Algorithm of selecting the tear replacement therapy in ambulatory practice

Brzheskiy V.V. St. Petersburg State Pediatric Medical University Aim: to determine the algorithm for selecting artificial tears for tear-replacement therapy for patients with different etiopathogenesis and clinical course of the dry eye syndrome. Patients and Methods: the analysis of fragments of studies performed by us in different years, which is based on the results of examination, treatment and follow-up of 820 patients with dry eye syndrome of different etiology and with different clinical course of the disease with a comparative analysis of the efficacy of “artificial tear” preparations registered in Russia. Results: the choice of the «artificial tear» preparation depends on the pathogenesis of the dry eye syndrome, the severity of its clinical course and the concomitant pathology of the cornea and conjunctiva in a particular patient. The pathogenetic orientation of tear replacement therapy is based on the elimination of the cause of disorder in the tear film stability. “Artificial tear” preparations based on hyaluronic acid and other natural polysaccharides, as well as carboxymethylcellulose, are effective in case of mucin component deficiency. The aqueous layer can be replaced with any low viscosity, medium viscosity and high viscosity «artificial tear», and lipid layer - with Cationorm or Systein Balance preparations. The severity of the xerotic process determines the patient compliance to preparations with certain viscosity: preservative-free low-viscosity preparations are effective in case of mild and extremely severe xerosis, preservative-free high viscosity preparations and gels are most effective in moderate and severe xerosis, respectively. «Artificial tear» preparations containing additional ingredients (metabolic, anti-inflammatory, antioxidant, osmoprotective, etc.) are used depending on the concomitant pathology of the cornea and conjunctiva. Conclusion: further studies with the analysis of the effectiveness of new drugs will make it possible, on the one hand, to refine the algorithm we considered, and to develop pathogenetically oriented compositions of artificial tears, on the other. Key words: dry eye syndrome, tear-replacement therapy, artificial tears. For citation: Brzheskiy V.V. Algorithm of selecting the tear replacement therapy in ambulatory practice //&nbsp;RMJ “Clinical ophthalmology”. 2018;1:13–19. <br

Modern possibilities of sodium hyaluronate in tear substitutive therapy of patients with “dry eye” syndrome

V.V. Brzheskiy, V.Yu. Popov St. Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation At present, artificial tear preparations based on sodium hyaluronate account for 53.3% of the total of 45 tear substitutes registered in Russia, of which 72.7% are from 22 of their non-preservative forms. The positive properties of hyaluronic acid (hygroscopicity, mucoadhesiveness, high tolerability when instilled into the conjunctival cavity) provide long-lasting hydration of an eye surface during its xerosis and cause high clinical efficacy in the treatment of patients with “dry eye” syndrome (DES). The same properties are naturally possessed by such preparations as Vismed, Vismed light, Vismed multi and Vismed gel, based on the sodium salt of the high molecular weight hyaluronic acid. In a number of experimental studies, the efficacy and safety of the Vismed line is proved: in vitro — on the culture of epithelial cells of the human conjunctiva, in vivo — on the model of traumatic corneal erosion in rabbits. The results of the experiments were further confirmed by clinical studies in the treatment of patients with DES of various origins. In this case, the Vismed line was more effective than solutions of carboxymethylcellulose, hydroxypropylmethylcellulose, carbomer 934P, and other compounds widely used in tear substitutive therapy. Key words: hyaluronic acid, artificial tear preparations, “dry eye” syndrome, Vismed. For citation: Brzheskiy V.V., Popov V.Yu. Modern possibilities of sodium hyaluronate in tear substitutive therapy of patients with&nbsp; “dry eye”syndrome. RMJ “Clinical ophthalmology”. 2018;4:179–185.<br

