Preexisting Glaucoma Research Articles

Glaucoma in Modified Osteo-odonto-keratoprosthesis Eyes: Role of Additional Stage 1A and Ahmed Glaucoma Drainage Device–Technique and Timing

To report the technique, timing, and outcomes of the Ahmed glaucoma drainage device in eyes with the modified osteo-odonto-keratoprosthesis (MOOKP) and the role of an additional stage 1A to the Rome-Vienna protocol. Retrospective interventional case series. Case records of 22 eyes of 20 patients with high intraocular pressure at various stages of the MOOKP procedure performed in 85 eyes of 82 patients were studied. Stage 1A, which includes total iridodialysis, intracapsular cataract extraction, and anterior vitrectomy, was done in all eyes as the primary stage. Seventeen Ahmed glaucoma drainage devices were implanted in 15 eyes of 14 patients (chemical injury in 9 [10 eyes] and Stevens-Johnson syndrome in 5 patients). Implantation was performed during and after stage 1A in 2 and 7 eyes, respectively, after stage 1B+1C in 1 eye, and after stage 2 in 6 eyes. Eleven of 15 eyes (73.3%) remained stable with adequate control of intraocular pressure over a mean follow-up period of 33.68 months (1-90 months). Complications related to the drainage device were hypotony in 1 eye and vitreous block of the tube in 1 eye. It is ideal to place the Ahmed glaucoma drainage device prior to the mucosal graft when the anatomy of the ocular surface is least altered with best outcomes. The technique of placement of the drainage device during the various stages of the MOOKP procedure has been described. The intraocular pressure stabilized in three quarters of the eyes with pre-existing glaucoma.

Neovascular glaucoma after central retinal vein occlusion in pre-existing glaucoma

BackgroundTo determine the outcome of central retinal vein occlusion (CRVO) in pre-existing glaucoma and the predisposing factors of developing neovascular glaucoma (NVG).MethodsWe retrospectively assessed a pre-existing glaucoma CRVO group and a non-glaucoma CRVO group to elucidate the demographics, clinical course and ocular parameters of these two cohorts. Among the pre-existing glaucoma cases, the predisposing factors for the development of NVG were monitored, including the retinal capillary non-perfusion status, intraocular pressure (IOP) and best-corrected visual acuity (BCVA) at presentation.ResultsOf 642 CRVO patients reviewed in this 10-year cohort study, 60 (9.3%) had pre-existing glaucoma at a mean follow-up of 30.8 months, including 28 (4.4%) primary open angle glaucoma (POAG), 27 (4.2%) primary angle closure glaucoma (PACG), and 5 (0.8%) normal tension glaucoma (NTG) cases. Although the presence of glaucoma in the CRVO eyes was not significantly associated with the risk of developing NVG, the incidence of developing NVG in pre-existing glaucoma eyes was significantly higher in the group with IOP greater than 20 mmHg at CRVO presentation (P = 0.02, Chi-square test) as well as in the ischemic CRVO group compared to the non-ischemic patients (P = 0.005, Fisher’s exact test). Overall, 20% of pre-existing glaucoma patients needed glaucoma surgery after a CRVO event, including 11.7% of patients who developed iris neovascularisation (INV) and 8.3% of patients who developed a high IOP without INV.ConclusionsBoth the retinal non-perfusion status and uncontrolled IOP contribute to NVG in patients with pre-existing glaucoma after CRVO. Following CRVO, glaucoma surgery is necessary for pre-existing glaucoma cases with intractable elevated IOP with or without INV.

Does Intravitreal Injections of Bevacizumab for Age-related Macular Degeneration Affect Long-term Intraocular Pressure?

To evaluate the long-term intraocular pressure (IOP) changes after intravitreal injection of bevacizumab for age-related macular degeneration. A total of 83 eyes that received intravitreal injections of bevacizumab for age-related macular degeneration were enrolled. IOP measurements at baseline, 6, 12, 18, and 24 months, and at the last follow-up after injection were analyzed. On the basis of the median number of injections, the changes in IOP were compared. The mean number of injections was 3.71±1.62. There was no significantly higher elevation than baseline IOP (14.11±2.76 mm Hg) after multiple intravitreal injections of bevacizumab (P>0.05). In the group which had ≥4 injections, mean IOP measurements were not higher compared with the group which had <4 injections during the follow-up period (P>0.05). In the patients with preexisting glaucoma (3 eyes), there were no significant increases of IOP during the follow-up period. IOP elevation was not observed during the long-term follow-up period. In addition, the numbers of injection and preexisting glaucoma did not affect IOP changes.

