical Study

Pseudoexfoliation [PXF] being a age related elastotic process is a well known entity among all ophthalmologists. PXF is most common form of secondary glaucoma.&#x0D; Objective: To study the clinical presentations and response to treatment of PXF glaucoma and also to throw light on its systemic associations.&#x0D; Methods: A total of 70 eyes of PXF glaucoma was considered for the study in duration of 6 months from june to November 2021 at a tertiary care center. All patients underwent detailed ophthalmic evaluation along with gonioscopy, optic disc assessment, visual fields and intraocular pressure. Based on all these , patients were graded as mild, moderate and advanced glaucoma and treated accordingly either with medical or surgical line of management. Patients were followed up for a duration of 6 months. ECG, echocardiography and dermatological evaluation of all the patients were done.&#x0D; Results: Mean age of 70 patients was 52.2 years and there was male preponderance .Powdery greyish white pseudoexfoliative material on pupillary margin was seen in 41 eyes[58.5%] and on anterior capsule was seen in 19 eyes[27.1%]. IOP in these 70 patients ranged between 14 to 40mmHg. Gonioscopy showed exfoliative material deposition in 14 eyes[20%] and increased pigmentation of trabecular meshwork in 44 eyes[62.85%]. Also, it revealed narrow angle( grade 1&amp;2) in 6 eyes and open angle (grade 3&amp;4) in rest .Visual filed changes were present in 57 of 70 eyes with PXF glaucoma. Optic disc changes in PXF glaucoma also showed variations with 17 eyes having CD ratio of&lt;0.5,while 38 eyes had a cupping between 0.6-0.8. Eleven eyes showed advanced cupping of &gt;0.8 while 4 eyes had glaucomatous optic atrophy.60 eyes were treated with medical line while 10 eyes were managed surgically. 4 patients had dermal nodules and diastolic dysfunction was noted in 31 patients.&#x0D; Conclusion: PXF confers a significantly higher risk of developing glaucoma in comparison with the general population and needs close monitering. PXF glaucoma and its systemic associations also has to be considered &#x0D; Keywords: PXF, pseudoexfoliative, ECG

Ocular Biometric Risk Factors for Progression of Primary Angle Closure Disease: The Zhongshan Angle Closure Prevention Trial

To assess baseline ocular biometric risk factors for progression from primary angle closure suspect (PACS) to primary angle closure (PAC) or acute angle closure (AAC). Prospective, observational study. Six hundred forty-three mainland Chinese with untreated PACS. Participants underwent baseline clinical examinations, including gonioscopy, anterior segment OCT (AS-OCT) imaging, and A-scan ultrasound biometry as part of the Zhongshan Angle Closure Prevention (ZAP) Trial. Primary angle closure suspect was defined as an inability to visualize pigmented trabecular meshwork in 2 or more quadrants based on static gonioscopy. Primary angle closure was defined as development of intraocular pressure above 24 mmHg or peripheral anterior synechiae. Progression was defined as development of PAC or an AAC attack. Multivariable logistic regression models were developed to assess biometric risk factors for progression. Six-year progression from PACS to PAC or AAC. Six hundred forty-three untreated eyes (609 nonprogressors, 34 progressors) of 643 participants were analyzed. In a multivariable model with continuous parameters, narrower horizontal angle opening distance of 500 μm from the scleral spur (AOD500; odds ratio [OR], 1.10 per 0.01-mm decrease; P= 0.03), flatter horizontal iris curvature (IC; OR, 1.96 per 0.1-mm decrease; P= 0.01), and older age (OR, 1.11 per 1-year increase; P= 0.01) at baseline were associated significantly with progression (area under the receiver operating characteristic curve [AUC], 0.73). Smaller cumulative gonioscopy score was not associated with progression (OR, 1.03 per 1-modified Shaffer grade decrease; P= 0.85) when replacing horizontal AOD500 in the multivariable model. In a separate multivariable model with categorical parameters, participants in the lowest quartile of horizontal AOD500 (OR, 3.10; P= 0.002) and IC (OR, 2.48; P= 0.014) measurements and 59 years of age or older (OR, 2.68; P= 0.01) at baseline showed higher odds of progression (AUC, 0.72). Ocular biometric measurements can help to risk-stratify patients with early angle closure for more severe disease. Anterior segment OCT measurements of biometric parameters describing the angle and iris are predictive of progression from PACS to PAC or AAC, whereas gonioscopy grades are not.