Realization of a cascade treatment algorithm for glaucoma in St. Petersburg

A.V. Antonova1, V.P. Nikolaenko1,2, V.V. Brzheskiy3 1City Multidisciplinary Hospital No. 2, St. Petersburg, Russian Federation 2St. Petersburg State University, St. Petersburg, Russian Federation 3St. Petersburg State Pediatric Medical University, St. Petersburg, Russian Federation Aim: to analyze the duration and regimen of topical treatment and the pattern of prior laser and surgical procedures in patients with glaucoma who were admitted to the hospital for IOP-lowering interventions. Patients and Methods: this study included 500 consecutively enrolled patients who underwent surgery for uncontrolled glaucoma in 2016–2020 and were followed up for 6–24 months. Disease history, cumulative "preservative" load, clinical examinations, and surgical outcomes were assessed. Results: preoperatively, most patients received the maximum medical therapy (i.e., three agents in two bottles). Simultaneous use of all four major classes of IOP-lowering medications occurred in 10% of patients only. Two-third of patients required surgical interventions to reduce IOP after a 6-year medical therapy. By the time of admission, 60% of patients were diagnosed with advanced or end-stage glaucoma. Prior laser or surgical procedures to reduce IOP were performed only in 142 patients and 52 patients, respectively. Treatment adherence was lower in men compared to women, irrespective of its stage. Conclusion: most patients received adequate medical therapy. However, in general, surgery was performed too late. It gives the impression that the efficacy of therapeutic and laser stages of cascade glaucoma treatment is no more than five years. In addition to the obvious drawbacks of a laissez-faire strategy (irreversible vision loss), the risk of surgical failure significantly increases. Long-term (at least 3-year) therapy using (non)fixed-dose combinations of agents containing preservatives is the major modifiable risk factor for early filtration loss. Preservative-free prostaglandin analogues improve treatment tolerability, adherence to treatment, and chances for success of IOP-lowering surgery. The authors’ results demonstrate that gender differences should be considered when planning treatment and follow-up visits. Keywords: glaucoma, IOP-lowering therapy, glaucoma surgery, ocular surface, preservatives, benzalkonium chloride. For citation: Antonova A.V., Nikolaenko V.P., Brzheskiy V.V. Realization of a cascade treatment algorithm for glaucoma in St. Petersburg. Russian Journal of Clinical Ophthalmology. 2021;21(3):123–128 (in Russ.). DOI: 10.32364/2311-7729-2021-21-3-123-128. </p

IOP-lowering therapy and ocular surface in glaucoma. Part 1. The effects of drug substances of glaucoma medications on the ocular surface

A.V. Antonova1, V.P. Nikolaenko1,2, V.V. Brzheskiy3 1City Multidisciplinary Hospital No. 2, St. Petersburg, Russian Federation 2St. Petersburg State University, St. Petersburg, Russian Federation 3St. Petersburg State Pediatric Medical University, St. Petersburg, Russian Federation This article reviews recent data on the effect of active ingredients and preservatives of IOP-lowering medications on the ocular surface. The rate and severity of ocular surface disease depend on the intensity and duration of glaucoma treatment as well as baseline ocular surface status. In addition, each class of IOP-lowering medications is characterized by specific effects on ocular surface. Long-term pharmacotherapy results in tear film instability and tear hyperosmolarity. Dose- and exposition-dependent loss of goblet cells, corneal epithelial toxicity, meibomian gland dysfunction, increased activity and expansion of fibroblasts, and pro-inflammatory cytokine release from goblet cells account for the development and progression of symptoms and signs of dry eye as demonstrated by progressive deterioration in Ocular Surface Disease Index (OSDI), Norn’s test, and Schirmer’s test. The result is poor adherence to medical treatment and poor outcomes&nbsp; of conjunctival glaucoma surgery.&nbsp; Our findings can be applied to develop perioperative management strategy of patients with glaucoma to maximize the chances of long-term surgical success. Keywords: glaucoma, IOP-lowering treatment, ocular surface, dry eye disease, Ocular Surface Disease Index, inflammation, preservatives, benzalkonium chloride, preservative-free medication. For citation: Antonova A.V., Nikolaenko V.P., Brzheskiy V.V. IOP-lowering therapy and ocular surface in glaucoma. Part 1. The effects of drug substances of glaucoma medications on the ocular surface. Russian Journal of Clinical Ophthalmology. 2020;20(2):79–84. DOI: 10.32364/2311-7729-2020-20-2-79-84. <br