Intraocular pressure elevation and post-DMEK glaucoma following Descemet membrane endothelial keratoplasty.

Intraocular pressure (IOP) elevation and post-keratoplasty glaucoma occur commonly after penetrating keratoplasty (PK), but also after Descemet stripping endothelial keratoplasty (DSEK). In this study, we evaluated the risk after Descemet membrane endothelial keratoplasty (DMEK) to develop IOP elevation and post-DMEK glaucoma. The 12-month incidence of IOP elevation and post-DMEK glaucoma was analyzed retrospectively in the first 117 consecutive eyes that underwent DMEK between September 2011 and December 2012 at the Universitätsmedizin-Charité, Berlin. IOP elevation was defined as IOP ≥ 22 mmHg, or ≥10 mmHg from preoperative baseline. The assessment included the pre-operative history of corneal disease and glaucoma. Furthermore, the response to anti-glaucoma treatment, the graft failure, the IOP, the visual acuity, and the endothelial cell count were evaluated. The 12-month incidence of IOP elevation was 12.10 % [95 % confidence interval (CI): 0.94 %, 18.37 %], post-DMEK glaucoma 2.7 % (95 % CI: -0.44 %, 5.84 %). The most frequent cause remained steroid-induced IOP elevation, with an 12-month incidence of 8.0 % (95 % CI: 7.95 %, 8.05 %). In all cases, IOP elevation was treated effectively by tapering down steroid medication and initiating or increasing anti-glaucoma medication. The incidence of postoperative postoperative pupillary block IOP elevation was 15.40 % (95 % CI: 8.93 %, 21.87 %). The number of eyes with iridocorneal contacts after surgery was low (4.2 %). Only the preoperative increased IOP is a significant risk factor for IOP elevation (p = 0.005). Visual acuity improved significantly after surgery (p < 0.001), and clear grafts were achieved in all eyes. Mean endothelial cell count did not differ between patients with and without IOP elevation. Incidence of IOP elevation and post-keratoplasty glaucoma after DMEK were low, but regular IOP measurements, especially in eyes with pre-existing glaucoma and bullous keratopathy, are necessary. Steroid-induced IOP elevation was the most frequent reason, and could be treated effectively by tapering down steroid medication or changing the steroid drug. Development of peripheral anterior synechiae after DMEK occured rarely. Therefore, the risk for IOP elevation and especially post-DMEK keratoplasty was reduced compared to PK and DSEK. In all cases, successful management by medical treatment was possible, and resulted in good visual acuity.

Intraocular pressure changes related to intravitreal injections of ranibizumab: analysis of pseudophakia and glaucoma subgroup.

The purpose of this study was to determine intraocular pressure (IOP) changes following intravitreal ranibizumab injections and to investigate the effect of pre-existing glaucoma and pseudophakia. Two hundred and two eyes of 175 patients who received repeated intravitreal ranibizumab injections were included in this study. IOP measurements were obtained at both 30 min and 24 h after each injection. IOP changes after the first, third, sixth, ninth, and twelfth injections were analyzed. Data gotten from subgroups with pre-existing glaucoma and pseudophakia were also analyzed. The mean number of injections was 4.81 ± 2.7 (range: 3-18), while the mean IOP prior to the first intravitreal ranibizumab injection was 15.11 ± 2.8 (9-25) mmHg. At the last visit, IOP was 14.66 ± 2.8 (9-22) mmHg. There was no cumulative increase in IOP at either 30 min or 24 h values throughout repeated injections. Pseudophakic patients had significantly lower mean IOP values at 30 min after all injections except for twelfth. The number of eyes with an IOP higher than 21 mm Hg and the mean IOP values were significantly higher in patients with pre-existing glaucoma at 30 min after the first and third injections. Pseudophakic eyes are less prone to immediate IOP spikes than phakic eyes. Pre-existing glaucoma may be a potential risk factor for uncontrolled IOP spikes immediately after intravitreal injection; nonetheless, this effect is usually transient and does not cause long-term problems. Also, ranibizumab injections can be administered safely under close monitoring.

