Investigation of intraocular pressure fluctuation as a risk factor of glaucoma progression

Purpose: Since the role of short- and long-term intraocular pressure (IOP) fluctuation as a predictor of glaucoma progression is still controversial, the purpose of this study was to investigate the role of IOP fluctuation in a non-selected patient cohort. Materials and methods: Two-hundred and forty eyes of 120 glaucoma patients (51% female) with a mean age of 64.5 years were included. Inclusion criteria were at least a visual field (VF) and a 48-hour diurnal phasing of IOP including nocturnal measurement. Glaucoma Progression was defined as – if available – confirmed progression of reproducible VF defects in at least three VF examinations or increase of cup area on optic nerve imaging (Heidelberg Retina Tomograph [HRT]) with at least two images after baseline. If results were stable or less than previously mentioned VF or HRT examinations were available, it was classified as “no progression”. Results: Glaucoma progression was seen in seven of 240 eyes in the VF analysis and ten of 240 eyes on HRT. Of all 240 eyes, 92 and 41 eyes fulfilled the criteria to be included for progression evaluation on VF and HRT analysis, respectively. Mean time to progression ± standard error was 3.6±0.2 years on VF and 4.5±0.3 years on HRT. Univariate and multivariate Cox regression analyses revealed short-term IOP fluctuation (P,0.0001) and maximum IOP (P,0.001) as risk factors for glaucoma progression on VF. There was no significant influence of demographic characteristics, ocular or general health on glaucoma progression. Conclusion: Short-term IOP fluctuation was associated with the progression of glaucoma in this non-selected cohort of glaucoma patients receiving phasing of IOP. Keywords: glaucoma progression, short-term IOP fluctuation, long-term IOP fluctuation, glaucoma imaging, visual fiel

Investigation of intraocular pressure fluctuation as a risk factor of glaucoma progression

Purpose: Since the role of short- and long-term intraocular pressure (IOP) fluctuation as a predictor of glaucoma progression is still controversial, the purpose of this study was to investigate the role of IOP fluctuation in a non-selected patient cohort. Materials and methods: Two-hundred and forty eyes of 120 glaucoma patients (51% female) with a mean age of 64.5 years were included. Inclusion criteria were at least a visual field (VF) and a 48-hour diurnal phasing of IOP including nocturnal measurement. Glaucoma Progression was defined as – if available – confirmed progression of reproducible VF defects in at least three VF examinations or increase of cup area on optic nerve imaging (Heidelberg Retina Tomograph [HRT]) with at least two images after baseline. If results were stable or less than previously mentioned VF or HRT examinations were available, it was classified as “no progression”. Results: Glaucoma progression was seen in seven of 240 eyes in the VF analysis and ten of 240 eyes on HRT. Of all 240 eyes, 92 and 41 eyes fulfilled the criteria to be included for progression evaluation on VF and HRT analysis, respectively. Mean time to progression ± standard error was 3.6±0.2 years on VF and 4.5±0.3 years on HRT. Univariate and multivariate Cox regression analyses revealed short-term IOP fluctuation (P,0.0001) and maximum IOP (P,0.001) as risk factors for glaucoma progression on VF. There was no significant influence of demographic characteristics, ocular or general health on glaucoma progression. Conclusion: Short-term IOP fluctuation was associated with the progression of glaucoma in this non-selected cohort of glaucoma patients receiving phasing of IOP. Keywords: glaucoma progression, short-term IOP fluctuation, long-term IOP fluctuation, glaucoma imaging, visual fiel

Retinal and optic nerve degeneration in α-mannosidosis

α-mannosidosis is a rare, autosomal-recessive, lysosomal storage disease caused by a deficient activity of α-mannosidase. Typical symptoms include intellectual, motor and hearing impairment, facial coarsening, and musculoskeletal abnormalities. Ocular pathologies reported previously were mainly opacities of the cornea and lens, strabismus, and ocular motility disorders. However, retinal and optic nerve degeneration have been rarely described

