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PRCIS The multiplicity of treatment options for lowering intraocular pressure (IOP) is both a blessing and a challenge. Some attention to cost-analysis might assist in choosing an optimal therapy, especially in a cost-constrained, international setting. PURPOSE The aim of this study was to quantify and to analyze the relative cost of various glaucoma surgical procedures and selective laser trabeculoplasty surgery per mm Hg IOP reduction ($/mm Hg) since standard cost-utility methods are not well suited to the study of glaucoma which characteristically only claims visual acuity in its end stages. METHODS Published glaucoma treatment studies were reviewed to quantitate the reduction of mean IOP and glaucoma medications for a given treatment modality. A US perspective was adopted, using Medicare allowable costs were used to calculate a newly introduced parameter-cost per mm Hg IOP reduction-at 1 year postoperatively. RESULTS The cost per mm Hg IOP reduction after 1 year of treatment ranged from $190/mm Hg for trabeculectomy to $1376/mm Hg for iStent. For reference, the cost of selective later trabeculoplasty surgery was $121/mm Hg. After the first year, cost/mm Hg ranged from $12 to $61/mm Hg. CONCLUSIONS Conventional glaucoma surgeries and selective laser trabeculoplasty surgery were the most cost-efficient surgical methods to lower IOP compared with the various minimally invasive glaucoma surgeries options. They may be more appropriate management when cost is an important issue.

Reporting treatment outcomes of slow coagulation transscleral cyclophotocoagulation (TSCPC) as an initial surgical intervention in pseudophakic patients with glaucoma.Retrospective case series.This single academic center study reviewed 74 pseudophakic patients who had a diagnosis of glaucoma and no previous glaucoma surgeries (mean age 82.6 ± 12.5 years; mean follow-up 18.7 ± 9.1 months). The intervention used was slow coagulation continuous wave TSCPC (1250-mW power and 4-second duration). The primary outcome measure was surgical success defined as an intraocular pressure (IOP) of 6-21 mm Hg with a ≥20% reduction from baseline, no reoperation for glaucoma, and no loss of light-perception vision. Secondary outcome measures included glaucoma medication use, visual acuity (VA), and complications.IOP decreased from 27.5 ± 9.8 mm Hg preoperatively to 16.1 ± 6.3 mm Hg postoperatively (P.001). The preoperative number of glaucoma medications was 4.1 ± 0.9 and 3.1 ± 1.3 post-TSCPC (P.001). The cumulative probabilities of success at 1 and 2 years were 60.6 % and 58.5%, respectively. When patients were divided into 2 groups based on their baseline IOP being21 mm Hg (high group) or ≤21 mm Hg (low group), success rates at 2 years were 64.9% and 45.5%, respectively (P = .144). The mean logarithm of the minimum angle of resolution VA changed from 0.70 ± 0.64 to 1.04 ± 0.87 at the last follow-up visit (P = .01). No serious complications were observed and most of the complications were mild and transient.Slow coagulation TSCPC has good efficiency, especially in patients with baseline IOP21 mm Hg, and safety profile as an initial surgical intervention in pseudophakic patients with glaucoma.

Omar Solyman,1,2 Hashem Abu Serhan,3 Hesham F Kamel,1 Amgad Eldib,1,4– 6 Ahmed S Abo Obaia,1 Amr Aref,1 Ibrahim Osama Sayed-Ahmed,7,8 Mohamed Khashaba,9 Mohamed M Khodeiry,1,8 Mokhtar M Abushanab1 1Department of Ophthalmology, Research Institute of Ophthalmology, Giza, Egypt; 2Department of ophthalmology, Qassim University Medical City, Al-Qassim, Saudi Arabia; 3Department of Ophthalmology, Islamic Hospital, Amman, Jordan; 4Division of Paediatric Ophthalmology, Strabismus, and Adult Motility, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA; 5UPMC Eye Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 6University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; 7Department of Ophthalmology, Baylor College of Medicine, Houston, TX, 77030, USA; 8Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, 33136, USA; 9Department of Anesthesiology, Research Institute of Ophthalmology, Giza, EgyptCorrespondence: Omar Solyman, Department of Ophthalmology, Research Institute of Ophthalmology, Giza, Egypt, Email o.solyman@rio.edu.egIntroduction: We describe and validate a low-cost simulation model for practicing anterior lens capsule continuous curvilinear capsulorhexis (CCC).Methods: A simulation model for CCC was developed from widely available low-cost materials. Ophthalmologists attending the annual scientific meeting of the Research Institute of Ophthalmology, Giza, Egypt, were asked to perform a five CCC model task and then anonymously answer a questionnaire that assessed the realism and training utility of the model using a five-point Likert scale (1 = unacceptable, 2 = poor, 3 = acceptable, 4 = favorable and 5 = excellent).Results: Twenty-seven ophthalmologists completed the task and the anonymous questionnaire. Overall, participants felt that the model simulated CCC step in cataract surgery well (mean: 3.5) and was comparable to other kinds of CCC simulation models (mean: 3.3). The model scored highly for its overall educational value (mean: 4.00) and for enlarging a small CCC (mean:3.7), while the feasibility of this model in practicing the management of a runaway leading edge of CCC scored 2.9.Conclusion: This model may provide an alternative method for training for CCC and other anterior lens capsule-related maneuvers. This option may be particularly helpful for residency training programs with limited access to virtual reality simulators or commercially available synthetic eye models.Keywords: cataract simulation, capsulorhexis, capsulotomy, microsurgical model