Proton beam therapy for presumed and confirmed iris melanomas: a review of 36 cases

To report the clinical features and outcomes of iris melanomas treated by proton beam therapy. A retrospective study was conducted at the Croix-Rousse University Hospital of Lyon, Department of Ophthalmology, in 36 patients treated by proton beam therapy for presumed (n = 29) and confirmed (n = 7) iris melanomas between July 1997 and October 2010. Ciliary body melanomas with iris involvement were excluded. The patients' mean age was 54.4 years (range, 22-82 years). The average tumor diameter was 3.8 mm (range, 2.5-8.0). The iridocorneal angle was invaded by the tumor in 47% of cases (n = 17), the ciliary body in 17% of cases (n = 6), and the sclera in 3% (n = 1). Raised intraocular pressure was present before treatment in 11.1 % of cases (n = 4). Tumor biopsy was performed in 19% of cases (n = 7). Four patients had undergone an initial incomplete surgical excision of tumor before radiotherapy. Surgical preparation of the eye with tantalum ring positioning had been performed in all cases 3-4 weeks before irradiation. The prescribed dose was 60 Cobalt Gray Equivalent (CGE) of proton beam radiotherapy delivered in four fractions on four consecutive days. The median follow-up was 50 months (mean 60.5, range 15-136). One patient (2.7%) was lost to follow-up. None of the patients showed tumor progression, local recurrence, or metastasis. None of the patients required secondary enucleation. Cataract was developed in 62% of patients, glaucoma in two cases (6%) after irradiation, and hyphema with the aggravation of pre-existing glaucoma in one patient. No patients developed neovascular glaucoma. Proton beam therapy appears to be the treatment of choice for the conservative treatment of iris melanomas with excellent tumor control and an acceptable rate of complications. Longer follow-up studies on a larger series is necessary to consolidate these results.

Ocular surface rehabilitation: Application of human amniotic membrane in high-risk penetrating keratoplasties

BackgroundHuman amniotic membrane is a versatile tool for management of ocular surface disorders. This study evaluates the effect of cryopreserved human amniotic membrane (hAM) on one-year survival of penetrating keratoplasties (PKP) in high-risk recipients. MethodThis is a retrospective noncomparative cohort study of 58 consecutive eyes undergoing PKP with concurrent placement of a self-retained cryopreserved hAM (PROKERA®) at a tertiary care center from January 2009 to July 2010. ResultsMean patient age was 66.7±17.2years and 30 (54%) were males. 51 eyes were pseudophakic and one aphakic. 27 eyes were glaucomatous; 24 had glaucoma drainage device and 2 had previous endocyclophotocoagulation. 12 patients had PKP for the first time and 46 had repeat PKP (average number of prior PKP=1.63±1.1, range: 1–5).Risk factors for graft failure included repeat PKP (79.3%), corneal neovascularization (51.7%), preexisting glaucoma (46.6%), and presence of anterior synechiae (37.9%). Both First Transplant and Repeat Transplant groups had similar survival rates until 6months after transplant (75% vs 74%, odds ratio=1.06, p=1.00). At 12months, First Transplant group showed a better survival rate (67% vs 43%, odds ratio=2.60, p=0.20). Eyes with >3 risk factors had a higher graft failure rate (odds ratio=5.81, p=0.003). ConclusionSurvey of the literature suggests that high-risk PKP with concurrent hAM placement demonstrate comparable graft survival. Presence of multiple risk factors is associated with poor survival.

