Virus-associated anterior uveitis and secondary glaucoma: Diagnostics, clinical characteristics, and surgical options

In this retrospective, single-center, observational study, we compared the clinical characteristics, analyzed the glaucoma development, and the glaucoma surgery requirement mediators in patients with different virus-associated anterior uveitis (VAU). In total, 270 patients (= eyes) with VAU confirmed by positive Goldmann-Witmer coefficients (GWC) for cytomegalovirus (CMV), herpes simplex virus (HSV), varicella-zoster virus (VZV), rubella virus (RV), and multiple virus (MV) were included. Clinical records of these patients were analyzed. Demographic constitution, clinical findings, glaucoma development, and surgeries were recorded. The concentrations of 27 immune mediators were measured in 150 samples of aqueous humor. The GWC analysis demonstrated positive results for CMV in 57 (21%), HSV in 77 (29%), VZV in 45 (17%), RV in 77 (29%), and MV in 14 (5%) patients. CMV and RV AU occurred predominantly in younger and male patients, while VZV and HSV AU appeared mainly with the elderly and females (P<0.0001). The clinical features of all viruses revealed many similarities. In total, 52 patients (19%) showed glaucomatous damage and of these, 27 patients (10%) needed a glaucoma surgery. Minimal-invasive glaucoma surgery (MIGS) showed a reliable IOP reduction in the short-term period. In 10 patients (37%), the first surgical intervention failed and a follow-up surgery was required. We conclude that different virus entities in anterior uveitis present specific risks for the development of glaucoma as well as necessary surgery. MIGS can be suggested as first-line-treatment in individual cases, however, the device needs to be carefully chosen by experienced specialists based on the individual needs of the patient. Filtrating glaucoma surgery can be recommended in VAU as an effective therapy to reduce the IOP over a longer period of time

Influence of Selective Laser Trabeculoplasty (SLT) on the iStent inject® outcomes

Background: To evaluate the influence of Selective Laser Trabeculoplasty (SLT) on iStent inject® outcomes in open-angle glaucoma (OAG). Methods: In this retrospective comparative cohort outcome study, 66 patients who were treated with two iStent inject® devices were included. Patients were divided into two subgroups consisting of patients without SLT treatment prior to surgery and patients who had been treated previously with 360° SLT but without sufficient response. Outcome measures included intraocular pressure (IOP) and number of antiglaucoma medications after 6 weeks with three, six, 12, and 24 month follow-ups. Results: Mean preoperative IOP decreased from 20.4 ± 5.3 mmHg to 14.8 ± 3.0 mmHg for patients without SLT treatment prior to surgery (p = 0.001) and from 19.2 ± 4.5 mmHg to 14.0 ± 1.6 mmHg for patients with insufficient response to 360° SLT treatment (p = 0.027) at 12 months after iStent inject® implantation. No significant difference was found between the two groups (p > 0.05). The number of antiglaucoma medications did not change in both groups (p > 0.05) and showed no significant difference between the two groups (p > 0.05). Conclusion: Prior SLT treatment seems to have no negative influence on the IOP lowering-effect of iStent inject® implantation in patients with OAG. It is therefore an appropriate incremental procedure with no exclusion criterion for an iStent inject® implantation

Aktuelle chirurgische und medikamentöse Therapieansätze im Glaukom

Die Diagnose Glaukom führt zur Einleitung therapeutischer Schritte; im Regelfall Beginn einer antiglaukomatösen Tropfenapplikation oder einer chirurgischen Intervention. Die klinischen Leitlinien (European Glaucoma Society EGS Guidelines 4th Ed.) empfehlen aktuell Therapieansätze zur Augeninnendruckreduktion als wichtigstem Risikofaktor der Glaukom- Progression. Mit der Entwicklung minimal-invasiver Operationsverfahren kann eine zusätzliche Möglichkeit zur effektiven Drucksenkung mit Erhalt der Lebensqualität in milden bis moderaten primären und sekundären Offenwinkelglaukomen den Patienten angeboten werden. Sie können dem Patienten sowohl als nächster Schritt bei insuffizienter Tropfentherapie als auch bei aus persönlichen Gründen abgelehnter antiglaukomatöser Therapie offeriert werden, bevor bulbuseröffnende, filtriende Verfahren eingesetzt werden müssen. Zusätzlich rückt ein neuroprotektiver Therapieansatz immer stärker in den Vordergrund. In den letzten 25 Jahren wurde noch einmal systematisch aufgearbeitet, dass das Glaukom als eine neurodegenerative Erkrankung durch Apoptose der retinalen Ganglienzellen und deren Axone zu definieren ist. Es liegt sowohl eine neuronale Degeneration im visuellen Signalweg als auch eine zerebrale diffuse Diffusionsstörung vor. Eine rein drucksenkende Therapie ist daher nicht immer imstande, die Progression eines Sehnervschadens langfristig aufzuhalten. Neuroprotektive Wirkstoffe entstammen nicht einer biochemischen Familie, sondern sind Faktoren aus unterschiedlichen Signalkaskaden mit anti-oxidativen, anti-inflammatorischen und anti-Protein aggregierenden Eigenschaften. Vielversprechende Ergebnisse der in vivo Tiermodellstudien zeigen eine signifikante neuroprotektive Wirkung von Curcumin und Coq10 auf die retinale Ganglionzelle. Zusammenfassend steckt der Einsatz neuroprotektiver Wirkstoffe in den Kinderschuhen. Trotz vieler in vivo Tiermodell-Studien erleben wir erst den Beginn der Translation der Neuroprotektiva auf den Menschen

