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Purpose This study describes the virtual clinic triage system implementation process at Hospital Santa Maria—Centro Hospitalar Universitário Lisboa Norte (HSM-CHULN) and analyzes its results regarding healthcare outcomes for the patients and the system. Methods A retrospective analysis was performed, comparing two cohorts (pre-virtual cohort; virtual triage cohort). Outcomes related to waiting time, number of hospital visits, decisions at first contact, and ancillary exam–based decisions were reported. Results Two hundred and ninety-two charts were reviewed (pre-virtual cohort: 132; virtual cohort: 160). Mean waiting time between referral and the first medical contact with the glaucoma department decreased on average by 71.3 days (human contact: 286.6 days; virtual triage contact: 215.3 days). Triage system significantly decreased waiting time for glaucoma patients, with an average decrease of 326.8 days between referral and treatment decision. Triage staging allowed to label 107 (66.9; 95% confidence intervals (CI): 59.6%, 74.2%) as non-urgent; 30 (18.8%; 95% CI: 12.7%, 24.9%) as urgent, and 23 (14.3%; 95% CI: 8.9%, 19.7%) as immediate contact, with the scheduling of future appointments reflecting National Institute for Health and Care Excellence (NICE) guidelines in every patient. Moreover, the number of visits to perform the same exams and obtain the same clinical decisions was reduced by 63.6%. Conclusion Our virtual screening strategy significantly decreased waiting time, number of hospital visits, and increased chances of data-assisted clinical decision. While results can be further improved, this system can add value in an overburdened healthcare system, where triage systems with remote decision-making may be valuable tools in optimizing glaucoma care, even without allocation of extra resources.

Background Microvascular rarefaction due to hypertension has been linked to disease severity and end-organ complications. Optical coherence tomography angiography (OCTA) has been explored as a potential tool to evaluate the retinal microvascular network in hypertensive patients. Methods PubMed, Scopus, Web of Science, and Cochrane were systematically searched to 10th of September of 2021, along with a manual search. Studies that used OCTA as a primary diagnostic method to evaluate the macular microvasculature of hypertensive patients were included. Meta-analysis was performed using a random-effects model. Primary outcomes were macular vessel density (VD) and foveal avascular zone (FAZ) at the superficial and deep capillary plexus. Results Of 947 screened articles, 9 were found eligible for qualitative and quantitative analysis. VD in hypertensive patients was reduced when compared with controls in the fovea (0.93, 95% confidence interval [CI] 0.87–0.99, P = 0.023) and the parafovea (0.95, 95% CI 0.93–0.97, P < 0.001) of the superficial capillary plexus. FAZ was larger in the deep plexus of hypertensive patients (1.10, 95% CI 1.03–1.18, P = 0.003). VD reduction was found in patients with worsening blood pressure control in 3 studies and prolonged disease in 2 studies. Conclusions Microvascular rarefaction of the macula is found in hypertensive patients with a reduction of foveal and parafoveal VD and an increase of FAZ area. Disease duration and severity might be related to a microvascular rarefaction. OCTA could offer a novel tool for the assessment and follow-up of hypertensive patients.

INTRODUCTION: The implantation of the PRESERFLO™ MicroShunt (PMS) device has been shown to significantly lower increased intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG). However, guidelines on best practice for patient selection and pre-/peri-/postoperative care management are lacking. The aim of this modified Delphi panel was to achieve expert consensus on the role of the PMS to treat patients with glaucoma in Europe. METHODS: Twelve European glaucoma surgeons experienced with the PMS procedure participated in a three-round modified Delphi panel. A targeted literature review and expert steering committee guided round 1 questionnaire development. Consensus was set at a pre-defined threshold of at least 70% of panellists selecting 'Strongly disagree'/'Disagree' or 'Strongly agree'/'Agree' for six-point Likert scale questions, or at least 70% selecting the same option for multiple-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions. RESULTS: Consensus was achieved for 60.3% (n = 38/63), 60.0% (n = 18/30), and 100.0% (n = 11/11) of Likert/multiple-choice questions in rounds 1, 2, and 3, respectively. There was agreement that the PMS procedure is effective at reducing IOP in patients with high-tension POAG (greater than 21 mmHg). Although surgical techniques may vary slightly, consensus was reached on several points, including the importance of posterior application of mitomycin C (MMC). Panellists agreed that the PMS postoperative follow-up appointment schedule is reasonably predictable and mostly characterised by fewer visits than with trabeculectomy, particularly in the early phase. Although panellists agreed that combined cataract/PMS surgery and the use of non-MMC wound-healing modulators/antifibrotics during the procedure are possible, further data are needed to determine efficacy. CONCLUSION: The expert consensus reached in this panel will help inform best practice guidelines in the treatment of patients with glaucoma in Europe. Panellists also highlighted key areas for future research to improve understanding of the PMS in the treatment algorithm of glaucoma. ispartof: OPHTHALMOLOGY AND THERAPY vol:11 issue:5 pages:1743-1766 ispartof: location:England status: published

PRCIS Automated gonioscopy is a recent method of recording angle pictures. Our study shows that agreement between observers is moderate in most categories used in clinical practice, underlying its clinical usefulness but also room for improvement. INTRODUCTION Iridocorneal angle (ICA) imaging methods have been recently developed to record gonioscopic images. The purpose of this study was to perform an interrater agreement analysis of ICA photographs. METHODS Multicentric cross-sectional observational study. Consecutive patients in 2 ophthalmology departments underwent automated gonioscopy. One picture per quadrant from each eye was selected for randomization. Pictures were graded and analyzed by 4 masked glaucoma specialists regarding angle opening, width, Shaffer and Spaeth gradings and other findings. Fleiss' κ statistics was performed to assess interrater agreement. RESULTS A total of 50 patients were recruited, with the sample containing a variety of diagnosis including pseudoexfoliation (22%), angle-closure suspect (12%), and pigmentary glaucoma (4%). The sample included phakic (68%) and pseudophakic patients, as well as cases with gonio-implanted surgical devices (10%). There was moderate agreement on angle opening, angle width, presence of angle vessels, and peripheral anterior synechiae (κ=0.435, 0.511, 0.558, 0.488, respectively; P