The Outcomes of Primary Pediatric Keratoplasty in Singapore

To evaluate the long-term corneal graft survival and risk factors for graft failure in pediatric eyes. Retrospective, interventional consecutive case series. Unilateral eyes of 105 patients aged 16 years and below were included from the Singapore Corneal Transplant Study between April 4, 1991 and April 4, 2011. Corneal graft survival was calculated using Kaplan-Meier survival analysis, and survival distributions were compared using log-rank test. Mean recipient age was 8.38 ± 5.63 years (range 0.18-15.92 years). Mean follow-up time was 34.16 ± 39.10months. Main diagnoses were corneal scar (22.9%), limbal dermoid (21.9%), anterior segment dysgenesis (15.2%), and keratoconus (14.3%). Forty-four eyes (41.9%) underwent penetrating keratoplasty (PK), 37 (35.2%) underwent anterior lamellar keratoplasty (ALK), 22 (21.0%) underwent lamellar corneal patch graft, and 2 (1.9%) underwent Descemet stripping automated endothelial keratoplasty (DSAEK). Kaplan-Meier survival rates for PK were 92.8% at 1 year, 88.9% at 2-4 years, and 80.9% at 5-16 years; survival rates for ALK were 88.0% at 1 year and 84.3% at 2-7 years; survival rates for corneal patch graft were 100% at 1-3 years and 90% at 4-10 years; these were not statistically significant (P= .362). Deep corneal vascularization (P= .012), preexisting active inflammation (P= .023), preexisting glaucoma drainage device (P= .023), and preexisting ocular surface disease (P= .037) were associated with reduced graft survival in a univariate analysis. We report good long-term graft survival following pediatric keratoplasty for various indications. Lamellar keratoplasty, when indicated, should be the procedure of choice in high-risk keratoplasties.

Outcomes Following Boston Type 1 Keratoprosthesis Implantation in Aniridia Patients at the University of Montreal

To describe outcomes after Boston Type 1 Keratoprosthesis (KPro) surgery in aniridic eyes. Retrospective, interventional case series. University-based tertiary care institution. Twenty-six aniridic eyes of 19 patients who underwent KPro implantation by a single experienced surgeon (M.H.-D.) between October 27, 2008 and January 16, 2012. Preoperative and postoperative best-corrected visual acuity (BCVA), intraoperative and postoperative complications, and keratoprosthesis retention. Mean age was 56 years (range, 28-72); 10 patients were male. Seven patients had bilateral procedures. No intraoperative complications were encountered. Preoperatively, BCVA was 20/300 or worse in all eyes. After a mean follow-up time of 28.7±13.5 months (range 4-50), the most recent BCVA was 20/200 or better in 14 eyes. Visual potential was limited by preexisting terminal glaucoma (n=2), phthisis after retinal detachment (n=4), and suprachoroidal hemorrhage (n=2). Other postoperative complications included retroprosthetic membrane formation (n=15), infectious keratitis (n=1), extrusion (n=2), and corneal melt (n=4). Uncomplicated vitritis was reported in 6 eyes. No endophthalmitis occurred in this series. Most eyes have glaucoma and are on medical treatment. The overall retention rate of the initial prosthesis was 77%. The prognosis in aniridic patients after KPro is variable. Meticulous follow-up and a subspecialty team approach are of utmost importance.

Severe intraocular pressure rise following intravitreal triamcinolone: a national survey to estimate incidence and describe case profiles

The objective of this study is to estimate the incidence of steroid-induced severe intraocular pressure (IOP) rise following intravitreal triamcinolone acetonide (IVTA) injection and to describe case profiles of the patients affected within the United Kingdom. A national survey was carried out to identify cases that had developed severe IOP rise requiring laser or surgery following IVTA through the British Ophthalmic Surveillance Unit. Respondents were mailed a questionnaire and with a follow-up questionnaire 1 year later, to ascertain characteristics of the patients identified. We also carried out a midpoint survey to ascertain national practice of IVTA at the time. There were 29 confirmed reports of severe IOP rise after IVTA in the 13-month period of surveillance. All the cases were unilateral and the mean time between the IVTA and the maximum recorded IOP was 16 weeks. Six of these patients had pre-existing glaucoma or ocular hypertension, and a further two were known to be 'steroid responders'. Using the adjusted denominators, obtained from our national survey, the estimated annual incidence would be between 3.6 and 9.5 per 1000 injections. These results confirm that severe IOP rise after IVTA is an uncommon but serious complication. Data obtained from this national study should aid clinicians in choosing the treatment best suited to their patients.

