Journal of Current Ophthalmology
Volume:34 Issue: 4, Oct-Dec 2022

To compare the outcomes of various invasive and noninvasive approaches to the treatment of malignant glaucoma.

Glaucoma‑related keywords were looked up in PubMed and Google Scholar, and related articles up to 2022 were used to put together this review article.

Numerous surgical methods and techniques have been introduced in the past few years. This review outlined current knowledge regarding the nonsurgical and surgical management of malignant glaucoma. In this regard, we first briefly outlined the clinical presentation, pathophysiology, and diagnosis of this disorder. Then, the current evidence on the management of malignant glaucoma was reviewed. Finally, we discuss the need for treatment of the other eye and the factors that might affect the outcome of surgical intervention.

Fluid misdirection syndrome, or malignant glaucoma, is a severe disorder that can occur spontaneously due to surgical intervention. The pathophysiology of malignant glaucoma is complicated, and numerous theories exist about the underlying mechanisms that may contribute to the disease. Malignant glaucoma can be treated conservatively using medications, laser therapy, or surgery. Laser treatments and medical treatments have been adequate for the treatment of glaucoma, but the effects have generally been short‑lived, and surgical treatment has proved to be the most effective. There have been a variety of surgical methods and techniques introduced. Still, none have been studied in a large proportion of patients as a control case to compare effectiveness, outcomes, and recurrence. Pars plana vitrectomy with irido‑zonulo‑capsulectomy still seems to have the best results.

To present a series of cases demonstrating pulsatile ocular blood flow registered with optical coherence tomography angiography (OCTA) and to describe the clinical characteristics of this phenomenon.

Seven primary open‑angle glaucoma patients(eight eyes) were included, with a median age of 67.0 years(range, 39–73 years), who demonstrated alternating hypointense bands of OCTA flow signal on the macular scan at increased intraocular pressure (IOP). All patients received comprehensive ophthalmic examination, OCTA examination with RTVue‑XR, and infrared video scanning laser ophthalmoscopy. Changes in retinal microcirculation were assessed on the raw OCTA scans as well as the resultant vessel density maps before and after IOP reduction.

Median IOP in study eyes was 39.0 mmHg (range, 36–58 mmHg). Hypointense bands of OCTA flow signal were associated with arterial pulsation on video scanning laser ophthalmoscopy in all eyes and agreed with the heart rate and resulted in a spotted grid pattern of hypoperfusion on vessel density maps in seven eyes. Median vessel density in superficial capillary plexus and deep capillary plexus was 32.4% and 47.2%, respectively, at high IOP, and increased statistically significantly to 36.5% (P = 0.016) and 50.9% (P = 0.016), respectively, after IOP reduction.

Alternating hypointense flow signal bands on OCTA scans are possibly caused by the pulsatile character of retinal blood flow during the cardiac cycle in eyes with high IOP and may reflect the imbalance between IOP and perfusion pressure. This phenomenon is responsible for the reversible decrease of vessel density at high IOP.

To evaluate the efficacy of opportunistic case finding in glaucoma detection and to determine factors associated with failure of glaucoma detection by eye health providers.

This study was conducted on 154 new definite primary open‑angle glaucoma (POAG) patients presenting to our glaucoma clinic. A questionnaire was prepared to determine if these subjects had sought eye care up to 12 months before presentation. The type of eye care provider and the principal reason for the visit were probed. The primary outcome measure was the frequency of a correct glaucoma diagnosis in their index visit. The secondary outcomes were factors associated with missed POAG diagnosis.

The great majority of study subjects (132 cases, 85.7%) had sought at least one ocular examination within 1 year before presentation. Among these patients, 73 cases (55.3%) had remained undiagnosed after the examination. Among the probed variables, age, gender, visual acuity, visual field defects, intraocular pressure, cup/disc ratio, nerve fiber layer thickness of the worse eye at presentation, and family history of glaucoma were comparable between correctly diagnosed and missed POAGs. The only factors significantly associated with missed POAG diagnosis were lack of significant refractive errors and visiting an optometrist rather than an ophthalmologist.

