Aqueous misdirection syndrome: an interesting case presentation

Prima Moinul,1 Cindy ML Hutnik2 1Faculty of Medicine, University of Calgary, Calgary, AB, Canada; 2Ivey Eye Institute, St Joseph’s Health Care, Department of Ophthalmology, University of Western Ontario, London, ON, Canada Objective: To report a case of an aqueous misdirection-like presentation in a pseudophakic patient.Design: Retrospective case review.Participant: An 84-year-old pseudophakic gentleman presented with bilateral blurred vision 8 years after cataract surgery. A refractive shift with shallow anterior chambers and elevated intraocular pressures were noted. No corneal edema was noted. Although aqueous suppression and topical atropine would relieve the signs and symptoms, the effect was temporary with fluctuating and variable changes in refraction, anterior chamber depth, and intraocular pressure. The presence of patent iridotomies had no effect on the fluctuations. A pars plana vitrectomy and surgical iridectomy were successful in preventing further fluctuations.Conclusion: Aqueous misdirection is a form of secondary angle closure glaucoma marked by elevated intraocular pressures, myopic shift in refraction, and central shallowing of the anterior chamber. Here, a case of a pseudophakic patient experiencing bilateral and fluctuating signs and symptoms resembling aqueous misdirection is presented. Surgical intervention with a pars plana vitrectomy and iridectomy prevented further fluctuations. Keywords: aqueous misdirection, glaucoma, pars plana vitrectomy, secondary angle closur

Clinical effectiveness of currently available low-vision devices in glaucoma patients with moderate-to-severe vision loss

Yogesh Patodia,1 Elizabeth Golesic,2 Alex Mao,2 Cindy ML Hutnik2 1Department of Medicine, Ross University, Iselin, NJ, USA; 2Department of Ophthalmology, University of Western Ontario, London, ON, Canada Purpose: The aim of this trial is to study the effectiveness of currently available low-vision devices in glaucoma patients with moderate-to-severe vision loss. Design: This is a randomized pilot clinical trial. Participants: Sixteen low-vision glaucoma patients participated in this study. Methods: Patients with a best-corrected visual acuity between 20/70 and 20/400 in the better eye and a diagnosis of stable primary or secondary open-angle glaucoma were randomized to a low-vision treatment group or a nonintervention control group. A telephone interview was conducted before and after the 4-week testing period to assess functional vision. Patients placed in the treatment group received a low-vision examination and used various currently available low-vision aids. Patients placed in the control group received a low-vision examination only. Changes in patients’ reading ability and overall visual ability were chosen as the primary outcomes. Other visual functioning domains (mobility, visual information processing and visual motor skills) were considered as secondary outcomes. Results: Ten patients in the treatment group showed a significant improvement in reading ability and overall visual ability compared to the control group. The difference in mean score for reading ability was 2.52 logits (2.02; P<0.05) and overall visual ability was 0.78 logits (0.64; P<0.05). However, no significant improvement was noted in the other visual functioning domains involving mobility and visual motor skills. Conclusion: Currently available low-vision devices primarily enhance central vision with limited benefits to functional activities relying on peripheral vision. Keywords: low vision, glaucoma, quality of life, activities of daily livin

Impression cytology implicates cell autophagy in aqueous deficiency dry eye

Tony Lin,1,2,* Richard Filek,3,* Joy M Wang,4 Chong H Wu,4 Hong Liu,2 Cindy ML Hutnik1–3 1Department of Ophthalmology, Western University, 2Ivey Eye Institute, St Joseph’s Health Care, St Joseph’s Hospital, 3Department of Pathology and Laboratory Medicine, 4Department of Biology, Western University, London, ON, Canada *These authors contributed equally to this work Purpose: Impression cytology in combination with a cell autophagy marker was used to demonstrate the utility of a novel frozen section technique, to assess the health of the ocular surface, as well as to correlate autophagic cell death with the commonly used clinical tests for dry eye. Methods: Female patients over the age of 18 years who attended an outpatient ophthalmology clinic were invited to participate. Schirmer’s test, tear film break-up time and the ocular surface disease index questionnaire were used as objective and subjective clinical tests for dry eye. The cellular biomarker microtubule-associated protein light chain 3 (LC3) was used as a marker of autophagic cell death. Results: Low LC3 nuclear staining was positively correlated with Schirmer’s test <10 mm. No correlation was found between other clinical tests for dry eye. Conclusion: This study demonstrates a positive linear relationship between Schirmer’s testing and LC3. There is a lack of correlation between the commonly used diagnostics tests for dry eye, highlighting our incomplete understanding and assessment of dry eye. Keywords: impression cytology, cell autophagy, dry eye, technique, Schirmer’s test, LC