IOP-lowering therapy and ocular surface in glaucoma. Part 2. The effect of preservatives on ocular surface

IOP-lowering therapy and ocular surface in glaucoma. Part 2. The effect of preservatives on ocular surface A.V.&nbsp;Antonova1, V.P.&nbsp;Nikolaenko1,2, V.V.&nbsp;Brzheskiy3 1City Multidisciplinary Hospital No. 2, St. Petersburg, Russian Federation 2St. Petersburg State University, St. Petersburg, Russian Federation 3St. Petersburg State Pediatric Medical University, St. Petersburg, Russian Federation This article reviews published data from different years (mainly recent data) on the effect of active ingredients and preservatives of IOP-lowering medications on ocular surface. The rate and severity of ocular surface diseases are directly associated with dosage regimen and duration of topical glaucoma treatment. Dose-dependent and time-dependent loss of goblet cells, expansion and activation of fibroblast populations, release of proinflammatory cytokines by conjunctival cells account for dry eye symptoms and signs, poor adherence to treatment, and poor results of glaucoma filtration surgery. However, the analysis of more than 16,000 PubMed publications using keywords “ocular surface” did not answer a number of important questions. Can ocular surface disease symptoms reduce following the surgery? Can ocular surface get back to its baseline anatomical functional state and provide long-term filtering bleb functioning? What is the maximum d uration of glaucoma pharmacotherapy to have a chance of ocular surface improvement after glaucoma surgery? The aim of our studies is to address these challenges. Keywords: glaucoma, glaucoma therapy, ocular surface, dry eye disease, OSDI, inflammation, preservatives, benzalkonium chloride, preservative-free agents. For citation: Antonova A.V., Nikolaenko V.P., Brzheskiy V.V. IOP-lowering therapy and ocular surface in glaucoma.&nbsp; Part 2. The effect of preservatives on ocular surface. Russian Journal of Clinical Ophthalmology. 2020;20(3):133–141. DOI: 10.32364/2311-7729-2020-20-3-133-141. <br

Addressing the specificities of contusion cataract surgery in adults

N.V. Kutukova1, A.&nbsp;Yu. Kutukov2, V.V. Brzheskiy2 1City Mariinskaya Hospital, St. Petersburg, Russian Federation 2St. Petersburg State Pediatric Medical University, St. Petersburg, Russian Federation Aim: to assess the clinical course and surgical procedures for contusion cataracts. Patients and Methods: 50 patients with a contusion cataract who underwent surgical treatment in 2008–2018 were included in the study group. 50 patients with a complicated cataract, either along with glaucoma (n=25) or diabetic cataract (n=25), were included in the control group. All patients were examined and treated in the same manner (i.e., eye exam was performed at admission, before the surgery, on postoperative days 1–3, and 1, 3, and 6 months after the surgery). Results: unilateral cataracts were revealed in the study group and bilateral cataracts were revealed in the control group. More than two-third of study group patients and only 14% of controls have the clinical signs of subluxated lens. In the study group, lens opacities were polymorphic. In the control group, nuclear opacities occurred in 30%, cortical opacities in 32%, and mixed opacities in 38%. In the course of&nbsp; surgical procedures, previously undiagnosed mild lens subluxation was identified in 12% of study group patients and less than 6% of controls. The total rate of zonular insufficiency in the study group was twice as much as in the control group. Additional devices (i.e., iris and capsular retractors, capsular tension rings etc.) were used in 46% of study group patients and 20% of control group patients. Visual acuity more than 12/20 was reported in 86% of study group patients and only 32% of control group patients. Conclusions: the clinical course and surgical performance of contusion cataracts should be considered when examining and operating these patients. Occult minimal lens subluxation is also important. Keywords: complicated cataract, traumatic cataract, contusion cataract, lens subluxation, iris capsular retractor, capsular tension ring, surgical specificities. For citation: Kutukova N.V., Kutukov A.Yu., Brzheskiy V.V. Addressing the specificities of contusion cataract surgery in adults. Russian Journal of Clinical Ophthalmology. 2020;20(4):187–190. DOI: 10.32364/2311-7729-2020-20-4-187-190. <br

