Effectiveness of Laser Goniopuncture as an Adjuvant Therapy to Non-Penetrating Deep Sclerectomy for Lowering Intraocular Pressure

Purpose : The purpose of this study is to examine the efficacy of laser goniopuncture (LG) in lowering intraocular pressure(IOP) after non-penetrating deep sclerectomy (NPDS). A minority of eyes undergoing successful NPDS demonstrate gradual increase in IOP 6-24 months after the procedure despite maintenance of good bleb elevation and an open superior angle. This is often the result of accretion of protein or pigment in the intact internal trabeculum diminishing the flow of aqueous into the intrascleral lake and bleb. Nd/YAG laser can be used to disrupt this material and modify the trabeculum restoring aqueous flow. Methods : Retrospective chart review. Inclusion criteria were all adults who had undergone NPDS with 0.4mg/ml Mitomycin C who thereafter unilateral LG after developing gradual IOP increase prior between January 2012 and August 2018, with pre-operative IOP measurements taken on the same day of the subsequent laser procedure. GP was performed using a Goldmann 4-mirror lens. Laser settings were typically set high, between 6 and 9 mJ, using the Ellex YAG, with a total energy application range between 500 and 800 mJ. IOP measurements of the same eye at subsequent visits were recorded along with date of appointment. IOP comparisons from baseline were performed using paired t-tests. Results : Mean IOP before LG was 25.4±9.4 (range: 11-62, N=78). Mean IOP for monthly intervals as follows: 11.2±6.8 (range: 3-39, N=43) at one month, 11.9±5.5 (range: 3-39, N=58) within six months, and 14±3.7 (range 9-23, N=31) at twelve to eighteen months after LG. Mean IOP differences compared to baseline were 15.3±11.1 (p\u3c0.001, 95% CI=11.9-18.7), 14±11.5 (p\u3c0.001, 95% CI=10.9-17.0), and 9.5±8.6 (p\u3c0.001, 95% CI=6.3-12.6), respectively. Conclusions : Laser goniopuncture was an effective adjuvant treatment modality for enhancing the efficacy of non-penetrating deep sclerectomy (NPDS) in lowering IOP, and was able to achieve a mean target IOP of 15 for up to eighteen months post-LG

A Rare Case of Vomiting-Induced Retrobulbar Hemorrhage

Retrobulbar hemorrhage may result in sudden accumulation of blood in the retrobulbar space which can lead to an orbital compartment syndrome. This potentially blinding condition is characterized by a rapid increase in intra-orbital pressure. While most commonly associated with orbital trauma, it may rarely occur with Valsalva events in patients on anticoagulants. In this report, we present a case of a retrobulbar hemorrhage secondary to self-induced vomiting, occurring in a patient on no anticoagulation medication

Effect of Pral Lumega-Z on Pericentral FDT Function in IOP-Stabilized Severe Glaucoma

Purpose : In some patients with advanced glaucoma pericentral visual function may continue to deteriorate despite excellent IOP control. This study assesses the potential utility of a recently introduced medical food, Lumega-Z, designed to restore the macular protective pigment layer. It contains \u3e35 micronutrients with antioxidant characteristice and three key carotenoids, lutein, zeaxanthine and meso-zeaxanthene. The latter, an enantiomer of lutein, is produced by isomerase conversion in juvenile primates but this enzyme is lacking in adults. Mesozeaxanthene is not available in standard diet, but can be prescribed in liquid suspension by eye care providers under Section 403(q)(5)(A)(iv) of the FDCA. This study evaluates the effect of Lumega-Z among compliant patients with severe glaucomatous visual field loss whose pericentral visual function was continuing to degenerate in at least one eye despite excellent IOP control. Methods : Patients confirmed to have ordered 12 consecutive months supply of Lumega-Z were evaluated by FDT 30-2. The attenuation threshold values for the central 5 loci were summed, and baseline values were compared with those obtained at 12 months. All subjects were perimetrically experienced with \u3e3 prior FDTs and demonstrated high reliability. Statistical significance of change was assessed by paired t-test. This assessment was a retrospective chart review of patients who had already elected to receive this treatment as part of their normal clinical treatment, and their masked alphanumeric data was assessed under noninvasive IRB waiver. Results : 20 eyes of 11 patients were assessed (2 monocular; 7F4M, mean age 75). Mean cumulative pericentral FDT threshold baseline values were 26.28(sem 1.3) versus 27.28(1.1) 12 months post-initiation of Lumega-Z (P=0.05; t=2.08, df=19, sed 0.48, 95%ci -2.0 to 0.004). No other change in therapy was carried out among any of the eyes under study during this assessment interval. Conclusions : Lumega-Z treatment was associated with significant improvement in FDT pericentral function among patients with severe glacuoma who had previously shown degeneration despite having had excellent intraocular pressure control