The value of corneoscleral rim cultures in keratoplasty: a systematic review and cost-effectiveness analysis

Efstathia Kiatos,1 James J Armstrong,2,3 Cindy ML Hutnik,3,4 Stephen M Tsioros,5 Monali S Malvankar-Mehta,1,4 William G Hodge1,4 1Department of Epidemiology and Biostatistics, 2Department of Pathology, 3Department of Ophthalmology, Schulich School of Medicine and Dentistry, Western University, 4Department of Ophthalmology, Ivey Eye Institute, St Joseph’s Health Care London, 5Department of Kinesiology, Western University, London, ON, Canada Purpose: This study evaluated the performance of donor corneoscleral rim cultures for predicting infection after corneal transplantation, and determines if there is a correlation between positive corneoscleral rim cultures and postkeratoplasty infection.Design and data sources: This was a systematic review, prognostic accuracy analysis, and cost-effectiveness analysis. Databases searched were: Medline (Ovid), Embase (Ovid), CINAHL, Cochrane Library, Web of Science, and BioSis Previews. Grey literature was also explored.Materials and methods: A systematic review was conducted to locate published and unpublished studies. All studies examining corneal button contamination and its association with endophthalmitis and keratitis posttransplantation were included. Extracted data were used to calculate sensitivity, specificity, positive predictive value, and negative predictive value. Cost data from the London Laboratory Services Group in London, ON were used to calculate the cost-effectiveness of culturing donor rim cultures.Results: Of 7,870 grafts, 954 had a positive rim culture (12.1%), with 12 patients going on to develop keratitis or endophthalmitis (1.3%). The prevalence of keratitis and endophthalmitis in this study was 0.15%, and the positive predictive value 1.5%. Of the 12 infections, nine were fungal and three bacterial. The estimated cost of a positive and negative test result was CAD$45.99 and$14.15, respectively. The cost to run all 7,870 tests was estimated to be $141,735.86, with an incremental cost-effectiveness ratio of$40,215.70.Conclusion: There was a significant divergence between bacterial and fungal rim-culture results. Bacterial cultures predicted clinical infection poorly, did not change management, and were expensive. Fungal cultures predicted clinical infection in over 10% of patients, had the potential to change management, and were 40% less expensive than full rim culturing (bacterial and fungal tests). Fungal rim cultures may be considered in areas where fungal infection rates are high. Keywords: corneoscleral rim cultures, eye infection, keratoplasty, culture techniques&nbsp

An observational study of bimatoprost 0.01% in treatment-naïve patients with primary open angle glaucoma or ocular hypertension: the CLEAR trial