Effect of gender on the ocular surface after trabeculectomy

A.V. Antonova1,2, V.P. Nikolaenko1,2, V.V. Brzheskiy3, A.Ja. Vuks4 1St. Petersburg State University, St. Petersburg, Russian Federation 2City Multidisciplinary Hospital No. 2, St. Petersburg, Russian Federation 3St. Petersburg State Pediatric Medical University, St. Petersburg, Russian Federation 4V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, St. Petersburg, Russian Federation Background: the effect of gender on the rate and course of ocular surface diseases (in particular, conjunctival and corneal xerosis) is fairly well known. Meanwhile, gender-dependent changes in the ocular surface after trabeculectomy have not yet been studied. Aim: to analyze the effect of gender on changes in the ocular surface after trabeculectomy. Patients and Methods: this study enrolled 443 patients (168 men and 275 women) who underwent surgical interventions for uncontrolled primary open-angle glaucoma (POAG) in 2016–2020 and were followed up for 6–24 months. Trabeculectomy was performed as the first IOP-lowering procedure in 418 patients (150 men and 268 women) and reoperation in 25 patients (18 men and 7 women). Changes in subjective symptoms (OSDI) and clinical and functional signs of dry eye syndrome (tear film break-up time/TBUT and total tear production by Schirmer's I test) characterizing the ocular surface in various surgical outcomes (complete and partial success, failure) in men and women were analyzed. Results: women have more severe subjective symptoms but not functional signs of dry eye preoperatively. They are characterized by strict adherence to treatment (manifested in lower initial IOP compared with men) but more frequent eye drop instillations and greater cumulative preservative load on the ocular surface. Gender is not an independent risk factor for surgical failure. Successful trabeculectomy results in a significant reduction in the severity of conjunctival and corneal xerosis symptoms (OSDI) for at least 2 years in both genders. Despite clear postoperative improvement, women are significantly inferior to men in this parameter at all study control points. TBUT in both men and women increases significantly during the first 6 months postoperatively, and over the next 1.5 years TBUT stabilizes at the achieved level. An increase in Schirmer's I test results in men becomes significant only at the end of the second year of follow-up. In women, a significant increase in total tear production is reported as early as 6 months after trabeculectomy and changes slightly over the next 1.5 years. Restarting IOP-lowering medications in partial success and failure of trabeculectomy eliminates the improvement of ocular surface condition achieved during the drug-free period as early as after 6 months. Conclusions: regardless of gender, successful trabeculectomy results in a significant and long-term (at least 2 years) improvement of subjective symptoms (OSDI) and functional signs (in particular, TBUT) of conjunctival and corneal xerosis. Women are characterized by a clearer improvement in the parameters studied than men. Significant gender differences are found only when comparing subjective symptoms in the first year after surgery. Restarting IOP-lowering medications postoperatively brings the parameters back to baseline levels. Keywords: gender, glaucoma, trabeculectomy, ocular surface, dry eye disease, OSDI, tear film break-up time, TBUT, Norn's test, Schirmer's I test. For citation: Antonova A.V., Nikolaenko V.P., Brzheskiy V.V., Vuks A.Ja. Effect of gender on the ocular surface after trabeculectomy. Russian Journal of Clinical Ophthalmology. 2023;23(3):136–145 (in Russ.). DOI: 10.32364/2311-7729-2023-23-3-5. <br