The efficacy of opportunistic case finding for POAG seems to be less than ideal in our settings. Lack of a significant refractive error and visiting an optometrist rather than an ophthalmologist were associated with a missed diagnosis of POAG. These observations reflect the need to adopt policies to improve glaucoma screening by eye care providers.

To evaluate the changes in biomechanical properties of the cornea using the Corvis ST device after the treatment of keratoconus patients with ultraviolet‑A/riboflavin corneal cross‑linking (CXL).

Thirty‑seven eyes from 37 consecutive patients with progressive keratoconus were included in this prospective observational case series. Corneal biomechanical parameters including the length of the applanated cornea (L1 and L2), corneal movement velocity during applanation (V1 and V2) at the moment of the first and second applanation, deformation amplitude (DA), distance between bending points of the cornea points of the cornea (PD), and concave radius of curvature (R) at the point of the highest concavity were recorded using the Corvis ST at baseline, 3 months, and 1 year after CXL.

The mean age of the patients was 23.27 years (range, 19–31 years). Among CorVis ST corneal biomechanical parameters, L1, DA, PD, and R at the point of the highest concavity did not change significantly. The length of the applanated cornea at the moment of second applanation (L2) showed a significant change 3 months after CXL, but no significant difference was found between the 3‑month and 1‑year values of this parameter. Corneal movement velocity during applanation (V1 and V2) did not change 3 months after doing CXL, but the changes in these parameters were significant 1 year after CXL.

Although the CorVis ST device may detect changes in some biomechanical properties of cornea after the treatment of keratoconus patients with CXL, many parameters remain unchanged, and this device cannot readily be used to find the effects of CXL.

To compare dexmedetomidine, ketamine, and etomidate in the induction of sedation and hemodynamic changes in patients undergoing cataract surgery by phacoemulsification method.

This was a double‑blind clinical trial study carried out on 128 patients. Using the block randomization method, the patients were divided into four equal groups (dexmedetomidine, ketamine, etomidate, and control). Mean arterial pressure, heart rate, and arterial oxygen saturation, Ramsay Sedation Score were recorded every 5 min intraoperatively, in recovery, and 1, 2, 4, and 6 h postoperatively. Moreover, the Aldrete score was measured in recovery time for discharge from the recovery room.

The mean age of participants was found to be 63.16 ± 6.07 years, and there was no statistically significant difference between the groups in terms of age, sex, and body mass index, SpO2, and heart rate (P > 0.05). From 15 min after the start of surgery to 6 h postoperatively, the mean arterial pressure in the dexmedetomidine group was significantly lower than that in the other three groups, including ketamine, etomidate, and control (P < 0.05). The mean sedation score (Ramsay) during recovery and 1 h postoperatively was higher in the dexmedetomidine group compared with that in the control group, whereas the recovery time in the dexmedetomidine group was higher than that in the other groups (P < 0.001). In addition, the amount of propofol consumption in the two groups of dexmedetomidine and ketamine was significantly less than that in the etomidate and control groups (P < 0.001).

According to the results, dexmedetomidine caused better hemodynamic changes with more reduction in blood pressure and heart rate, and patients in the dexmedetomidine group did not require any specific medical treatment. Moreover, higher patient satisfaction and longer recovery duration were observed in the dexmedetomidine group than in the other study groups. As such, it is suggested that dexmedetomidine be used as an adjuvant in cataract surgery for more sedation, analgesia, and optimal intraoperative conditions.

To determine the prevalence of visually significant uncorrected refractive error (URE) in Rafsanjan and investigate the related factors. URE is the leading cause of visual impairment (VI) which causes the second‑highest number of years lived with disability. The URE is a preventable health problem.