Cataract and glaucoma are two of the most common ocular comorbidities. Cataract surgery has been shown to influence intra-ocular pressure (IOP) in patients with glaucoma; nevertheless, the extent of this effect remains controversial, especially in patients with open-angle glaucoma (OAG). The aim of this review is to determine the real effect of cataract surgery on IOP change in patients with OAG, focusing on data retrieved from randomised controlled trials (RCTs).A systematic review was performed, including six different RCTs that studied the net effect of cataract surgery on IOP. Eligibility criteria required a full washout from hypotensive therapy, allowing accurate measurement of unmedicated IOP, both before and after surgery.Included studies revealed a consistent reduction on IOP occurring after surgery, varying between 4.1 and 8.5 mmHg depending on the RCT. There was also a decrease in the number of glaucoma medications, with a mean reduction of 0.2-1.0 agents postoperatively. Evaluation of adverse outcomes of cataract surgery showed a very favourable safety profile.Although the role of cataract surgery in the algorithm of glaucoma treatment remains to be established, this review highlights a consistent decrease on IOP following surgery and a reduced dependency on glaucoma medications. Potential downgrade in medication can thus be considered in well-controlled glaucoma patients after phacoemulsification. PROSPERO registry: CRD42022343378.

PurposeTo compare outcomes of primary trabeculectomy using either mitomycin C (MMC) alone versus MMC augmented with intracamerular bevacizumab in patients with open-angle glaucoma.MethodsRetrospective, cohort, two-centre, comparative study. Patients’ data were screened between October 2015 and March 2019, with inclusion requiring a minimum follow-up of 24 months. Primary outcome was intraocular pressure (IOP) lowering at 24 months, with surgical success defined with different maximum IOP targets (≤18, ≤16 and ≤14 mm Hg) and at least 30% reduction and higher than 5 mm Hg. Absolute success was achieved if no IOP-lowering medication was needed and a qualified success if otherwise. Safety outcomes were analysed.ResultsA total of 110 eyes underwent trabeculectomy with MMC, 51 of these combined with intracamerular bevacizumab. Both strategies were effective in terms of IOP lowering (baseline vs 2 years postoperatively: 24.4 (8.0) mm Hg vs 12.1 (5.3) mm Hg in the MMC group; 25.1 (8.7) vs 10.8 (3.8) mm Hg in the MMC+bevacizumab group; pConclusionsIntracamerular bevacizumab in MMC-augmented primary trabeculectomy increases the chances of obtaining low IOP outcomes. This strategy may be useful when planning for surgeries aiming at target pressures in the low teens.Trial registration numberISRCTN93098069.

Background/aimsOptical coherence tomography angiography (OCTA) allows the study of vessel density (VD). We intended to perform a systematic review of studies focusing on longitudinal changes in peripapillary and macular VD measurements in glaucoma.MethodsA search was performed across MEDLINE, Scopus, ISI Web of Science and Google Scholar, using the following query from inception until 20 September 2019: ((“optical coherence tomography angiography”[tiab]) OR (optical coherence tomography angiography[MeSH]) OR (“OCTA”[tiab]) OR (“OCT-A”[tiab]) OR (“angio-OCT”[tiab]) OR (“OCT- angiography”[tiab]) OR (“OCT-angio”[tiab]) OR (“OCT-angiographie”[tiab])) AND (glaucom*[tiab] OR glaucoma[MeSH]). Prospective studies that quantitatively assessed the longitudinal changes in VD in glaucoma with at least 3 months of follow-up were included.ResultsTen out of 4516 studies were included. The rate of VD change in glaucoma varied from 0.036/year to 1.08/year and 1.3% to 3.2% per year, with significantly different rates between glaucoma and healthy controls. Five studies assessed VD change after glaucoma surgery, obtaining variable results, ranging from a temporary VD decrease to increase after 3 months. Meta-analysis was not possible due to a wide variation in methods, measurements and region of VD.ConclusionOCTA is a non-invasive technology, which shows promise in glaucoma. Measures should be taken to increase the quality and standardise the methodology of VD measures in OCTA longitudinal studies, for future meta-analyses.

Aim and objective Report three different solutions in case of XEN-augmented Baerveldt fails. Background Drainage devices have been used for refractory pediatric glaucoma. To avoid early hypotony and corneal damage, Mermoud et al. introduced the augmentation of a XEN implant with a Baerveldt tube. In some cases, this technique fails to lead to a high intraocular pressure (IOP) and surgical revision. Case description Three cases of children with this combined implant needed surgical revision due to high IOP. Three different approaches were performed: XEN replacement in one case, stretching the Baerveldt's tube into the anterior chamber (AC) in the second case, and explant of the device followed by an implant of a new Baerveldt-250 in the same quadrant in the third case. Successful control of IOP (>18 mm Hg) was achieved in all patients under no topical treatment. Conclusion Despite the attractiveness of the XEN-augmented Baerveldt implant in refractory pediatric glaucoma as an alternative to conventional surgery, we have to learn how to deal with failures. Three different approaches are presented with good short-term results. The long-term efficacy is yet to be assessed. Clinical significance Describe three possible options when faced with a need for surgical revision in XEN-augmented Baerveldt implant. How to cite this article José P, Abegão Pinto L, Teixeira FJ. XEN-augmented Baerveldt Failure: Three Different Revision Approaches for Pediatric Patients. J Curr Glaucoma Pract 2021;15(2):96–98.