The Effect of Induced Intraocular Stray Light on Recognition Thresholds for Pseudo-High-Pass Filtered Letters

PURPOSE: The Moorfields Acuity Chart (MAC)—comprising pseudo-high-pass filtered “vanishing optotype” (VO) letters—is more sensitive to functional visual loss in age-related macular degeneration (AMD) compared to conventional letter charts. It is currently unknown the degree to which MAC acuity is affected by optical factors such as cataract. This is important to know when determining whether an individual's vision loss owes more to neural or optical factors. Here we estimate recognition acuity for VOs and conventional letters with simulated lens aging, achieved using different levels of induced intraocular light scatter. METHODS: Recognition thresholds were determined for two experienced and one naive participant with conventional and VO letters. Stimuli were presented either foveally or at 10 degrees in the horizontal temporal retina, under varying degrees of intraocular light scatter induced by white resin opacity-containing filters (WOFs grades 1 to 5). RESULTS: Foveal acuity only became significantly different from baseline (no filter) for WOF grade 5 with conventional letters and WOF grades 4 and 5 with VOs. In the periphery, no statistical difference was found for any stray-light level for both conventional and VOs. CONCLUSIONS: Recognition acuity measured with conventional and VOs is robust to the effects of simulated lens opacification, and thus its higher sensitivity to neural damage should not simultaneously be confounded by such optical factors. TRANSLATIONAL RELEVANCE: The MAC may be better able to differentiate between neural and optical deficits of visual performance, making it more suitable for the assessment of patients with AMD, who may display both types of functional visual loss

Ageing changes in retinal outer nuclear layer thickness and cone photoreceptor density using adaptive optics-free imaging

Purpose: To investigate age-related changes of the outer nuclear layer (ONL) thickness and cone density, and their associations in healthy participants using a modified, narrow scan-angle Heidelberg Retina Angiograph (HRA2). Methods: Retinal cones were imaged outside the fovea at 8.8° eccentricity and cone density was compared to ONL thickness measurements obtained by Spectral-Domain Optical Coherence Tomography (SD-OCT) at the same locations. Fifty-six eyes of 56 healthy participants with a median age (interquartile range, IQR) of 37 years (29–55) were included. Results: Median (IQR) cone count was 7,472 (7,188, 7,746) cones/mm2 and median (IQR) ONL thickness was 56 (52, 60) µm for healthy participants. Both cone density and ONL thickness were negatively associated with age: cone density, R2 = 0.16 (F(1,54) = 10.41, P = 0.002); ONL thickness, R2 = 0.12 (F(1,54) = 7.41, P = 0.009). No significant association was seen between cone density and ONL thickness (R2 = 0.03; F(1,54) = 1.66, P = 0.20). Conclusion: Cone density was lower, and ONL thinner, in older compared to younger participants, therefore, image-based structural measures should be compared to age-related data. However, cone density and ONL thickness were not strongly associated, indicating that determinants of ONL thickness measurements other than cone density measurements, and including measurement error, have a major influence