Orbital Apex Inflammation: A Curious Case of COVID-19

A 25-year-old man presented to an urgent care facility with sudden loss of vision in his right eye, diplopia, and anosmia. He tested positive by reverse-transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Nine days later, he presented at our emergency department, at which time ophthalmic examination revealed reduced visual acuity in the right eye, with poor color vision and a relative afferent pupillary defect. He had a moderate adduction deficit and mild hypertropia of the right eye, with an intermittent exotropia. Magnetic resonance imaging of the orbits revealed asymmetric, abnormal enhancement of the right optic nerve sheath extending to the right orbital apex. His ocular symptoms resolved completely with systemic steroids. All infectious and inflammatory labs returned negative except for COVID-19. Ocular findings have been consistently implicated throughout this pandemic. This case highlights an unidentified presentation with optic nerve involvement and orbital inflammation

Efficacy of Transcleral Diode Cyclophotocoagulation in a sub-Saharan Rural Population with Severe Glaucomatous Ocular Hypertension

Purpose : Gross elevation of intraocular pressure in patients with end stage glaucoma can be accompanied by chronic frontal headache, stabbing eye pain, and autonomic side effects including hyperhidrosis, indigestion, nausea, and cardiac arrhythmia. Topical antiglaucoma medications in rural sub-Saharan Africa are typically reserved for treatment of patients with survival of reading vision. This study assesses the efficacy of trans-scleral diode cyclodestruction in eyes of Malawian adult patients with uncontrolled ocular hypertension and BCVA of HM or worse. Methods : Consenting adult patients with end-stage glaucoma and uncontrolled ocular hypertension were treated ab externo with Iridex SLx 810 diodle laser via G-probe after placement of retrobulbar lidocaine under IRB-approved protocol. Applanation IOP at each visit was measured independently by 2 clinicians, and their readings averaged. IOP Change from baseline at each time interval was assessed by paired t-test. Results : 40 eyes of 33 patients (28M,5F; mean age 60) were treated. A mean of 19 spots were placed (+/-sem0.6) at a mean setting of 2059(+/-162)mW. Mean pre-treatment IOP was 38.1(+/-1.9)mmHg. Post-treatment IOP values at 1, 2 and 4 months were 24.3(+/-1.7), 22.8(+/-1.6) and 19.1(+/-1.1)mmHg, respectively (P\u3c0.00001 for all three intervals). Visual acuity was not significantly altered (2 eyes improved, all others stable), but symptomatic relief was reported by a majority of those undergoing diode laser treatment. No significant complications were encountered. Conclusions : Mean intraocular pressure was decreased by 36%, 40%, and 50% at one, two and four months after trans-scleral diode cyclophotocagulation, achieving normal mean IOP level by 4 months without additional therapy. The diode treatments fit well into the clinical routine, and these very encouraging results with standard trans-scleral diode in end-stage patients has motivated us to move forward with a similar prospective program of micropulse diode cyclophotooagulation for patients with moderate to severe glaucoma

Effect of Selective Laser Trabeculoplasty in a sub-Saharan Rural Population

Purpose : Recent studies have demonstrated uniquely high efficacy of selective laser trabeculoplasty (SLT) in glaucoma patients of African heritage in St. Lucia, West Indies and Durban, South Africa. These results are encouraging because both medication and incisional surgery are impractical long-term options in rural sub-Saharan Africa, where glaucoma is the leading cause of permanent blindness, and facilities and financial resources are scarce, with only one opththalmologist per million population. This study assesses the potential utility of SLT among a rural population in one of Africa\u27s most economically deprived regions at the Eyes of Africa Clinic, a facility where wind and solar power provide the only reliable source of electrical power. Methods : Consenting adult glaucoma patients with inadequate IOP control on a single topical agent were offered the opportunity to undergo SLT treatment in either or both eyes. Baseline IOP values were compared with those obtained at 1-2 wks, 4, 8 & 12 wks by paired t-test. Laser settings were agressive, aiming to elicit champagne bubbles from the trabecular meshwork with each application. The Latina SLT lens was used with the Ellex Tango YAG/SLT. Topical brimonidine and proparacaine were applied prior to treatment, and prednisolone acetate 1% immediately afterward. Results : 112 eyes of 79 patients on topical monotherapy (102 on timolol; 18F,61M; mean age 61.9(+/-sem2.3) underwent 360 degree SLT with a mean of 106(+/-3) applications at mean 1.65(+/-0.04)mJ. Their mean pre-treatment IOP was 29.6(+/-1.8)mmHg. 1-2 wks post laser mean IOP values were unchanged (29.6(+/-1.8)). By 4 weeks post-SLT mean IOP had decreased to 24.8(+/-1.7)mmHg (P=0.0035). At 8 weeks the mean IOP was 20.4(+/-0.9)mmHg(P Conclusions : Mean IOP reduction ~10 mmHg (was achieved at 3 months using aggressive SLT settings among the eyes of this central African population already receiving one topical antiglaucoma medication for their substantially elevated eye pressure. This IOP response is commensurate with response levels observed previously in South Africa and the West Indies, and is comparable in its extent to mean % IOP reduction typically associated with incisional glaucoma surgery