PURPOSE OF REVIEW: The complications and inadequate efficacy of prior cyclodestructive procedures limited their role in glaucoma management. Recent advances in treatment techniques and parameters for laser cyclophotocoagulation has expanded its role in today’s glaucoma practice. In this review, we discuss the treatment outcomes of slow-coagulation continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) as a glaucoma surgical procedure for multiple types of glaucoma in lowering intraocular pressure (IOP). RECENT FINDINGS: Slow-coagulation TSCPC is a relatively new technique for CW-TSCPC that, unlike the “pop” power titration technique of laser energy delivery, aims to avoid the production of the “pop” sound that signals explosive inflammatory energy delivery to the ciliary body and nearby tissue. In slow coagulation TSCPC, laser energy is applied in a fixed and lower amount over a longer duration, compared to the conventional pop technique. This laser energy approach leads to more stable, reliable, titratable and selective ciliary body ablation for control of intraocular pressure, especially relative to the controversial current use of micro-pulse TSCPC. SUMMARY: Slow-coagulation CW-TSCPC can be used safely, efficiently, reproducibly, and efficaciously in wide range of glaucoma types including those with no history of incisional surgeries, good visual acuity, and medically refractory glaucomas.

Purpose: To report a unique case of metastatic paraganglioma presenting as a junctional scotoma. Observations: A 38-year-old Caucasian man with a history of abdominal paraganglioma presented with minimally blurred vision 20/25 visual acuity in the left eye. The patient was found to have a junctional scotoma upon visual field testing. Cranial MRI revealed a large peri-clival mass compressing the pre-chiasmal optic nerves and other loci of metastatic disease. Intracranial masses, including metastases, can present with a relatively intact central acuity and nonspecific visual symptoms. Conclusions and Importance: To the best of our knowledge, this is the first report of metastatic paraganglioma causing a junctional scotoma. In cases with junctional scotoma, careful neuro-ophthalmic assessment and imaging are of paramount importance, even in patients with excellent visual acuity.

Purpose To report the outcomes of slow-coagulation continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) in post-keratoplasty glaucoma refractory to medical therapy. Methods Medical records of 47 patients (mean age of 70.7 ± 15.7 years and follow-up of 13.9 ± 7.1 months) were retrospectively enrolled. All patients had the diagnosis of secondary glaucoma after penetrating keratoplasty (PKP; n = 28) or Descemet's stripping automated endothelial keratoplasty (DSAEK; n = 19) with no previous history of incisional glaucoma or TSCPC surgeries. Study participants underwent slow-coagulation CW-TSCPC (1250-milliwatt power and 4-second duration). Results A statically significant reduction of IOP from 31.8 ± 8.0 mmHg preoperatively to 16.9 ± 9.0 mmHg postoperatively was noted ( p Conclusions Our study suggests that slow-coagulation TSCPC may be a safe and efficient surgical glaucoma treatment modality in patients with medically uncontrolled post-keratoplasty glaucoma.

AimsTo report treatment outcomes of slow-coagulation continuous-wave transscleral cyclophotocoagulation (TSCPC) as an initial surgical intervention in patients with neovascular glaucoma (NVG).MethodsA retrospective study including 53 patients (mean age of 69.6±16.6 years and mean follow-up of 12.7±8.9 months) with a diagnosis of NVG and no previous incisional glaucoma or cyclophotocoagulation surgeries. All patients underwent slow-coagulation continuous-wave TSCPC (1250-milliwatt power and 4-second duration).Primary outcome measure was surgical success defined as an intraocular pressure (IOP) from 6 to 21 mm Hg with a reduction ≥20% from baseline, no reoperation for glaucoma and no loss of light perception vision. Secondary outcome measures include IOP, glaucoma medications, visual acuity (VA) and complications.ResultsIOP decreased from 40.7±8.6 mm Hg preoperatively to 18.4±12.2 mm Hg postoperatively (pConclusionsSlow-coagulation TSCPC is an effective and relatively safe initial surgical intervention in medically uncontrolled NVG.