Umsetzung eines digitalen Semesters Augenheilkunde während der COVID-19-Pandemie

Hintergrund Die erste Welle der COVID-19-Pandemie stellte Lehrende und Studierende vor große Herausforderungen, da die studentische Lehre trotz Einschränkung des Präsenzunterrichts stattzufinden hatte. Für Präsenzunterricht und Veranstaltungen mit Patientenkontakt mussten kurzfristig zwischen Mitte März und Beginn des Semesters im April Alternativen gestaltet werden. Ziel der Arbeit Beschreibung von Konzept und Umsetzung der studentischen Lehre an der Augenklinik der Universitätsmedizin Mainz in kompletter digitaler Form im Sommersemester 2020. Konzeptvorstellung Vorlesung, Untersuchungskurs und Praktikum der Augenheilkunde finden an der Universitätsmedizin Mainz im 5. und 6. Semester im Studiengang Humanmedizin statt. Grundlage der Neukonzeption war der bisherige Kursaufbau. Das umgesetzte Konzept umfasste Vorlesungen als Videopodcasts, Untersuchungsvideos, Online-Untersuchungskonferenzen, leitsymptomorientierte interaktive Patientenfälle, Operationsvideos, Anamnesevideos von Patienten und die Gestaltung eines „Live-Patientenzimmers“, in dem Patientenfälle inklusive Live-Übertragung des Spaltlampenbefundes und der Fundoskopie präsentiert wurden. Die Evaluation durch Studierende zeigte eine sehr gute Annahme des Konzeptes. Diskussion Es gelang innerhalb eines Zeitrahmens von 4 Wochen eine vollständige Überarbeitung und Digitalisierung des Kurses Augenheilkunde. Der größte Anteil der Neugestaltung beinhaltete die mediale Produktion von Untersuchungsvideos, interaktiven Patientenfällen und Videopodcasts der Vorlesungen. Diese digitalen Lehrkonzepte können auch in den nächsten Semestern nach Wiederaufnahme des Präsenzunterrichts genutzt werden und die Präsenzlehre in der Augenheilkunde unterstützen.Background The first wave of the COVID-19 pandemic posed great challenges for teachers and students, as teaching had to take place despite the restriction of classroom teaching. For attendance lessons and events with patient contact alternatives had to be arranged at short notice between mid-March and the beginning of the semester in mid-April. Objective Description of the concept and implementation in the student teaching at the Department of Ophthalmology of the University Medical Center Mainz in complete digital form in spring 2020. Presentation of concept Lectures, examination course and practical training in ophthalmology take place in the 5th and 6th semester of the study of human medicine. The basis of the new concept were the former course curricula. Implemented concepts included a complete revision and implementation of lectures as video podcasts, examination videos, online examination conferences, interactive patient cases, narrated videos of surgery, anamnesis videos of patients and the design of the virtual patient room, a live online practice with presentation and examination of patients including transmission of the slit-lamp image to reproduce anterior and posterior segment examination. An evaluation showed a very positive reception of the new concept by students. Discussion Within a tight timeframe of 4 weeks a complete revision of the ophthalmology course was achieved. The implementation was time-consuming, with the largest share in the media production of examination videos, interactive patient cases and video podcasts of the lectures. We consider a reduction of classroom teaching for parts of the learning objectives that can be represented by such videos to be possibly useful. An independent digital appropriation of such content may enable a more productive learning environment in face-to-face teaching

Pars plana vitrectomy for malignant glaucoma in non-glaucomatous and in filtered glaucomatous eyes

Purpose: To assess the outcomes of pars plana vitrectomy for the treatment of malignant glaucoma in patients with and without previous filtration surgery. Patients and methods: Data of 15 patients developing malignant glaucoma after trabeculectomy (60%) or following ophthalmic interventions other than filtration surgery (40%) were recorded retrospectively. Pars plana vitrectomy was performed in case of failed medical or laser treatment recreating the normal pathway of aqueous humor. The main outcome measures were the postoperative intraocular pressure (IOP), the frequency of complications, and success rate based on the following criteria: IOP reduction by $20% and to #21 mmHg (definition one) or an IOP , 18 mmHg (definition two) with (qualified success) and without (complete success) glaucoma medication. Results: Vitrectomy reduced IOP from baseline in eyes with and without previous trabeculectomy during a median follow-up of 16.4 months (range 7 days to 58 months); although the majority of patients required glaucoma medication to reach desired IOP. The complete success rates were 11% (both definitions) for patients with filtering blebs and none of the patients without previous trabeculectomy had complete success at the 12-month visit. Complications were few and included transient shallowing of the anterior chamber, choroidal detachment, corneal decompensation, filtering bleb failure, and need for further IOP-lowering procedures. Conclusion: Pars plana vitrectomy is equally effective for malignant glaucoma caused by trabeculectomy or interventions other than filtration surgery, although IOP-lowering medication is necessary in nearly all cases to maintain target IOP