Pregnancy and neonatal outcomes of COVID -19: coreporting of common outcomes from PAN-COVID and AAP-SONPM registries

Objective Few large cohort studies have reported data on maternal, fetal, perinatal and neonatal outcomes associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection in pregnancy. We report the outcome of infected pregnancies from a collaboration formed early during the pandemic between the investigators of two registries, the UK and Global Pregnancy and Neonatal outcomes in COVID‐19 (PAN‐COVID) study and the American Academy of Pediatrics (AAP) Section on Neonatal–Perinatal Medicine (SONPM) National Perinatal COVID‐19 Registry. Methods This was an analysis of data from the PAN‐COVID registry (1 January to 25 July 2020), which includes pregnancies with suspected or confirmed maternal SARS‐CoV‐2 infection at any stage in pregnancy, and the AAP‐SONPM National Perinatal COVID‐19 registry (4 April to 8 August 2020), which includes pregnancies with positive maternal testing for SARS‐CoV‐2 from 14 days before delivery to 3 days after delivery. The registries collected data on maternal, fetal, perinatal and neonatal outcomes. The PAN‐COVID results are presented overall for pregnancies with suspected or confirmed SARS‐CoV‐2 infection and separately in those with confirmed infection. Results We report on 4005 pregnant women with suspected or confirmed SARS‐CoV‐2 infection (1606 from PAN‐COVID and 2399 from AAP‐SONPM). For obstetric outcomes, in PAN‐COVID overall and in those with confirmed infection in PAN‐COVID and AAP‐SONPM, respectively, maternal death occurred in 0.5%, 0.5% and 0.2% of cases, early neonatal death in 0.2%, 0.3% and 0.3% of cases and stillbirth in 0.5%, 0.6% and 0.4% of cases. Delivery was preterm (< 37 weeks' gestation) in 12.0% of all women in PAN‐COVID, in 16.1% of those women with confirmed infection in PAN‐COVID and in 15.7% of women in AAP‐SONPM. Extreme preterm delivery (< 27 weeks' gestation) occurred in 0.5% of cases in PAN‐COVID and 0.3% in AAP‐SONPM. Neonatal SARS‐CoV‐2 infection was reported in 0.9% of all deliveries in PAN‐COVID overall, in 2.0% in those with confirmed infection in PAN‐COVID and in 1.8% in AAP‐SONPM; the proportions of neonates tested were 9.5%, 20.7% and 87.2%, respectively. The rates of a small‐for‐gestational‐age (SGA) neonate were 8.2% in PAN‐COVID overall, 9.7% in those with confirmed infection and 9.6% in AAP‐SONPM. Mean gestational‐age‐adjusted birth‐weight Z‐scores were −0.03 in PAN‐COVID and −0.18 in AAP‐SONPM. Conclusions The findings from the UK and USA registries of pregnancies with SARS‐CoV‐2 infection were remarkably concordant. Preterm delivery affected a higher proportion of women than expected based on historical and contemporaneous national data. The proportions of pregnancies affected by stillbirth, a SGA infant or early neonatal death were comparable to those in historical and contemporaneous UK and USA data. Although maternal death was uncommon, the rate was higher than expected based on UK and USA population data, which is likely explained by underascertainment of women affected by milder or asymptomatic infection in pregnancy in the PAN‐COVID study, although not in the AAP‐SONPM study. The data presented support strong guidance for enhanced precautions to prevent SARS‐CoV‐2 infection in pregnancy, particularly in the context of increased risks of preterm delivery and maternal mortality, and for priority vaccination of pregnant women and women planning pregnancy. Copyright © 2021 ISUOG. Published by John Wiley & Sons Ltd