Post penetrating keratoplasty glaucoma: cumulative effect of quantifiable risk factors.

Purpose:To ascertain the incidence, identify risk factors and calculate cumulative effect of risk factors in patients developing glaucoma following optical penetrating keratoplasty.Materials and Methods:We carried out retrospective analysis of 445 patients, those underwent optical PK and had a minimum follow up of 6 m. Data on post-operative intra-ocular pressure (IOP) recorded at 3, 6, 9, 12 and 18 m or more was analyzed. Various risk factors including age, sex, indications for penetrating keratoplasty, pre-existing glaucoma and type of surgical procedures performed were analyzed by using univariate analysis and logistic regression technique.Results:Ninety (21%) of eyes developed post-PK glaucoma. On applying logistic regression, age, sex, indication of surgery, pre-existing glaucoma were found to be significant risk factors for the development of post-PK glaucoma (P < 0.05). Using logistic regression equation the cumulative risk of developing post-PK glaucoma in an individual patient can be calculated.Conclusions:Male patients, aged more than 40 years, having opaque grafts as an indication and with pre-existing glaucoma were found to be higher risk of developing post-PK glaucoma. Patients at higher cumulative risk for development of post-PK glaucoma may be closely monitored during follow-up.

Recurrent endophthalmitis following a scleral fixated intraocular lens in a glaucoma patient

Dear Editor, We would like to highlight the possibility of recurrent endophthalmitis in a patient with a scleral-fixated intraocular lens (IOL) and glaucoma. A 65-year-old patient with a history of primary angle closure glaucoma in both eyes, on topical anti-glaucoma medications, presented with redness, pain, and watering in his left eye for 5 days. The patient had undergone a scleral-fixated IOL implantation in his left eye 1 year ago, after his IOL had got dislocated subsequent to an episode of trauma. He developed endophthalmitis in that eye after 6 months and was treated with intravitreal antibiotics. No causative organism was isolated then. His anti-glaucoma medications had been neglected after the IOL placement. Scleromalacia was not noted in the surgical records of the patient. The axial lengths of the right and left eye were 22.3 and 22.4 mm, respectively. He underwent trabeculectomy with mitomycin C (0.2 mg/ml sub-conjunctivally for 2 min) in the left eye after resolution of endophthalmitis, for uncontrolled intraocular pressure (IOP; 44 mmHg) and pain. Visual acuity was perception of light with inaccurate projection of rays. On follow-up, the bleb remained vascularized and minimally raised. The current episode of redness and pain occurred 4 months after trabeculectomy. The left eye had a visual acuity of no light perception, circumciliary congestion with fixed hypopyon [Fig. 1a]. There was uveal tissue prolapse through scleral flap site constructed for scleral-fixated IOL [Fig. 1b]. The bleb was low and there was vascularization over the bleb. The IOP in the Left eye (LE) was 34 mmHg. Ultrasound of the LE revealed moderate amplitude spikes in the vitreous cavity suggestive of exudates. He was started on topical timolol and brimonidine, and was given anterior chamber vancomycin wash, followed by intensive topical antibiotics (concentrated cefazolin 50 mg/ml and tobramycin 14 mg/ml). On culture of the anterior chamber aspirate, Staphylococcus aureus was isolated. Four weeks later, the hypopyon had resolved. However, there was hypotony and a choroidal detachment was noted on ultrasound. The uveal prolapse had settled and the overlying conjunctiva showed vascularization. Figure 1 (a) Fixed hypopyon with circumciliary congestion. (b) Uveal tissue prolapse through scleral flap site for scleral-fixated intraocular lens Increase in IOP after scleral fixation of IOL has been reported in literature. Yan et al.,[1] in a retrospective review of 65 eye, of scleral-fixated posterior chamber IOL implantation, reported elevated IOP requiring intervention in 16% of eyes with pre-existing glaucoma and 13% of eyes that did not have pre-existing glaucoma Our patient had high IOP, which led to uveal tissue prolapse at scleral flap site for scleral-fixated IOL. This exposed uveal tissue probably acted as a conduit for the entry of microorganisms into the eye, resulting in endophthalmitis. Even though he underwent trabeculectomy, the surgery failed. The possibility of bleb related endophthalmitis was ruled out in the absence of a thin avascular bleb. Scleral-fixated IOLs should be used in glaucoma patients with additional care. They have to be very carefully monitored both for IOP control and scleral flap site integrity in case of high IOP. In case of glaucoma poorly responsive to topical medications, simultaneous trabeculectomy at the time of scleral fixation of IOL has also been described.[2] A glaucoma drainage device could have been considered for IOP control in cases with high risk of failure of trabeculectomy.