Purpose: To analyse the long-term efficacy and safety of bleb needling in glaucoma patients previously submitted to XEN implantation. Methods: Retrospective, observational study. Charts from patients who underwent XEN gel implant surgery between October 2015 and December 2017 were reviewed. Needling protocol involves use of Mitomycin C 0.2 mg/mL in an operating room. Primary outcome was defined as intraocular pressure (IOP) lowering efficacy at 12 months post-operative. Complete success was defined as a decrease in IOP > 20% and overall value Results: About 94 charts were reviewed, with 18 patients (19%) having undergone needle revision. This salvage procedure was performed after 3.3 ± 3.4 months, achieving a mean IOP reduction of 8.3 ± 8.4 mmHg at 12 months after the procedure (pre-needling: 24.0 ± 5.2 mmHg vs 12th month: 13.5 ± 5.9 mmHg, p Conclusion: XEN salvage procedure with mitomycin C is a valid option in early bleb failure. This single intervention had a long-lasting effect on bleb survival, with almost two-thirds achieving long term significant drop-free IOP reduction.

PReCIS:: Angle location of the XEN implant both in isolated and in combined procedures did not appear to influence long-term outcomes. However, more posterior stent placements seem to be associated with increased early postoperative complications. Purpose The purpose of this study was to assess success and safety outcomes of different levels of insertion of the XEN45 gel stent in the angle in standalone and combined procedures. Methods This was a cross-sectional study of patients in whom XEN had been implanted without intraoperative gonioscopy. Automated gonioscopy was used for postoperative analysis of the XEN location, classified as anterior or posterior relative to the scleral spur. Absolute success was defined as ≥20% intraocular pressure decrease from baseline and ranging from 6 to 21 mm Hg without medication and qualified success if medicated. The need for additional drainage surgery was considered failure, but needling was allowed. Clinical data were retrieved from patient files. Results Gonioscopy-assisted XEN location was performed on 42 eyes of 33 patients (14 isolated and 28 combined procedures) on average 18±9 months after surgery. Absolute (32% vs. 35%; P>0.99) and qualified (44% vs. 65%; P=0.22) success was similar in both anterior and posterior placements, respectively. Kaplan-Meier survival analysis yielded similar median survival times for both groups. The distribution of XEN insertion level in the angle was similar in standalone and combined procedures (P=0.75). Although overall safety outcome measures did not differ significantly, the proportion of intraoperative and early postoperative complications was higher in posterior XEN placements (P=0.03). Conclusions Different locations of XEN45 did not seem to significantly impact late success and safety outcomes, although stents inserted more posteriorly may be associated with a higher rate of early complications. Combined implantation of XEN with phacoemulsification does not seem to influence stent location in the iridocorneal angle in a setting without intraoperative gonioscopy.

BACKGROUND: Ciclo plasty using high-intensity focused ultrasound (HIFU) technology acts through the selective coagulation of the ciliary body. Our aim was to evaluate the safety and efficacy profiles of 8-s probe HIFU cyclocoagulation using the EyeOP1 device. METHODS: Prospective pragmatic trial. Inclusion criteria: adult glaucoma patients with uncontrolled IOP despite optimised medical therapy, and/or intolerant to medical therapy required to achieve target IOP. Primary outcome: surgical success defined as IOP reduction from baseline >20% with final IOP ≤21 mmHg, without adding any IOP-lowering drugs, and without loss of light perception; or decreased use of IOP-lowering drugs with stable/decreased IOP, without loss of light perception. Secondary outcomes: mean IOP, intra and postoperative complications, best-corrected visual acuity (BCVA) and number of IOP-lowering drugs at each visit. Outcome data were collected preoperatively and at postoperative day 1, and months 1, 3, 6 and 12. RESULTS: Forty-nine eyes of forty-nine patients (28 male) with a mean age of 70 ± 14 years were enroled. Pre-operative IOP was 26.9 ± 7.4 mmHg under 2.8 ± 0.9 topical medications, decreasing to 17.8 ± 6.4 mmHg under 2.3 ± 1 drugs at 12 months (p

The patient's compliance on the therapeutics to treat glaucoma is significantly low contributing for a fast evolution of the disease. This article presents an autonomous system with controlled release using an alpha2-adrenergic receptor agonist, brimonidine, usually used to treat glaucoma. More specifically, biocompatible and layer-by-layer drug delivery films containing monolayers with brimonidine encapsulated in polymer-β-cyclodextrin were prepared with the objective to obtain a system able to release precise amounts of drug at specific times. To delay the erosion-controlled drug release, we included nanosheets of graphene oxide and layers of a biodegradable polymer (poly-β-aminoester) between the drug-containing monolayers to obtain a time-controlled drug delivery system. An increase in the number of graphene oxide layers is proportional to the brimonidine release delay and its kinetic release can be tuned as a function of the number of layers. Two types of films with brimonidine encapsulated in β-cyclodextrin were analyzed. One of them composed of barrier layers with PBAE and another with two types of barrier layers, PBAE and graphene oxide. The results indicate that one graphene oxide bilayer can delay the brimonidine release for more than 24 h. In vitro assays confirmed that the films have a cell viability of 100%.

Purpose To quantitatively evaluate the inter-annotator variability of clinicians tracing the contours of anatomical layers of the iridocorneal angle on digital gonio photographs, thus providing a baseline for the validation of automated analysis algorithms. Methods Using a software annotation tool on a common set of 20 images, five experienced ophthalmologists highlighted the contours of five anatomical layers of interest: iris root (IR), ciliary body band (CBB), scleral spur (SS), trabecular meshwork (TM), and cornea (C). Inter-annotator variability was assessed by (1) comparing the number of times ophthalmologists delineated each layer in the dataset; (2) quantifying how the consensus area for each layer (i.e., the intersection area of observers' delineations) varied with the consensus threshold; and (3) calculating agreement among annotators using average per-layer precision, sensitivity, and Dice score. Results The SS showed the largest difference in annotation frequency (31%) and the minimum overall agreement in terms of consensus size (∼28% of the labeled pixels). The average annotator's per-layer statistics showed consistent patterns, with lower agreement on the CBB and SS (average Dice score ranges of 0.61-0.7 and 0.73-0.78, respectively) and better agreement on the IR, TM, and C (average Dice score ranges of 0.97-0.98, 0.84-0.9, and 0.93-0.96, respectively). Conclusions There was considerable inter-annotator variation in identifying contours of some anatomical layers in digital gonio photographs. Our pilot indicates that agreement was best on IR, TM, and C but poorer for CBB and SS. Translational Relevance This study provides a comprehensive description of inter-annotator agreement on digital gonio photographs segmentation as a baseline for validating deep learning models for automated gonioscopy.