Vasculitis-like hemorrhagic retinal angiopathy in Wegener’s granulomatosis

Background: Granulomatosis with polyangiitis, also known as Wegener’s granulomatosis, is a chronic systemic inflammatory disease that can also involve the eyes. We report a case of massive retinal and preretinal hemorrhages with perivascular changes as the initial signs in granulomatosis with polyangiitis (Wegener’s granulomatosis). Case presentation: A 39-year-old Caucasian male presented with blurred vision in his right eye, myalgia and arthralgia, recurrent nose bleeds and anosmia. Fundus image of his right eye showed massive retinal hemorrhages and vasculitis-like angiopathy, although no fluorescein extravasation was present in fluorescein angiography. Laboratory investigations revealed an inflammation with increased C-reactive protein, elevated erythrocyte sedimentation rate and neutrophil count. Tests for antineutrophil cytoplasmic antibodies (ANCA) were positive for c-ANCA (cytoplasmatic ANCA) and PR3-ANCA (proteinase 3-ANCA). Renal biopsy demonstrated a focal segmental necrotizing glomerulonephritis. Granulomatosis with polyangiitis (Wegener’s granulomatosis) was diagnosed and a combined systemic therapy of cyclophosphamide and corticosteroids was initiated. During 3 months of follow-up, complete resorption of retinal hemorrhages was seen and general complaints as well as visual acuity improved during therapy. Conclusion: Vasculitis-like retinal changes can occur in Wegener’s granulomatosis. Despite massive retinal and preretinal hemorrhages that cause visual impairment, immunosuppressive therapy can improve ocular symptoms

Comparison of phacotrabeculectomy versus phacocanaloplasty in the treatment of patients with concomitant cataract and glaucoma

Background Cataract and glaucoma are both common comorbidities among older patients. Combining glaucoma surgery with minimal invasive phacoemulsification (phaco) is a considerable option to treat both conditions at the same time, although the combination with filtration surgery can produce a strong inflammatory response. Combined non-penetrating procedures like canaloplasty have shown to reduce intraocular pressure (IOP) comparable to trabeculectomy without the risk of serious bleb-related complications. The purpose of this retrospective study was to compare the outcomes of phacotrabeculectomy and phacocanaloplasty. Methods Thirty-nine eyes with concomitant cataract and glaucoma who underwent phacotrabeculectomy (n = 20; 51.3%) or phacocanaloplasty (n = 19; 48.7%) were included into this trial on reduction of IOP, use of medication, success rate, incidence of complications and postsurgical interventions. Complete success was defined as IOP reduction by 30% or more and to 21 mmHg or less (definition 1a) or IOP to less than 18 mmHg (definition 2a) without glaucoma medication. Results Over a 12-month follow-up, baseline IOP significantly decreased from 30.0 ± 5.3 mmHg with a mean of 2.5 ± 1.2 glaucoma medications to 11.7 ± 3.5 mmHg with a mean of 0.2 ± 0.4 medications in eyes with phacotrabeculectomy (P < .0001). Eyes with phacocanaloplasty had a preoperative IOP of 28.3 ± 4.1 mmHg and were on 2.8 ± 1.1 IOP-lowering drugs. At 12 months, IOP significantly decreased to 12.6 ± 2.1 mmHg and less glaucoma medications were necessary (mean 1.0 ± 1.5 topical medications; P < .05). 15 patients (78.9%) with phacotrabeculectomy and 9 patients (60.0%) in the phacocanaloplasty group showed complete success according to definition 1 and 2 after 1 year (P = .276). Postsurgical complications were seen in 7 patients (36.8%) of the phacocanaloplasty group which included intraoperative macroperforation of the trabeculo-Descemet membrane (5.3%), hyphema (21.1%) and bleb formation (10.5%). Although more complications were observed in the phacotrabeculectomy group, no statistically significant difference was found. Conclusions Phacocanaloplasty offers a new alternative to phacotrabeculectomy for treatment of concomitant glaucoma and cataract, although phacotrabeculectomy yielded in better results in terms of IOP maintained without glaucoma medications