Clinical characteristics and surgical outcomes of phacoemulsification in true exfoliation syndrome

To review the clinical characteristics and surgical outcomes of patients with true exfoliation syndrome of the lens capsule having phacoemulsification cataract surgery. Hong Kong Eye Hospital, Kowloon, Hong Kong. Case series. Eyes of patients with true exfoliation syndrome diagnosed clinically or intraoperatively had standard phacoemulsification and intraocular lens (IOL) implantation. The anterior capsules removed during capsulorhexis were sent for histological confirmation. Twenty-four eyes of 18 patients were included. All eyes were confirmed to have true exfoliation syndrome by histological examination of the anterior lens capsule. Seven eyes (29.2%) had preexisting chronic glaucoma; 5 (20.8%) had laser iridotomy before the diagnosis. During phacoemulsification, all eyes had a continuous curvilinear capsulorhexis without complications. Trypan blue staining was used during capsulorhexis in 11 eyes (45.8%). Posterior capsule rupture occurred during lens chopping in 1 eye (4.2%). No loose zonular fibers or radial extension of capsulorhexis occurred. Capsular bag IOL implantation was successfully performed in all cases except the 1 with a posterior capsule rupture, in which an anterior chamber IOL was implanted. Phacoemulsification was safely performed in eyes with true exfoliation syndrome. Trypan blue staining can be used to facilitate capsulorhexis creation. Ultrasound biomicroscopy or anterior segment optical coherence tomography may be useful in preoperative assessment of such cases. The disease may be associated with glaucoma and laser iridotomy.

Neuronal complications of intravitreal silicone oil: an updated review

Silicone oil (SiO) has a well-established role as a long-term endotamponade agent in the management of complicated retinal detachments. Complications of intraocular SiO include keratopathy, glaucoma, cataract and subretinal migration of the oil droplets. SiO tamponade can also lead to a severe optic neuropathy caused by retrolaminar migration. Nevertheless, intracranial migration of the SiO through the optic nerve posterior to the lamina cribrosa to the optic chiasm and brain is uncommon. The mechanism is still under debate, but it has been suggested elevated intraocular pressure, macrophages or optic nerve head anatomical predispositions as potential explanations. Moreover, central scotoma may develop in eyes with SiO not only at the time of oil removal, but also during the period of tamponade. We performed a PubMed search of neuronal complications of silicone oil over a period of 25 years. This review summarizes our current understanding of the specific pathogenic mechanisms of intraocular SiO neuronal side effects, concluding that pre-existing glaucoma and optic nerve abnormalities are the main risk factors associated with this damage. In their absence, the risk of extraocular SiO penetration is so low that the use of SiO endotamponade in complex retinal detachment patients does not need to be modified. MRI images to assess extraocular SiO migration are only necessary in very few and special cases, such as patients with optic nerve abnormalities and glaucoma.

Descemet stripping with automated endothelial keratoplasty: A comparative study of outcome in patients with preexisting glaucoma