Donald R Nixon,1 Susan Simonyi,2 Meetu Bhogal,2 Christopher S Sigouin,3 Andrew C Crichton,4 Marino Discepola,5 Cindy ML Hutnik,6 David B Yan71Private Practice, Barrie, ON, 2Allergan Inc, Markham, ON, 3CLINWest Research, Burlington, ON, 4University of Calgary, Calgary, AB, 5McGill University, Montreal, QC, 6London Health Sciences Centre, London, ON, 7University of Toronto, Toronto, ON, CanadaBackground: This study was designed to evaluate the occurrence and severity of ocular hyperemia in subjects with elevated intraocular pressure (IOP) due to primary open angle glaucoma (POAG) or ocular hypertension (OHT) following treatment with bimatoprost 0.01% in a real-world clinical setting.Methods: This was an open-label, observational study conducted at 67 centers in Canada. Subjects with elevated IOP due to POAG or OHT instilled bimatoprost 0.01% topically as monotherapy once daily. Ocular hyperemia was graded by the investigator at baseline and weeks 6 and 12 using a photographic five-point grading scale. Change in IOP from baseline was also evaluated at these time points. This analysis includes only the subgroup of 522 subjects who were naïve to IOP-lowering medication prior to the study.Results: After 12 weeks of treatment with bimatoprost 0.01%, hyperemia was graded as none-to-mild (grades 0, +0.5, or +1) for 93.3% of subjects and as moderate-to-severe (grades +2 or +3) for 6.7%. At weeks 6 and 12, most subjects (93.2% and 93.5%) had no change in hyperemia grade from baseline. IOP was reduced by 7.4 mmHg (29.8%) at week 6 and 7.7 mmHg (30.9%) at week 12 from baseline.Conclusion: This real-world, observational study found that bimatoprost 0.01% instilled once daily reduced IOP by a mean of 30% from baseline without moderate or severe ocular hyperemia in 93% of treatment-naïve subjects with POAG or OHT.Keywords: glaucoma, intraocular pressure, hyperemia, bimatopros

An observational study of bimatoprost 0.01% in patients on prior intraocular pressure-lowering therapy: the Canadian Lumigan® RC Early Analysis Review (CLEAR) trial

Andrew C Crichton,1 Donald R Nixon,2 Susan Simonyi,3 Meetu Bhogal,3 Christopher S Sigouin,4 Marino J Discepola,5 Cindy ML Hutnik,6 Darryl C Baptiste,3 David B Yan7 On behalf of the CLEAR Study Group 1Division of Ophthalmology, University of Calgary, Calgary, AB, Canada; 2Private practice, Barrie, ON, Canada; 3Medical Affairs, Allergan Inc., Markham, ON, Canada; 4CLINWest Research, Burlington, ON, Canada; 5Department of Ophthalmology, McGill University, Montreal, QC, Canada; 6Department of Ophthalmology and Pathology, Ivey Eye Institute, London, ON, Canada; 7Department of Ophthalmology, University of Toronto, Toronto, ON, Canada Purpose: To evaluate the ocular hyperemia and intraocular pressure (IOP)-lowering efficacy of bimatoprost 0.01% in subjects with elevated IOP due to primary open-angle glaucoma (POAG) or ocular hypertension (OHT) in a real-world clinical setting. Subjects and methods: This open-label, 12-week, observational study was conducted at 67 centers in Canada. Subjects with elevated IOP due to POAG or OHT instilled bimatoprost 0.01% as monotherapy once daily. Ocular hyperemia was graded by the investigator at baseline, week 6, and week 12 using a standardized photographic 5-point grading scale. Change in IOP from baseline was also evaluated at these time points. This analysis includes the subgroup of 268 subjects who had been previously treated with latanoprost 0.005%, bimatoprost 0.03%, travoprost 0.004%, and travoprost 0.004% with SofZia™ or nonselective beta-adrenergic receptor blockers prior to the study. Results: After 12 weeks of treatment with 0.01% bimatoprost, ocular hyperemia was graded as none-to-mild hyperemia (grades 0, +0.5, or +1) for 94.1% of subjects and as moderate-to-severe hyperemia (grades +2 or +3) for 5.9%. No statistically significant shifts in ocular hyperemia ratings were observed at week 12 for any of the prior IOP-lowering therapies except bimatoprost 0.03%, in which 20.8% of subjects experienced an improvement. The mean percentage change from baseline IOP at week 12 following the switch to bimatoprost 0.01% monotherapy ranged from –2.3%±17.3% to –26.3%±12.4%. Furthermore, the decreased mean percentage change from baseline IOP was statistically significant across all prior IOP-lowering medications, except for bimatoprost 0.03% at the 6- and 12-week visits and travoprost 0.004% at the 6-week visit. Conclusion: This observational study demonstrates that bimatoprost 0.01% was well tolerated among POAG and OHT subjects who switched from prior IOP-lowering medication. Furthermore, a switch in ocular hypertensive treatment to bimatoprost 0.01% was associated with an additional 10%–15% reduction in IOP. Keywords: glaucoma, intraocular pressure, hyperemia, bimatopros