© The Author(s), under exclusive licence to The Royal College of Ophthalmologists 2019, Aim Previous data suggest the existence of retinal vascular changes and impaired autoregulation in the very early stages of diabetic retinopathy (DR). We compared the retinal plexuses between patients with type 1 diabetes (T1D) without DR and a demographically similar healthy cohort, using optical coherence tomography angiography (OCT-A). Methods Patients with T1D and no signs of DR were prospectively recruited from an outpatient clinic. Using OCT-A (AngioVue®), the parafoveal superficial (SCP) and deep (DPC) capillary plexus as well as the foveal avascular zone (FAZ) and perimeter were gathered. Mean comparison tests and linear regression analysis were used as statistical tests (STATA v14). Results Studied population included 48 subjects (24 T1D). The analysis of SCP revealed an attenuation of the capillary network compared with the control group in both parafoveal (51.8 ± 4.5 vs. 55.8 ± 3.2, p < 0.001) and perifoveal (51.9 ± 3.3 vs. 53.9 ± 1.9, p = 0.01) regions. A similar finding was observed in the DCP for both parafoveal (56.4 ± 4.3 vs. 60.4 ± 2.2, p < 0.001) and perifoveal (54.7 ± 3.9 vs. 60.8 ± 3.4, p = 0.001) sectors. Also, a longer time since T1D diagnosis was associated with a larger FAZ area (p = 0.055) and perimeter (p = 0.03). Conclusions Significant differences in the retinal microvasculature were observed between healthy subjects and T1D patients using OCT-A, even before clinically detectable disease on fundus biomicroscopy., The authors would like to thank AstraZeneca Foundation/Faculty of Medicine of the University of Lisboa.

The XEN gel stent is a minimally invasive surgical device aimed at creating a subconjunctival drainage of aqueous humor, thereby reducing intraocular pressure (IOP). Being a novel device, doubts remain with regard to the efficacy and safety of its implantation in the early stage of new users. This paper illustrates the XEN implantation learning curve, assessed through several surgeons of different expertise.This was a retrospective study on the first 6 XEN implants performed by each of the 10 certified ophthalmic surgeons. Simultaneous cataract surgery was allowed (phaco-XEN). Primary outcomes were as follows: surgical time; intraoperative and postoperative surgical complications. Secondary outcomes were as follows: IOP; the number of topical drugs in use; the need for needling procedures. Outcome data were collected preoperatively and at postoperative days 1, 7, 15, 30, 60, and 90. Statistical analysis was performed with STATA 14.1 and SPSS.Sixty patients were included (56.7% female patients). Mean age was 73 years (45 to 89). Mean preoperative IOP was 23.8±8.95 mm Hg. From the included patients, 29 (48.3%) were submitted to simple XEN implant and 31 (51.7%) to phaco-XEN. In both groups, mean surgical time decreased by 9 minutes throughout the 6-implant learning curve. Final IOP was 15±7.27 mm Hg in the stent group (-43% than baseline), and 14.92±3.32 mm Hg in the phaco-XEN group (-16% than baseline). On average, patients decreased 2 topical IOP-lowering drugs. Needling procedures were performed in 17 patients (28.3%).XEN gel stent was associated with a fast learning curve, by both experienced surgeons and novice residents. By the sixth implant, both groups had considerably decreased mean surgical time and complication rates.

PURPOSE: To develop a new methodology to detect glaucoma damage based on circumpapillary microvascular density (cpmVD) as measured by optical coherence tomography angiography (angioOCT). METHODS: AngioOCT scans from a random eye of 40 healthy subjects (aged 63 ± 14 years) and 82 glaucoma patients (aged 66 ± 9 years with an average visual field loss of −7.8 ± 6.5 dB) were used to develop a new angioOCT evaluation methodology. Optic disc-centred 3 × 3 mm images were collected (Angioplex(®), Zeiss Cirrus 5000 HD-OCT). An annular area with an inner radius of 1.16 mm and outer radius of 1.44 mm was chosen as the region of interest (ROI), with cpmVD calculated through lower envelope modulation avoiding the influence of the major retinal vessels. Additionally, the cpmVD and the microvascular density (mVD), stratified by sectors, were compared with the respective retinal nerve fibre layer (RNFL) thickness. RESULTS: A significantly lower cpmVD was observed in the glaucoma group, for all visual field sectors (p 0.05). CONCLUSIONS: The presented open-source methodology provides a robust quantitative analysis of the 360˚ mVD. It shows that cpmVD, and mVD sectors measured by angioOCT, can be used in everyday glaucoma practice.

The PAUL Glaucoma Implant is an effective intraocular pressure (IOP)-lowering device with an acceptable safety profile. Its design as a nonvalved device with a small tube diameter using a vicryl ligation suture around the tube that is posteriorly reabsorbed instead of an ab luminal stent makes it an option in cases selected for glaucoma drainage device implantation.The aim was to determine the 1-year efficacy and safety of PAUL Glaucoma Implant using a uniform, standardized surgical procedure.Retrospective, cohort study. Patient charts were screened between December 2018 and January 2020, with inclusion requiring a minimum follow-up of 12 months. Primary outcome was IOP-lowering at 12 months, with surgical success defined as ≤18 mm Hg and at least 30% reduction and higher than 5 mm Hg. Absolute success was achieved if no IOP-lowering medication was needed and qualified success if otherwise. Safety outcomes were also analyzed. A standardized protocol was followed in all cases, which included mitomycin C application and 1 vicryl ligation of the tube.A total of 24 eyes from 21 patients fulfilled inclusion criteria. Median patient age at time of surgery was 42 years (range: 1 to 76 y). IOP decreased from 31.4 (10.0) mm Hg in preoperative period to 12.5 (4.3) mm Hg in the last follow-up (P0.001). Qualified success criteria were fulfilled by 75% of cases, while absolute success was 33%. The mean number of IOP-lowering drugs used before surgery was 3.0 and 0.9 at the 12-month visit (P0.001). No postoperative hypotony requiring intervention was recorded.PAUL Glaucoma Implant appears to be a safe and effective glaucoma drainage implant for the treatment of moderate and advanced glaucoma.