PurposeTo compare postoperative complications after Descemet stripping with automated endothelial keratoplasty (DSAEK) in patients with and without glaucoma. MethodsFor this retrospective study a series of 298 DSAEK cases performed at the Doheny Eye Institute were taken, we compared postoperative complications in eyes with glaucoma on medication (55) or with previous glaucoma surgeries (64) with a time-matched group of all other DSAEK cases (179, control). ResultsWith a mean follow-up of 1.85±1.12years, the complication rates were 12.8%, 11.1%, and 26.8% for postoperative graft detachment, graft failure, and IOP elevation, respectively. Graft detachment was an independent risk factor for graft failure (odds ratio OR=12.35, 95% confidence interval CI [5.46–27.90], P<0.001). Graft detachment was not associated with either history of glaucoma or glaucoma surgery (P>0.05). Glaucoma on medication had no increased risks of graft failure compared to normal eyes (P=0.38). However, increased risk of failure was seen in eyes with prior incisional glaucoma surgeries (OR=4.26, 95% CI [1.87–9.71], P<0.001). Medically managed glaucoma has increased risks of postoperative IOP elevation (OR=2.39, 95% CI [1.25–4.57], P=0.013), whereas surgically managed glaucoma has no significant elevation (P=0.23). Elevation of IOP was not significantly correlated with graft failure (P=0.21). ConclusionDSAEK is the preferred treatment for corneal endothelial dystrophy. We observed that having glaucoma or glaucoma surgery is not associated with graft detachment. A history of glaucoma surgery and postoperative graft detachment appeared to be important risk factors for graft failure. And more studies are indicated to study long-term IOP evolution in post-DSAEK patients and its association with graft survival.

De novo ocular hypertension after Descemet stripping endothelial keratoplasty: comparative 3-year incidence, risk factors, and outcomes

ObjectiveTo compare the 3-year incidence of de novo ocular hypertension (OHT) after Descemet stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK). For DSAEK, to evaluate predictors for OHT and 2-year outcomes after OHT development.MethodsThis was a review of the prospective Singapore Corneal Transplant Study at a single tertiary referral center. Consecutive DSAEKs and PKs for Fuchs’ endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK) in eyes without pre-existing glaucoma were analyzed. OHT incidence after DSAEK and PK were compared using Kaplan–Meier survival analysis, and OHT risk factors identified using Cox proportional regression. OHT was defined: intraocular pressure (IOP) ≥ 24 mmHg or ≥ 10 mmHg from baseline. Secondary outcomes 2 years after OHT development in DSAEK were rates of glaucoma medical therapy failure, IOP success, graft failure and rejection, and best-spectacle corrected visual acuity (BSCVA).ResultsThere were 108 (96.4%) DSAEKs and 216 (96%) PKs. The 1-, 2- and 3-year de novo OHT incidence was not significantly different between DSAEK (36.1%, 47.2%, 47.2%, respectively) and PK (35.7%, 44.9%, 45.8%, respectively; P = 0.914). OHT incidence did not differ in subgroup analyses of multiple clinical variables (P > 0.1). OHT predictors after DSAEK were: fellow eye glaucoma (hazard ratio [HR] 3.20, P = 0.004), age <60 years (HR 2.41, P = 0.016), concurrent goniosynechiolysis (HR 3.29, P = 0.021), post-graft complications or procedures (HR 2.85, P = 0.006). Two years after OHT onset, 29.7% of DSAEKs failed glaucoma medical therapy requiring trabeculectomy. Complete and qualified IOP success was achieved in 23.5% and 76.5%, respectively. Graft failure developed in 9.8% and graft rejection in 5.9%. At 6 months, 1, and 2 years from OHT onset, 86.3%, 88.3%, and 92.1% achieved BSCVA 20/40, respectively.ConclusionDSAEK and PK have comparable OHT risks. A significant 30% of DSAEK eyes with OHT require filtration surgery. Effective IOP control and good graft and visual outcomes are achieved with treatment.

Spontaneous expulsive suprachoroidal hemorrhage caused by decompensated liver disease

Expulsive suprachoroidal hemorrhage can be surgical or spontaneous. Spontaneous expulsive suprachoroidal hemorrhage (SESCH) is a rare entity. Most of the reported cases of SESCH were caused by a combination of corneal pathology and glaucoma. We are reporting a rare presentation of SESCH with no pre-existing glaucoma or corneal pathology and caused by massive intra- and peri-ocular hemorrhage due to decompensated liver disease.