Comparison of ICare and IOPen vs Goldmann applanation tonometry according to international standards 8612 in glaucoma patients

AIM: To compare IOPen and ICare rebound tonometry to Goldmann applanation tonometry (GAT) according to International Standards Organization (ISO) 8612 criteria. METHODS: Totally 191 eyes (n=107 individuals) were included. Criteria of ISO 8612 were fulfilled: 3 clusters of IOP, measured by GAT, were formed. The GAT results were given as mean±standard deviation. RESULTS: GAT (19.7±0.5 mm Hg) showed a significant correlation to ICare (19.8±0.5 mm Hg) (r=0.547, P<0.001) and IOPen (19.5±0.5 mm Hg) (r=0.526, P<0.001). According to ISO 8612 criteria in all 3 IOP groups the number of outliers (of the 95% limits of agreement) exceeded 5% for ICare and IOPen vs GAT: No.1 (n=68) 29.4% and 22.1%, No.2 (n=62) 35.5% and 37.1%, No.3 (n=61) 26.2% and 42.6%, respectively. CONCLUSION: The strict requirements of the ISO 8612 are not fulfilled in a glaucoma collective by ICare and IOPen at present. As long as the Goldmann tonometry is applicable it should be used first of all for reproducible IOP readings. ICare and IOPen tonometry should be considered as an alternative tool, if application of Goldmann tonometry is not possible

Correlation of NUCB2/Nesfatin-1 with Cytokine Levels in Primary Open-Angle Glaucoma

Purpose: Nesfatin-1 is produced in various tissues of the body including the hypothalamus. Neuroprotective properties of the neuropeptide hormone Nesfatin-1 were recently described. The aim of the study was to analyze the molecule Nesfatin-1 as a possible biomarker in POAG with neuroprotective properties pointing out the retinal-hypothalamic axis as target site in POAG and to obtain a molecular signature of cytokines in POAG as neuroinflammatory processes are a key factor of glaucoma development. Methods: In this study, n=35 patients with moderate and advanced POAG (mean age 65.0y, IOP 13.9 ± 3.0mmHg) and n=35 healthy controls (mean age 51.6y, IOP 14.3 ± 2.7mmHg) were included. Clinical parameters including IOP, cup to disc ratio (CDR), glaucoma medication and retinal nerve fiber layer thickness (RNFL) were recorded. Plasma was collected for NUCB2/nesfatin-1 measurement using a Nesfatin-1 ELISA and for detection of 13 inflammatory cytokines using a multiplex bead-based immunoassay (MagPix). Multiple linear regression analysis was performed to adjust for confounding factors. Results: Sex-independent or sex-dependent variables showed no significant differences in the Nesfatin-1 level (p>0.05). As a trend, an increase in NUCB2/nesfatin-1 in male glaucoma patients was found. Increased concentrations of 11 cytokines (GM-CSF, Interferon-γ, Interleukin-1β, IL-2, 4, 5, 6, 7, 10, 12 and TNF-α) were detected in POAG. The female glaucoma patients demonstrated elevated cytokine concentrations compared to male patients. NUCB2/nesfatin-1 showed a significant correlation to IL-2 and IL-13 levels in POAG. Stepwise multiple regression analysis showed no difference in NUCB2/nesfatin-1 level between POAG and healthy controls after adjusting for sex and age (all p>0.05). Conclusion: As a trend, male POAG patients showed increased plasma NUCB2/nesfatin-1 levels. We further found inflammation as contributing factor to the pathogenesis of glaucoma, with a greater inflammatory response in women