© 2021 Leal et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms., Non-infectious uveitis (NIU) is a group of sight-threatening diseases that generates significant burden for the healthcare systems due to its adverse outcomes, irreversible structural complications in the eye with loss of visual function, limited clinical expertise and low-grade evidence for best practice. The usefulness of multidisciplinary care, specifically close collaboration between Rheumatologists and Ophthalmologists in NIU, has been emphasized in the literature. In this paper, the assessment tools and protocols used in our clinic are depicted and an overview of our activity with a brief description of the patients included in our registry, between 2018 and 2020 is provided. The cohort of 290 patients assessed in our NIU clinic, their demographics, sources of referral, details about immunosuppression treatment, and internal and external collaborations is described. This experience-based manuscript aims to describe the general functioning of our multidisciplinary NIU clinic, highlighting the benefits and drawbacks of multidisciplinary team management in patients with NIU, ultimately initiating a dialogue on what an NIU clinic should be and providing information for newly NIU clinics start-up. In conclusion, establishing a standardized and multidisciplinary clinic in NIU allows to systematically observe and follow-up this infrequent disease at a tertiary hospital level, thus improving quality of care delivery and research avenues.

Copyright © 2020 The Authors. This work is licensed under a Creative Commons Attribution-Non-Commercial-No-Derivatives 4.0 International License., Purpose: We hypothesize that patients with type 1 diabetes (T1D) may have abnormal retinal vascular responses before diabetic retinopathy (DR) is clinically evident. Optical coherence tomography angiography (OCTA) was used to dynamically assess the retinal microvasculature of diabetic patients with no clinically visible retinopathy. Methods: Controlled nonrandomized interventional study. The studied population included 48 eyes of 24 T1D patients and 24 demographically similar healthy volunteers. A commercial OCTA device (AngioVue) was used, and two tests were applied: (1) the hypoxia challenge test (HCT) and (2) the handgrip test to induce a vasodilatory or vasoconstrictive response, respectively. The HCT is a standardized test that creates a mild hypoxic environment equivalent to a flight cabin. The handgrip test (i.e., isometric exercise) induces a sympathetic autonomic response. Changes in the parafoveal superficial and deep capillary plexuses in both tests were compared in each group. Systemic cardiovascular responses were also comparatively evaluated. Results: In the control cohort, the vessel density of the median parafoveal superficial and deep plexuses increased during hypoxia (F1,23 = 15.69, P < 0.001 and F1,23 = 16.26, P < 0.001, respectively). In the T1D group, this physiological response was not observed in either the superficial or the deep retinal plexuses. Isometric exercise elicited a significant decrease in vessel density in both superficial and deep plexuses in the control group (F1,23 = 27.37, P < 0.0001 and F1,23 = 27.90, P < 0.0001, respectively). In the T1D group, this response was noted only in the deep plexus (F1,23 = 11.04, P < 0.01). Conclusions: Our work suggests there is an early impairment of the physiological retinal vascular response in patients with T1D without clinical diabetic retinopathy.

Aim: To analyse the efficacy and safety of a standardized laser suture lysis protocol following trabeculectomy. Materials and methods: Prospective interventional study conducted at a tertiary centre, between June 2016 and July 2017. Consecutive patients undergoing primary trabeculectomy with mitomycin C (0.4 mg/mL) for open angle glaucoma were enrolled. According to study protocol, a first laser suture lysis was performed routinely when intraocular pressure was greater than 10 mmHg, starting at postoperative day 8, and a second laser suture lysis was done whenever the intraocular pressure was newly greater than 10 mmHg, with a minimum interval of 1 week after the first laser suture lysis. Primary outcome was intraocular pressure (mean value, and mean difference from baseline in percentage). Safety parameters were also analysed. Results: Thirty-three eyes of 28 patients (13 males) were enrolled with a mean age of 69.6 ± 15.1 years. Pre-operative intraocular pressure was 24.9 ± 8.6 mmHg. All eyes underwent a laser suture lysis before the 12th postoperative week, with a mean intraocular pressure–lowering efficacy of 42.4% (p Conclusion: In our study, laser suture lysis was an effective tool to lower intraocular pressure during the early postoperative period, with an acceptable safety profile.

© 2020 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd., Purpose: The Baerveldt-XEN technique is intended to reduce the risk of early hypotony after Baerveldt implant, while keeping a good long-term intra-ocular pressure (IOP) control. The aim of this study is to discuss the surgical success rate of the Baerveldt-XEN and compare it with the commercially available flow-restrictor device (Ahmed glaucoma valve - AGV). Methods: Single-centre, cohort study. Consecutive glaucoma patients with uncontrolled IOP > 21 mmHg on maximum tolerated medical therapy, and who had an aqueous shunt as the planned surgical procedure. Patients underwent implantation of Baerveldt-XEN. An age-, gender- and glaucoma aetiology-matched database of AGV patients was used for comparison. Complete surgical success was defined as a final IOP between 6 and 21 mmHg, and 20% reduction from baseline with no need for IOP-lowering medication. Qualified success was the same criteria but resorting to medications. Results: Twenty-four eyes from 24 subjects with glaucoma were included in this study, 12 patients underwent Baerveldt-XEN implantation and 12 AGV. Twelve months after the Baerveldt-XEN implant, the IOP reduced from 33 ± 9 mmHg to 14 ± 3 mmHg (p < 0.001). The qualified and complete success rate was 50% and 25%, respectively. With the AGV, the IOP reduced from 29 ± 7 mmHg to 16 ± 7 mmHg (p = 0.001). The matched AGV group compared to the Baerveldt-XEN, presented a higher complete success rate (58.3%) and a qualified success rate of 33.3% (p = 0.72). No sight-threatening complications were recorded in both groups. Conclusions: The Baerveldt-XEN disclosed a low complete success rate at 1 year of follow-up, although with no major safety concerns. While studies with a longer follow-up are needed to demonstrate the potential advantages and disadvantages of the Baerveldt-XEN, this technique may be less likely to achieve drop-free efficacy when compared to other flow-restrictor strategies.