Glaucoma associated with the management of rhegmatogenous retinal detachment

Transient or permanent elevation of intraocular pressure (IOP) is a common complication following vitreoretinal surgery. Usually secondary glaucoma, which develops after scleral buckling procedures, or pars plana vitrectomy for repair of rhegmatogenous retinal detachment, is of multifactorial origin. It is essential, for appropriate management, to detect the cause of outflow obstruction. An exacerbation of preexisting open-angle glaucoma or a steroid-induced elevation of IOP should also be considered. Scleral buckling may be complicated by congestion and anterior rotation of the ciliary body resulting in secondary angle closure, which can usually resolve with medical therapy. The use of intravitreal gases may also induce secondary angle-closure with or without pupillary block. Aspiration of a quantity of the intraocular gas may be indicated. Secondary glaucoma can also develop after intravitreal injection of silicone oil due to pupillary block, inflammation, synechial angle closure, or migration of emulsified silicone oil in the anterior chamber and obstruction of the aqueous outflow pathway. In most eyes medical therapy is successful in controlling IOP; however, silicone oil removal with or without concurrent glaucoma surgery may also be required. Diode laser transscleral cyclophotocoagulation and glaucoma drainage devices constitute useful treatment modalities for long-term IOP control. Cooperation between vitreoretinal and glaucoma specialists is necessary to achieve successful management.

Descemet Membrane Endothelial Keratoplasty and Hybrid Techniques for Managing Failed Penetrating Grafts

To report the outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet membrane automated endothelial keratoplasty (DMAEK) for failed penetrating keratoplasties (PKs). Retrospective chart review of patients with a failed PK who were managed with DMEK or DMAEK surgery. Surgical technique, clinical findings, visual outcomes, and complications were documented and reported. Six patients (mean age, 62 years; mean follow-up, 10 months) underwent DMEK (4 patients) or DMAEK (2 patients) under a failed PK. The graft diameter of the failed PK was 8 mm in all patients. In 3 patients, a 9-mm donor graft (DMAEK, 2; DMEK, 1) was used, whereas in the remaining patients, an 8-mm donor graft was chosen. Descemet membrane was stripped in 3 eyes because of the presence of Descemetic scarring. Four of the 6 eyes had a triple procedure. Two patients had preexisting open-angle glaucoma, whereas 1 patient developed postoperative steroid-response glaucoma. The median preoperative best-corrected visual acuity was 20/70, and postoperatively at 1, 3, and 6 months, 20/50, 20/40, and 20/30, respectively. The median donor endothelial cell density was 2801 cells per square millimeter, and at 3 and 6 months postoperatively, 1906 and 1880 cells per square millimeter, respectively. Three of the 4 DMEK eyes had peripheral graft detachment that attached successfully with 1 air injection. There was 1 primary failure that was managed with Descemet stripping endothelial keratoplasty. DMEK or DMAEK can be considered to treat failed PKs. However, prior experience in performing these techniques in virgin eyes is recommended before use with a failed PK, which can present an additional challenge.

Ocular Hypertension Following Intravitreal Anti-vascular Endothelial Growth Factor Agents

Age-related macular degeneration (AMD) is the leading cause of severe vision loss in adults over the age of 65 years. The advent of anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections has revolutionized the management of exudative AMD. However, multiple case series of sustained elevated intraocular pressure (IOP) after intravitreal injections of anti-VEGF agents have been reported. Sustained elevated IOP has been reported with all anti-VEGF agents being used in ophthalmology and even in patients without any prior history of glaucoma. No clear correlations to injection frequency or patient characteristics have emerged from the multiple reports so far, but it appears that patients with pre-existing glaucoma or ocular hypertension and those receiving a greater number of injections with shorter injection intervals may be at a higher risk for developing ocular hypertension related to anti-VEGF agents. Until future studies elucidate the pathophysiology of sustained IOP following anti-VEGF injections, it is prudent to recognize the possibility of elevations in IOP in association with anti-VEGF therapy. Treating physicians should look for subtle optic nerve head changes and IOP measurements suspicious for glaucoma and have a low threshold for treating elevated IOP if the patient is likely to require multiple intravitreal anti-VEGF injections. Ocular hypertension following anti-VEGF injections appears to be amenable to anti-glaucoma treatment and every effort should be made to preserve the peripheral vision in these patients where central vision is already threatened by exudative AMD.