Secondary aphakic glaucoma in children: a 15-year retrospective study

N.N. Sadovnikova, V.V. Brzhesky, M.A. Zertsalova, A.Yu. Baranov St. Petersburg State Pediatric Medical University, St. Petersburg, Russian Federation Aim: to assess the incidence of glaucoma in children who underwent congenital cataract surgery, to determine the risk factors for its development. Patients and Methods: this retrospective study included 206 children (301 eyes) aged 10 years or less who underwent congenital cataract surgery in the Ophthalmology Department of St. Petersburg State Pediatric Medical University (SPbGPMU) with an average follow-up period of 8.8±0.2 years. The children were divided into 4 groups by age at the surgical procedure. Group 1 included children operated on at the age of 90 days and younger; group 2 — aged from 91 to 365 days; group 3 — from 1 year to 4 years 11 months 29 days old; group 4 — from 5 to 10 years old. Co-existing ocular disorders were present in 247 (82,1%) eyes. Co-occurring extraocular disorders were found in 52 (25,2%) of 206 operated patients. Results: by the last visit, no patient in group 4 developed glaucoma. Glaucoma was diagnosed in 21 eyes (27.3%) of 14 patients from group 1, in 16 eyes (21.1%) of 12 patients from group 2 and in 10 eyes (12.5%) of 8 patients from group 3. In 57.4% of cases, glaucoma was controlled with medications, and surgery was performed on 20 eyes, including sinus trabeculectomy and Ahmed valve implantation. Statistically significant risk factors for the development of secondary glaucoma encompassed cataract extraction in children younger than 1 year of age, microcornea, additional intraocular surgical interventions, and aphakia. Conclusion: a less effective visual outcome of aphakic glaucoma treatment is caused by multiple factors, including amblyopia, nystagmus, as well as delayed diagnosis and untimely surgical intervention. Thus, to ensure early diagnosis of glaucoma, it is necessary to put tonometry and measurement of the axial length of the eye on the list of diagnostic tools for the outpatient follow-up of patients who underwent congenital cataract surgery. Keywords: aphakic glaucoma, congenital cataract, Ahmed valve, Cataract extraction, microcornea, aphakia, intraocular surgical interventions. For citation: Sadovnikova N.N., Brzhesky V.V., Zertsalova M.A., Baranov A.Yu. Secondary aphakic glaucoma in children: a 15-year retrospective study. Russian Journal of Clinical Ophthalmology. 2023;23(2):80–85 (in Russ.). DOI: 10.32364/2311-7729-2023-23-2-80-85. <br

The efficacy of sinustrabeculectomy in the modern clinical practice

A.V. Antonova1,2, V.P. Nikolaenko1,2, V.V. Brzhesky3, A.Ya. Vuks4 1St. Petersburg State University, St. Petersburg, Russian Federation 2City Multidisciplinary Hospital No. 2, St. Petersburg, Russian Federation 3St. Petersburg State Pediatric Medical University, St. Petersburg, Russian Federation 4V.M. Bekhterev National Medical Research Center of Psychiatrics and Neurology, St. Petersburg, Russian Federation Aim: to assess the hypotensive effect of sinustrabeculectomy (STE) carried out within the "cascade" treatment algorithm for glaucoma. Patients and Methods: this open prospective interventional single-center cohort study was performed in 443 consequently included patients who underwent surgery for primary open-angle non-compensated glaucoma (POAG) and then were under follow-up for 6–24 months. The STE outcomes were evaluated using commonly accepted criteria of "complete success" and "qualified success", as well as "qualified failure" and "complete failure". The analysis of postoperative intraocular pressure (IOP) changes over time was performed using statistical methods. Results: the "complete success" of surgical operation achieved in 305 (68.9%) cases was associated with a significant and long-lasting decrease (at least for two years) in IOP values. The "qualified success", assuming that the renewal of medication therapy was an essential condition for maintaining a steady IOP was reported in 118 (26.6%) cases. Thus, the surgical treatment in combination with the postoperative hypotensive therapy helped to normalize IOP for at least two years in 423 (95.5%) patients of the study group. The "complete" STE failure due to the loss of filtration and the onset of indications for repeat surgery was reported in 20 (4.5%) cases. The triple combination treatment of glaucoma does not preclude from initiating further surgical IOP normalization and can be used safely prior to planned STE. A statistically significant IOP decrease from the baseline was achieved in all patients (even in the "complete failure" cases) at all 3 endpoints of the study (at 6, 12 and 24 months). The most pronounced and stable decrease in IOP during a two-year follow-up was associated with the "complete success" STE. Conclusion: a statistically significant IOP decrease from the baseline was achieved in all patients even after the "complete failure" of the surgical treatment at all endpoints of the study. The most pronounced and stable decrease in IOP during a two-year follow-up was associated with the "complete success" STE. The preoperative IOP level did not correlate with the results of STE and cannot be considered as a factor predicting its success or failure. Keywords: glaucoma, sinustrabeculectomy , intraocular pressure, glaucoma surgery, cascade algorithm, complete success, qualified success, complete failure. For citation: Antonova A.V., Nikolaenko V.P., Brzhesky V.V., Vuks A.Ya. The efficacy of sinustrabeculectomy in the modern clinical practice. Russian Journal of Clinical Ophthalmology. 2023;23(1):21–26 (in Russ.). DOI: 10.32364/2311-7729-2023-23-1-21-26. </p