PURPOSE Ultrasound cycloplasty (UCP) acts through the selective coagulation of the ciliary body using high-intensity focused ultrasound (HIFU) technology. The aim of this study was to investigate whether the application of ultrasound beams targeting the ciliary body using an external probe influences astigmatism. METHODS Multicentre, prospective, single-arm, open-label study in adult patients with primary open-angle glaucoma and moderately uncontrolled intraocular pressure (IOP) under glaucoma medication. The primary outcome was induced corneal astigmatism, calculated from topography, and assessed statistically through vector analysis. Secondary outcomes included induced total astigmatism and mean changes from baseline in best-corrected visual acuity (logMAR) and IOP. Subgroup analysis was performed to assess the impact of device centring on corneal and total induced astigmatism. RESULTS Fifty eyes were enrolled. Mean age was 69.6 ± 11.3 years. At 1, 3 and 6 months postprocedure, HIFU-induced corneal astigmatism was 0.88 D × 93°, 0.87 D × 106° and 1.16 D × 97°, respectively, while induced total astigmatism was 0.62 D × 103°, 0.42 × 106° and 0.39 × 107°. By the last follow-up, the percentage of patients with

We present a deep learning semantic segmentation algorithm for processing images acquired by a novel ophthalmic device, the NIDEK GS-1. The proposed model can sophisticate the current reference exam, called gonioscopy, for evaluating the risk of developing glaucoma, a severe eye pathology with a considerable worldwide impact in terms of costs and negative effects on affected people’s quality of life, and for inferring its categorization. The target eye region of gonioscopy is the interface between the iris and the cornea, and the anatomical structures that are located there. Our approach exploits a dense U-net architecture and is the first automatic system segmenting irido-corneal interface images from the novel device. Results show promising performance, providing about 88% of mean pixel-wise classification accuracy in a 5-fold cross-validation experiment on a very limited size dataset of annotated images.

Purpose: The aim of this study is to assess the agreement between manual and automated gonioscopy for iridocorneal angle opening. Methods: The research is a cross-sectional observational study. Manual and automated gonioscopy were performed to consecutive patients in a glaucoma clinic. Iridocorneal angle opening grading was performed according to Shaffer’s classification. Automated gonioscopy was performed with NGS-1 automated gonioscope (NIDEK Co., Gamagori, Japan). The automated gonio-photos were graded by two independent observers. Agreement between automated and manual gonioscopy and also among raters was ascertained by Fleiss’ kappa statistic and comparison of area under curve. Results: In total, 88 eyes of 47 subjects were analysed. Mean age was 63 ± 10 years. Twenty eyes (22.7%) were excluded from grading due to poor quality images. Angle closure was detected in 23.4% with dynamic gonioscopy in comparison with 4.3% using automated image grading. The agreement for angle closure diagnosis between dynamic and automated gonioscopy was low (κ = 0.09 ± 0.10; p = 0.18). The area under curve for detecting eyes with angle closure showed poor accuracy between automated and manual methods (area under curve: 0.53 ± 0.05, 95% confidence interval: 0.44–0.62). There was modest inter-rater agreement for angle opening assessment of automated images with Fleiss’ kappa of 0.17 (95% confidence interval: 0.035–0.238). Conclusion: Manual and automated gonioscopy showed only slight agreement for the assessment of iridocorneal angle opening status. Further improvements of the NGS-1 automated gonioscopy and technique are desired for widespread use in a real-life setting.

Background: The purpose of this prospective study was to evaluate the efficacy and safety of the Ultrasound Cyclo Plasty (UCP) procedure using high-intensity focused ultrasound in surgery-naïve open-angle glaucoma patients. Methods: prospective, non-randomized, single-arm, multicenter clinical trial. Sixty-six eyes with primary open-angle glaucoma, intraocular pressure (IOP) ≥21 mmHg and with no history of filtering surgery were enrolled. Patients were treated by UCP with a therapy probe comprising six piezoelectric transducers, consecutively activated for 8 s each. Complete ophthalmic examination was performed before the procedure, 1 day after the procedure, and 1, 3, 6, 12, 18 and 24 months after the procedure. Primary outcomes were complete success (defined as IOP lowering from baseline ≥20% without additional glaucoma medications) and vision-threatening complications. Secondary outcomes were the presence of complications and the reduction of the number of medications used. Results: IOP was significantly reduced after one procedure (p &lt, 0.05), from a mean pre-operative value of 24.3 ± 2.9 mmHg (n = 2.3 hypotensive medications) to a mean value of 15.9 ± 3.6 mmHg (n = 2.2 hypotensive medications) at 2 years (mean IOP lowering of 33%). Surgical success was achieved in 74% of eyes. Notwithstanding side effects such as transient anterior chamber inflammation, refractive error changes, transient hypotony and macular edema, no major intra or post-operative complications such as phthisis, induced cataract, neovascularization or significant vision loss were observed. Conclusions: Ultrasound Cyclo Plasty is a valuable, effective and well-tolerated procedure to lower IOP in patients with open-angle glaucoma without previous filtering surgery.