Digital Gonioscopy Based on Three-dimensional Anterior-Segment OCT: An International Multicenter Study

To develop and evaluate the performance of a 3-dimensional (3D) deep-learning-based automated digital gonioscopy system (DGS) in detecting 2 major characteristics in eyes with suspected primary angle-closure glaucoma (PACG): (1) narrow iridocorneal angles (static gonioscopy, Task I) and (2) peripheral anterior synechiae (PAS) (dynamic gonioscopy, Task II) on OCT scans. International, cross-sectional, multicenter study. A total of 1.112 million images of 8694 volume scans (2294 patients) from 3 centers were included in this study (Task I, training/internal validation/external testing: 4515, 1101, and 2222 volume scans, respectively; Task II, training/internal validation/external testing: 378, 376, and 102 volume scans, respectively). For Task I, a narrow angle was defined as an eye in which the posterior pigmented trabecular meshwork was not visible in more than 180° without indentation in the primary position captured in the dark room from the scans. For Task II, PAS was defined as the adhesion of the iris to the trabecular meshwork. The diagnostic performance of the 3D DGS was evaluated in both tasks with gonioscopic records as reference. The area under the curve (AUC), sensitivity, and specificity of the 3D DGS were calculated. In Task I, 29.4% of patients had a narrow angle. The AUC, sensitivity, and specificity of 3D DGS on the external testing datasets were 0.943 (0.933-0.953), 0.867 (0.838-0.895), and 0.878 (0.859-0.896), respectively. For Task II, 13.8% of patients had PAS. The AUC, sensitivity, and specificity of 3D DGS were 0.902 (0.818-0.985), 0.900 (0.714-1.000), and 0.890 (0.841-0.938), respectively, on the external testing set at quadrant level following normal clinical practice; and 0.885 (0.836-0.933), 0.912 (0.816-1.000), and 0.700 (0.660-0.741), respectively, on the external testing set at clock-hour level. The 3D DGS is effective in detecting eyes with suspected PACG. It has the potential to be used widely in the primary eye care community for screening of subjects at high risk of developing PACG.

Changes of trabecular meshwork pigmentation in patients with pigment dispersion syndrome: A 15-year study.

To report the changes of trabecular meshwork (TM) pigmentation and clinical outcomes of patients with pigment dispersion syndrome (PDS) after resolution of reverse pupillary block.Twenty one eyes of 11 PDS patients were followed up periodically for 15 years after resolution of reverse pupillary block with either Nd: YAG laser peripheral iridotomy (LPI) or trabeculectomy. Visual acuity (VA), best-corrected visual acuity (BCVA), slit lamp examination, intraocular pressure (IOP), Humphrey visual field analysis (VFA), gonioscopy and stereoscopic funduscopy were performed on admission and every 6 months postoperatively. TM pigmentation was quantitatively evaluated and graded every 5 years after the treatment, in which the circumference of anterior chamber angle was divided into 4 quadrants: superior, inferior, nasal and temporal. Postoperative IOP, VA, BCVA, VFA, TM pigmentation and adjunctive anti-glaucoma medications were main outcome measurements and compared with baseline.Eleven patients (9 males, 2 females) were identified as PDS according to the diagnostic criteria, with average age of 38.25 ± 6.93 years (range, 31–55 years) at initial diagnosis. The mean IOP level was 33.1 ± 9.8 mmHg (range, 22–56 mmHg) at diagnosis. Ten PDS eyes received LPI, and the other eleven eyes underwent uneventful trabeculectomy. The median TM pigmentation score of the 21 PDS eyes was 16 (interquartile range [IQR], 15–16) on admission, which changed to 14 (IQR, 13–15), 13 (IQR, 12–14), 12(IQR, 10.5–12) at 5-, 10-, 15-year follow-up visits respectively. The decrease rate of TM pigmentation was 37% in inferior quadrant, while in nasal, temporal, and superior quadrant the reduction rate was 28%, 23%, and 18%, respectively, at the last follow-up visit. Majority of these enrolled eyes (19/21) had stable VA and BCVA with average endpoint IOP of 15.1 ± 3.4 mmHg.TM pigmentation in PDS patients attenuates with time after reverse pupillary block was resolved, in which the inferior quadrant seems faster than the other quadrants.

Selective Laser Trabeculoplasty in the Treatment of Ocular Hypertension and Open-Angle Glaucoma: Clinical Review.