In this cross‑sectional study participants from Rafsanjan who were 35–70 years were enrolled between 2014 and 2020. Demographic and clinical characteristics data were gathered, and eye examination was performed. Visually significant URE was defined as present if habitual visual acuity was (HVA; visual acuity with present optical correction) >0.3 logMAR in the best eye and the visual acuity of that eye showed >0.2 logMAR improvement after the best correction. Logistic regression was used to determine the association between predicting variables (age, sex, wealth, education, employment, diabetes, cataract, and refractive error characteristics) and outcome (URE).

Among the 6991 participants of Rafsanjan subcohort of the Persian Eye Cohort, 311 (4.4%) had a visually significant URE. Diabetes was significantly more prevalent in the participants with visually significant URE, at 18.7% versus 13.1% in patients without significant URE (P = 0.004). In the final model, each year of increase in age was associated with 3% higher URE (95% confidence interval [CI]: 1.01–1.05). In comparison to low hyperopia, participants with low myopia had 5.17 times more odds of visually significant URE (95% CI: 3.38–7.93). However, antimetropia decreased the risk of visually significant URE (95% CI: 0.02–0.37).

Policymakers should pay special attention to elderly patients with myopia to effectively reduce the prevalence of visually significant URE.

To study the inter‑eye asymmetry in cases diagnosed with type 2 macular telangiectasia (MacTel).

Herein, type 2 MacTel cases were staged as per Gass and Blodi classification with multiple imaging techniques. Based on disease stage symmetry, two groups identified. Group 1: Symmetrical stage and Group 2: Asymmetrical stage MacTel disease. Prevalence, demography, and clinical features of MacTel cases showing inter‑eye asymmetry were analyzed.

Two hundred and eighty eyes of 140 patients diagnosed clinically with type 2 MacTel (84‑Group 1 and 56‑Group 2) were evaluated. Eighty‑nine (64%) were female, and the median age of the entire cohort was 62.5 years(inter‑quartile range: 57.0–68.75). MacTel disease with asymmetric stage was seen in 56 (40%) of the 140 patients. At presentation, a two‑stage difference was noted in 46% (n = 26) of the patients with asymmetrical MacTel disease. A 10% conversion from symmetrical to asymmetrical disease stage was noted at the final visit. Of the 280 eyes evaluated for type 2 MacTel disease, 12 (4%) eyes showed no findings suggestive of MacTel on clinical examination and fluorescein angiography, optical coherence tomography (OCT), and OCT angiography when available and were labeled as unilateral type 2 MacTel disease.

Type 2 MacTel can show inter‑eye disease stage asymmetry. Unilateral type 2 MacTel disease is a distinct stage in MacTel which would need further evaluation and consideration while staging.

To determine the intrasession, intraobserver, interobserver, and repeatability of choroidal thickness measurements in the healthy subjects imaged on enhanced depth imaging system of RTVue XR spectral domain optical coherence tomography (OCT).

In this prospective, cross‑sectional study, seventy eyes of 70 healthy volunteers with no known ocular disease were imaged using high‑density scanning protocol of RTVue XR OCT. In a single imaging session, three sequential 12 mm macular‑enhanced depth horizontal line scans were obtained through the fovea. Two experienced examiners measured the subfoveal choroidal thickness (SFCT), choroidal thickness at 500 µm nasally and temporally from the fovea in all the eyes, using the manual calipers provided in the software. The graders were masked to each other’s measurement readings. The coefficient of repeatability (CR) and intraclass correlation coefficient (ICC) were used to measure the reliability within graders. Intergrader variability was assessed using Bland‑Altman method and 95% limits of agreement (LoA).