Objectives: To analyse drug development for open-angle glaucoma during the last 20 years. Methods: Research was performed by referring to clinical trials registered at the International Clinical Trials Registry Platform (ICTRP). A search for the condition “open-angle glaucoma” with the intervention “drug” was performed. We included trials registered from 01/01/1995 to 01/01/2015, only involving studies in phases 1, 2, and 3. Only studies resorting to novel treatment strategies (either novel drugs or yet-untested fixed associations of approved medication) were considered. Results: We recorded 158 studies for the condition of open-angle glaucoma with a drug-based intervention; 65 of the studies reported phase 2 trials and 74 reported phase 3 trials. Pharmaceutical companies were the primary sponsors of 95.3% of the trials. Most of the studies (66.5%, n = 105) involved a new drug, and the remainder (33.5%, n = 53) tested fixed drug associations. The bulk of the trials (n = 99, 62.7%) involved the use of prostaglandin analogues, either as a comparator or a study drug. In descending order of frequency, the studies conducted involved Rho-kinase inhibitors (n = 15), carbonic anhydrase inhibitors (n = 14), β-blockers (n = 7), angiostatic steroids (n = 6), α2-adrenergic agonists (n = 4), 5-HT2A receptor agonists (n = 4), and NMDA receptor antagonists (n = 2). A cyclin-dependent kinase inhibitor, an LIM-domain kinase 2 inhibitor, an A1 adenosine receptor agonist, catechin, macrolide, saffron, and seawater were each tested in 1 clinical trial. Conclusion: Research into the medical treatment of glaucoma indicates the use of prostaglandin analogues. However, there are a significant number of trials testing other drug classes, particularly Rho-kinase inhibitors. This new focus could lead to a potential increase in the number of therapeutical options for the management of glaucoma in the future.

Die Kataraktoperation ist eine der am häufigsten durchgeführten Operationen in den Industrieländern. Neben ihrer signifikanten Auswirkung auf die Sehschärfe wird der Phakoemulsifikation auch eine potenzielle Intraokulardruck(IOD)-senkende Wirkung zugeschrieben. Während die aktuelle Evidenzlage auf eine insgesamt signifikante und anhaltende IOD-Senkung nach Kataraktoperationen hindeutet, ist noch unklar, welche spezifischen okulären Merkmale dazu beitragen könnten vorherzusagen, welche Patienten wahrscheinlich von diesem IOD-senkenden Effekt profitieren würden. Dies bei Glaukompatienten klar zu benennen ist jedoch wichtig, wenn die Kataraktoperation einen Platz in der Behandlung des Glaukoms erhalten soll. Die vorliegende Arbeit gibt einen Überblick über die Literatur zu diesem Thema und geht darauf ein, welche Mechanismen der IOD-Senkung zugrunde liegen und welche Patientengruppen mit höherer Wahrscheinlichkeit im Hinblick auf die IOD-Senkung von diesem Eingriff profitieren könnten, um so letztlich zur Optimierung der Versorgung der steigenden Zahl der Patienten beizutragen, bei denen gleichzeitig Glaukom und Katarakt vorliegen. Übersetzung aus Ophthalmic Res 2015;53:141-148 (DOI:10.1159/000377635)

Migraine symptoms are frequently referred by glaucoma patients. Although most studies analyze headache in the acute setting of angle closure, many patients with chronic occludable angles also complain of headaches. The aim of this study was to determine the impact of laser peripheral iridotomy (LPI) on the magnitude and frequency of headache symptoms in patients with occludable angles. Prospective cohort study. Patients with indication for prophylactic LPI due to occludable iridocorneal angle were included. Headache symptoms were assessed before and at least 4 weeks after LPI using the Headache Impact Test-6 (HIT-6) questionnaire. A HIT-6 score of ≥ 50 points was labeled as a clinically significant headache. Thirty-one subjects were included. Prophylactic LPI was performed in 60 eyes, as 2 patients were pseudophakic in the fellow eye. Baseline HIT-6 score was 59.9 ± 11.8, with over three quarters of these patients scoring higher than 50 points (n = 24). A statistically significant reduction in HIT-6 score was found after LPI treatment (45.4 ± 7.7, p

Aim High-intensity focused ultrasound cystoplasty (UCP) aims to noninvasively and selectively target the ciliary body, thus lowering intraocular pressure (IOP). To be used on a large scale, the safety of the UCP procedure should be studied. Therefore, its effect on pupil behavior is important to better inform patients and to help physicians predict possible treatment side effects. This study aimed to evaluate to what extent UCP procedure (EyeOP-1®) affects pupil dynamics. Materials and methods Consecutive glaucoma patients with uncontrolled IOP despite optimal medication scheduled for UCP treatment were recruited and followed for 6 months. Pupillometry (PlusoptiX® S04) was performed at baseline, and 1, 3 and 6 months after UCP procedure at scotopic and mesopic conditions. The difference between pupil diameter (PD) in both lighting conditions was calculated at the three follow-up visits. Demographic, clinical characteristics and specific ocular parameters (anterior chamber depth and volume, white-to-white measurement, axial length, phakic status) were registered. Statistical analysis was performed using STATA 14.1. Results Sixteen eyes of 16 patients with a mean age of 69 ± 11 years were included. Mean preoperative IOP and number of medications were 23.6 ± 3.0 mm Hg and 2.4 ± 1.3, respectively. Mean baseline scotopic and mesopic PD were 4.8 ± 0.8 mm and 4.4 ± 0.9 mm, respectively (difference = 0.38 ± 0.30 mm; range 0.1 to 1.2 mm). At month-1, the pupil diameter (PD) change between scotopic (4.6 ± 0.7 mm) and mesopic (4.5 ± 0.8 mm) conditions decreased to 0.03 ± 0.34 mm, p = 0.01. On the longer follow-up periods, however, the amplitude difference in PD compared to baseline was no longer significant (month-3: 0.28 ± 0.49 mm; month 6: 0.23 ± 0.41 mm; p >0.05). At the end of follow-up, mean scotopic and mesopic PD were 4.7 ± 1.0 mm and 4.4 ± 0.9 mm, respectively. Conclusion and clinical significance In the early postoperative period after UCP treatment, most patients present with a less light-reactive pupil, which seems to normalize with time. How to cite this article Sousa DC, Ferreira NP, Marques-Neves C, Somers A, Vandewalle E, Stalmans I, Pinto LA. High-intensity Focused Ultrasound Cycloplasty: Analysis of Pupil Dynamics. J Curr Glaucoma Pract 2018;12(3):102-106.