Selective laser trabeculoplasty (SLT) is a glaucoma treatment that reduces intraocular pressure (IOP). Its mechanism is based on the biological effects of the selective application of laser energy to pigmented trabecular meshwork (TM) cells, resulting in increased outflow facility. Herein, we review current publications on SLT and summarize its efficacy and safety for different indications in open-angle glaucoma (OAG) and ocular hypertension (OHT) treatment. SLT effectively reduces IOP when used as a primary treatment. In patients whose IOP is medically controlled, SLT helps to reduce medication use, and when maximally tolerated topical therapy is ineffective, SLT facilitates the realization of the target IOP. SLT is a repeatable procedure for which the vast majority of complications are mild and self-limiting. With effective IOP reduction, low complication rates and the potential to repeat the procedure, SLT offers the possibility of delaying the introduction of medical therapy and other more invasive treatment modalities while simultaneously avoiding the accompanying complications. With this knowledge, we suggest that SLT be considered as an essential primary treatment option in OAG and OHT, switching to other treatment modalities only when laser procedures are insufficient for achieving the required target IOP.

Spontaneous filtering bleb with subsequent secondary glaucoma June consultation #1.

A 32-year-old previously healthy woman was referred for evaluation and management of newly diagnosed hypotony in the right eye. Her ocular history was significant only for moderate myopia and an idiopathic Horner syndrome in the left eye diagnosed at age 13. The patient endorsed a history of fluctuating and decreasing vision in the right eye over the past 6 months. She denied any ocular pain, previous ocular surgery, or recent trauma. The patient was otherwise healthy and denied any previous autoimmune disease or systemic infection. She wore soft, daily disposable contact lenses and reported no abnormalities on previous routine eye examinations. At presentation, the patient's uncorrected distance visual acuity was 20/25 in the right eye and 20/200 in the left. Lensometry revealed a previous refraction of -3.00 + 0.50× 150 in the right eye and -4.00 + 1.75× 174 in the left. Intraocular pressures (IOPs) were 4 mm Hg and 15 mm Hg by applanation, and central corneal thicknesses were 573 μm and 564 μm in the right and left eyes, respectively. Slitlamp examination revealed an area of scleral thinning near the limbus in the right eye from 5 to 7 o'clock with mild overlying chemosis (Figure 1JOURNAL/jcrs/04.03/02158034-202107000-00023/figure1/v/2021-06-26T110826Z/r/image-tiff). Gonioscopy showed an open angle with mild trabecular meshwork pigmentation in both eyes without any cyclodialysis clefts, peripheral anterior synechiae (PAS), or other abnormalities. Dilated fundus examination was significant for mild optic nerve edema and chorioretinal folds in the right eye. Optical coherence tomography (OCT) of the optic nerve confirmed mild disc edema (Figure 2JOURNAL/jcrs/04.03/02158034-202107000-00023/figure2/v/2021-06-26T110826Z/r/image-tiff) and OCT of the macula confirmed mild chorioretinal folds. Anterior segment OCT (AS-OCT) and ultrasound biomicroscopy failed to show any other abnormalities. The patient was initially observed without treatment and presented urgently approximately 1 month later with decreased vision and ocular discomfort. Repeat examination revealed an IOP of 31 mm Hg and a focal area of PAS to the previous area of scleral thinning (Figure 3JOURNAL/jcrs/04.03/02158034-202107000-00023/figure3/v/2021-06-26T110826Z/r/image-tiff). In one respect, the newly elevated IOP was considered transiently therapeutic to help reverse the hyperopic shift, disc edema, and hypotony-related maculopathy. However, the situation quickly became more worrisome when shortly thereafter the IOP elevated to 55 mm Hg at subsequent follow-up, and multiple IOP-lowering medications were initiated. Over numerous additional visits, the patient's IOPs ranged from 30 to 39 mm Hg in the right eye despite rapidly advancing to maximally tolerated medical therapy including acetazolamide. She was noted to have a new relative afferent pupillary defect of the right eye, and Humphrey visual fields showed early arcuate defects (Figure 4JOURNAL/jcrs/04.03/02158034-202107000-00023/figure4/v/2021-06-26T110826Z/r/image-tiff). What would be your approach to managing this healthy, young, myopic woman who presented with hypotony due to a spontaneous, perilimbal filtration bleb that later occluded with PAS, resulting in intractably elevated IOP and field loss? What is the differential diagnosis? Would you perform a systemic workup for her initial scleral thinning, and if so, what would you check? Would you intervene for her elevated IOP in the right eye? If so, what would be your surgical approach?