Changes in the functionality of tear film and autorefractometry reading after instillations of artificial tear products of different viscosity

V.V. Brzheskiy1, E.L. Efimova1, M.A. Kopylova1, P.V. Kocharina1, A.A. Primak1, V.P. Nikolaenko2 1St. Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation 2St. Petersburg State University, Saint-Petersburg, Russian Federation Aim: to study the changes in the critical parameters of tear film stability and autorefractometry in patients with mild dry eye syndrome (DES) after instilling artificial tear products of different viscosity. Patients and Methods: thirty patients aged 23–70 with mild bilateral DES were examined using the Visionix VX120+Dry Eye multi-diagnostic unit equipped with the TF-Scan to fix and assess tear film stability and tear breakup time (TBUT). The critical refraction and tear film parameters were evaluated by keratometry, corneal topography, TBUT, and tear meniscus height measurements. Next, an artificial tear product was instilled, i.e., group 1 (14 patients, 28 eyes) received a 0.15% sodium hyaluronate-based preparation, and group 2 (16 patients, 32 eyes) received a 0.4% sodium hyaluronate-based preparation. The examination was repeated after 30 sec and 5 min. Controls were seven healthy individuals (14 eyes). Results: in DES, breaks in the tear film appeared earlier and affected greater corneal surface area. A "Destabilized tear film area" parameter of the Visionix VX120+Dry Eye contributed significantly to the knowledge of tear film functionality, thereby empowering the diagnostic armamentarium in DES. As early as 30 sec after instillation of both artificial tear preparations, breakup-free time tended to increase, while the area of tear film destabilization tended to reduce. After 5 min, this trend continued to increase, particularly after instilling 0.15% sodium hyaluronate-based preparation. At the same time, changes in keratometry readings (i.e., sphere and cylinder) and astigmatism axis orientation were reported. Corneal refractive power (more in the flattest axis) increased, in particular, after the instillations of 0.15% hyaluronic acid. The range of changes was 0.00–0.75 D for the sphere power, 0.00–0.50 D for the cylinder power, and 0–69 degrees f or astigmatism axis orientation. Conclusions: our findings with the Visionix VX120+Dry Eye multi-diagnostic unit demonstrate a significant variation of autorefractometry readings in DES depending on the extent of ocular surface hydration. These phenomena raise questions about the accuracy of autorefractometry readings. Therefore, autorefractometry should be performed after normalizing tear film volume and stability. Keywords: dry eye syndrome, Visionix®, autorefractometry, tearscopy, the effect of artificial tears on results. For citation: Brzheskiy V.V., Efimova E.L., Kopylova M.A. et al. Changes in the functionality of tear film and autorefractometry reading after instillations of artificial tear products of different viscosity. Russian Journal of Clinical Ophthalmology. 2021;21(4):200–204 (in Russ.). DOI: 10.32364/2311-7729-2021-21-4-200-204. <br