Introduction: Image processing of optical coherence tomography scans through binarization techniques represent a non-invasive way to separately asses and measure choroidal components, in vivo. In this review, we systematically search the scientific literature regarding binarization studies published so far. Methods: A systematic research was conducted at PubMed database, including English literature articles for all of the following terms in various combinations: binarization, choroid/al, enhanced depth spectral domain/swept source optic coherence tomography, and latest publications up to November 2018 were reviewed. Results: Thirty-seven articles were included and analyzed regarding studied disease, binarization method, studied variables, and outcomes. Most of the studies have focused on the more common retinal pathologies, such as age-related macular degeneration, central serous chorioretinopathy and diabetic retinopathy but binarization techniques have also been applied to the study of choroidal characteristics in ocular inflammatory diseases, corneal dystrophies and in postsurgical follow-up. Advantages and disadvantages of binarization techniques are also discussed. Conclusion: Binarization of choroidal images seems to represent a promising approach to study choroid subcomponents in an increasingly detailed manner. info:eu-repo/semantics/publishedVersion

Nanotechnology enabled the development of materials and devices with great utility in different fields of medicine. By using engineered-based nano-devices and structures, human biological systems may be controlled and repaired at a molecular scale, ultimately leading to a biological benefit. In particular, in the field of glaucoma treatment, nanotechnology may, for example, enhance drug residence time on the ocular surface and ocular bioavailability, as well as improve surgical success by both optimizing postoperative scarring and providing a wider safety window. Further studies are still needed to entirely explain the pharmacodynamics of nanotechnology-based therapeutic approaches and prove their biological consequences in human eyes. This review aims to summarize the literature concerning the advances in nanotechnology, specifically regarding ocular devices applied to the treatment of glaucoma. info:eu-repo/semantics/publishedVersion

Purpose: To determine intra- and inter-rater agreement of anterior lamina cribrosa depth (ALCD) manual measurements using enhanced-depth imaging optical coherence tomography (EDI-OCT). Methods: Observational study. EDI-OCT of the optic nerve head was performed in healthy subjects. ALCD was defined as the perpendicular distance between the line connecting both edges of Bruch's membrane opening and the anterior border of the lamina cribrosa (LC), at the maximum depth point. Two experienced operators performed manual ALCD measurements of the LC independently, and one of the observers performed the same measurements twice. Intra- and inter-rater agreement was evaluated using intraclass correlation coefficients (ICC) and concordance correlation coefficients (CCC) for the right eye vertical (REV) and horizontal (REH) scans and left eye vertical (LEV) and horizontal (LEH) scans. Results: 120 eyes of 61 subjects, with a mean age of 62.1 ± 15.0 years. The mean REV, REH, LEV and LEH ALCD were 456.2 ± 84.3, 444.5 ± 92.2, 436.7 ± 81.6, 427.6 ± 82.7 μm, respectively. ALCD intra- and inter-rater ICC and intra- and inter-rater CCC varied between 0.85-0.95, 0.84-0.93, 0.85-0.95 and 0.84-0.93, respectively. Conclusions: ALCD manual intra- and inter-rater measurements with EDI-OCT showed high agreement. EDI-OCT is a reliable tool for ALCD measurement, which can provide potentially useful information for integrated glaucoma management.

Purpose: To determine the frequency of epiretinal membranes (ERM) in eyes with primary open-angle glaucoma subjected to trabeculectomy. Methods: We conducted a retrospective study on patients subjected to trabeculectomy with at least a 6-month follow-up. Ophthalmologic examination and spectral-domain optical coherence tomography (SD-OCT) were analyzed. Eyes with previous surgical or laser treatments or other pathologies (other than glaucoma and ERM) were excluded. Results: A total of 50 eyes (40 patients) were included in this study. The mean follow-up time after surgery was 27.8 months. After surgery, 9 eyes (18%) had preretinal macular fibrosis and 19 eyes (38%) had cellophane macular reflex. Of the 16 eyes with a preoperative macular SD-OCT, 3 (18.8%) developed ERM and 4 (25%) progressed from cellophane macular reflex to preretinal macular fibrosis, after surgery. The ERM frequency did not differ significantly between eyes subjected to trabeculectomy with or without the use of antimetabolites (P=0.08), or between eyes subjected to simple or combined surgery (phacotrabeculectomy) (P=0.09). Conclusion: Trabeculectomy may predispose one to the appearance and progression of ERM. Further studies are needed to clarify this intriguing relation. info:eu-repo/semantics/publishedVersion

Purpose Elevated intra-ocular pressure (IOP) has been identified as a major risk factor for glaucoma. Additionally, extensive literature depicts a vascular dysfunction to exist in these patients. However, a large ocular blood flow-oriented trial to integrate these findings in the clinical setting is lacking. This study would likely help to identify which of these vascular data can be used as a clinical tool for screening and disease stratification. Method Prospective, cross-sectional, case–control hospital-based study. Patients with primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), ocular hypertension (OHT), glaucoma suspects and healthy volunteers were recruited. In addition to a comprehensive ophthalmological examination, a vascular-oriented questionnaire was completed and ocular blood flow assessment (colour Doppler imaging of retrobulbar vessels, retinal oximetry, dynamic contour tonometry, optical coherent tomography enhanced-depth imaging of the choroid) were performed. Statistical analysis was based on multiple imputation to account for missingness. Results A total of 614 subjects (291 males) were recruited between March and December 2013 (POAG: 214, NTG: 192; OHT: 27; glaucoma suspect: 41; healthy controls: 140). Glaucoma groups (NTG and POAG) were age and gender matched with the control group (p > 0.05). Glaucoma groups were paired in terms of functional and structural parameters (p > 0.08). Mean ocular perfusion pressure was higher in the glaucoma groups than in controls (p