A TYPICAL CASE OF PIGMENTARY GLAUCOMA

Pigment dispersion syndrome and pigmentary glaucoma are conditions characterized by pigment dispersion originating from the posterior part of the iris and its accumulation on the trabecular meshwork, corneal endothelium, and anterior surface of the lens. The pigment on the trabecular meshwork can cause chronic inflammation with a secondary reduction of its function and an increase in intraocular pressure. The case presented represents a typical example of pigmentary glaucoma in a myopic patient in which signs, symptoms, and complications typical of these pathologies were present. We report and describe a case in which the patient presented with complaints of progressive decrease in vision of two year duration. The patient also had myopia with classical signs of PDS like Krukenberg's spindle on the posterior corneal surface were evident on slit lamp examination; transillumination defects in the iris could not be elicited by retroillumination as the iris was heavily pigmented. Gonioscopy revealed heavy and uniform pigmentation of trabecular meshwork. Patient was follow-up for a period of 6 months with clinical and instrumental examinations.

Glaucoma Expert-Level Detection of Angle Closure in Goniophotographs With Convolutional Neural Networks: The Chinese American Eye Study

To compare the performance of a novel convolutional neural network (CNN) classifier and human graders in detecting angle closure in EyeCam (Clarity Medical Systems, Pleasanton, California, USA) goniophotographs. Retrospective cross-sectional study. Subjects from the Chinese American Eye Study underwent EyeCam goniophotography in 4 angle quadrants. A CNN classifier based on the ResNet-50 architecture was trained to detect angle closure, defined as inability to visualize the pigmented trabecular meshwork, using reference labels by a single experienced glaucoma specialist. The performance of the CNN classifier was assessed using an independent test dataset and reference labels by the single glaucoma specialist or a panel of 3 glaucoma specialists. This performance was compared to that of 9 human graders with a range of clinical experience. Outcome measures included area under the receiver operating characteristic curve (AUC) metrics and Cohen kappa coefficients in the binary classification of open or closed angle. The CNN classifier was developed using 29,706 open and 2,929 closed angle images. The independent test dataset was composed of 600 open and 400 closed angle images. The CNN classifier achieved excellent performance based on single-grader (AUC=0.969) and consensus (AUC=0.952) labels. The agreement between the CNN classifier and consensus labels (κ=0.746) surpassed that of all non-reference human graders (κ=0.578-0.702). Human grader agreement with consensus labels improved with clinical experience (P=0.03). A CNN classifier can effectively detect angle closure in goniophotographs with performance comparable to that of an experienced glaucoma specialist. This provides an automated method to support remote detection of patients at risk for primary angle closure glaucoma.

Anatomic Changes and Predictors of Angle Widening after Laser Peripheral Iridotomy: The Zhongshan Angle Closure Prevention Trial

To assess anatomic changes after laser peripheral iridotomy (LPI) and predictors of angle widening based on anterior segment (AS) OCT and angle opening based on gonioscopy. Prospective observational study. Primary angle-closure suspects (PACSs) 50 to 70 years of age. Participants of the Zhongshan Angle Closure Prevention (ZAP) Trial underwent gonioscopy and AS-OCT imaging at baseline and 2 weeks after LPI. Primary angle-closure suspect was defined as the inability to visualize pigmented trabecular meshwork in 2 or more quadrants on static gonioscopy. Laser peripheral iridotomy was performed on 1 eye per patient in superior (between 11 and 1 o'clock) or temporal or nasal locations (at or below 10:30 or 1:30 o'clock). Biometric parameters in horizontal and vertical AS-OCT scans were measured and averaged. Linear and logistic regression modeling were performed to determine predictors of angle widening, defined as change in mean angle opening distance measured at 750 μm from the scleral spur (AOD750); poor angle widening, defined as the lowest quintile of change in mean AOD750; and poor angle opening, defined as residual PACS after LPI based on gonioscopy. Anatomic changes and predictors of angle widening and opening after LPI. Four hundred fifty-four patients were included in the analysis. Two hundred nineteen underwent superior LPI and 235 underwent temporal or nasal LPI. Significant changes were found among most biometric parameters (P < 0.006) after LPI, including greater AOD750 (P < 0.001). One hundred twenty eyes (26.4%) showed residual PACS after LPI. In multivariate regression analysis, superior LPI location (P= 0.004), smaller AOD750 (P < 0.001), and greater iris curvature (P < 0.001), were predictive of greater angle widening. Temporal or nasal LPI locations (odds ratio [OR], 2.60, P < 0.001) was predictive of poor angle widening. Smaller mean gonioscopy grade (OR, 0.34, 1-grade increment) was predictive of poor angle opening. Superior LPI location results in significantly greater angle widening compared with temporal or nasal locations in a Chinese population with PACS. This supports consideration of superior LPI locations to optimize anatomic changes after LPI.