The present study aims to investigate the effect of temporary cerebrospinal fluid pressure (CSFP) reduction on optic nerve head (ONH) and macular vessel density (VD) using optical coherence tomography angiography. Forty-four eyes of 44 adults with diagnostic lumbar puncture and CSFP reduction were recruited. Thirty-two eyes of 32 healthy volunteers were controls. ONH and macular VD images were evaluated differences between baseline and after CSFP reduction. The results showed that the mean CSFP decreased from (11.6±2.1) mmHg to (8.2±3.4) mmHg (P 0.05). In the study group, decreased VD in the macular parainferior region was associated with CSFP reduction (R2=0.192, P=0.003), the reduction of macular VD in parafoveal (R2=0.098, P=0.018), parainferior (R2=0.104, P=0.021), parasuperior (R2=0.059, P=0.058), paranasal (R2=0.057, P=0.042), paratemporal (R2=0.079, P=0.026) was associated with mean ocular perfusion pressure decrease following CSFP reduction. ONH vessel density did not differ after CSFP reduction (all P>0.05). In conclusion, macular vessel density decreased in association with CSFP reduction. Retinal vessel density in the macular region is more sensitive than that in peripapillary region after CSFP reduction.

Mohamed M Khodeiry,1,2 Xiangxiang Liu,1,3 Mohamed S Sayed,1 Raquel Goldhardt,1 Giovanni Gregori,1 Thomas A Albini,1 Richard K Lee1 1Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA; 2Research Institute of Ophthalmology, Department of Ophthalmology, Giza, 12557, Egypt; 3Beijing Eye Institute, Beijing Tongren Eye Center, Beijing Tongren Eye Hospital, Capital Medical University, Beijing, 100730, People’s Republic of ChinaCorrespondence: Richard K LeeBascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, 900 NW 17 th Street, Miami, FL 33136, USATel +1 305 326-6400Fax +1 305 547-3658Email rlee@med.miami.eduPurpose: Peripapillary halos (PPH) are peripapillary changes observed surrounding the optic nerve head in normal eyes and eyes with different disorders. Recognizing the microstructure and mechanism of development of these halos will help clinicians understand the different associated retinal and optic nerve head pathologies. We describe the in vivo histological characteristics of PPH in birdshot chorioretinopathy (BSCR).Patients and Methods: This was a prospective observational case-series in a single tertiary referral center. Six eyes of three patients with PPH associated with BSCR were determined through clinical examination, fundus photography, and fundus autofluorescence (FAF). Patients underwent swept-source optical coherence tomography (SS-OCT) imaging of the optic nerve head and peripapillary region.Results: In SS-OCT B-scans across the area of PPH, we observed thinning and interruption of retinal pigment epithelium (RPE)-Bruch’s membrane complex. These halos are a circumferential form of alpha zone RPE-associated crescentic peripapillary atrophy (PPA), unlike the PPH observed with myopia and normal aging.Conclusion: PPH in BSCR patients may be a sign of prior inflammatory optic neuropathy.Keywords: birdshot chorioretinitis, optical coherence tomography, optic nerve head, peripapillary halo, peripapillary atrophy

Traumatic optic neuropathy leads to bidirectional degeneration of retinal ganglion cells and axons and results in optic nerve scaring, which inhibits the regeneration of damaged axons. Compared with its glial counterpart, the fibrotic response causing nerve scar tissue is poorly permissive to axonal regeneration. Using collagen1α1-GFP reporter mice, we characterize the development of fibrotic scar formation following optic nerve crush injury. We observe that perivascular collagen1α1 cells constitute a major cellular component of the fibrotic scar. We demonstrate that extracellular molecules and monocytes are key factors contributing to the pathogenesis of optic nerve fibrotic scar formation, with a previously unrecognized encapsulation of this scar. We also characterize the distribution of collagen1α1 cells in the retina after optic nerve crush injury based on in vivo and whole-mount retinal imaging. Our results identify collagen1α1 cells as a major component of fibrotic scarring following ONC and are a potential molecular target for promoting axonal regeneration after optic nerve injury.