Intragrader CR for grader one was 4.11 µm (95% confidence interval [CI], −2.84–11.06) for SFCT and 5.73 µm (95% CI, −3.71–15.16) for the grader two. Intragrader ICC of grader one ranged from 0.996 for SFCT to 0.994 for temporal choroidal thickness. Intragrader ICC of grader two ranged from 0.993 for temporal choroidal thickness to 0.991 for SFCT. Intergrader CR ranged from 5.24 µm (95% CI, −4.66–15.15) for SFCT to 5.89 µm (95% CI, −7.27–19.04) for temporal choroidal thickness. Intergrader 95% LoA for SFCT, nasal and temporal choroidal thickness were, −15.84–12.15 µm, −15.99–17.7 µm, and − 19.12–15.57 µm, respectively.

Choroidal thickness measurements can be quantified with good repeatability using RTVue XR OCT, which would be useful in patients with chorioretinal diseases.

To evaluate the epidemiologic pattern of intravitreal injections (IVIs) during Coronavirus Disease 2019 (COVID‑19) pandemic.

The records of patients receiving IVIs in two 12‑month periods immediately before and after the beginning of the COVID‑19 epidemic were included. Age, province of residency, indication, number of injections, and number of operating room (OR) visits were analyzed.

Compared to pre‑COVID period, a 37.6% decrease in the number of patients receiving IVI in COVID period was seen (10518 vs. 6569). There was a parallel decrease in the number of OR visits(25590 vs. 15010: 41.4%) and injections(34508 vs. 19879: 42.4%). Regarding IVI indication, age‑related macular degeneration (AMD) showed the highest decrease in IVI rate (46.3%) which was significantly higher than decrease in other indications (P < 0.001). Retinopathy of prematurity (ROP) patients showed no change after epidemic. Mean overall age in AMD group was the highest (67.7 ± 13.2 years) compared to other indication groups (excluding ROP) (P < 0.001); while the mean age of the other indications was not significantly different from each other (excluding ROP).

COVID pandemic decreased the number of IVIs significantly. While previous studies suggested that the AMD patients had the highest risk of visual loss due to failure to receive IVIs in a timely manner, this very same group showed the highest decrease in the IVI number after pandemic. The health systems should devise strategies to protect this most vulnerable group of patients in future similar crises.

To determine by serial measurements and compare the pupillary mydriasis effect of tropicamide and phenylephrine drops administered as a vaporized spray over closed lids in one eye and through conventional instillation of eye drops in the other eye in a pediatric cohort.

This prospective study was conducted on healthy children aged 6–15 years. After visual assessment, investigator 1 examined the child for initial pupillary size. Investigator 2 instilled the drops in one eye and applied the spray to the other eye randomly, and the response of the child was noted using the Wong‑Baker pain rating scale. The eyes receiving the spray and the eyes receiving drop instillation were considered as Groups 1 and 2, respectively. Subsequently, serial pupillary measurements were carried out every 10 min for up to 40 min by investigator 1. The patient compliance for the two methods of drug instillation was also compared.

The study comprised 80 eyes. At 40 min, both the groups showed no statistical difference in the mydriasis effect, with Group 1 showing 7.23 mm mydriasis and Group 2 showing 7.58 mm (P = 0.058). The analysis of the pain rating scale showed better compliance with the spray method of drug instillation, which was statistically significant (P = 0.044).

Our study shows that spray application is a less invasive method for pupillary dilatation, which has better compliance and provides equally good dilatation as conventional methods. This study proves the efficacy of spray application in an Indian pediatric cohort.

To investigate the macular microvascular changes after different kinds of chemotherapy in patients with extramacular retinoblastoma (RB).

In this study, 28 eyes of 19 patients with bilateral RB treated with intravenous systemic chemotherapy (IVSC group) and 12 eyes of 12 patients with unilateral RB treated with intra‑arterial chemotherapy (IAC group) were compared with 6 normal fellow eyes of 6 patients with unilateral RB treated with IVSC (IVSC fellow eye group), and 7 normal fellow eyes of 7 unilateral RB patients treated with IAC (IAC fellow eye group), as well as 12 age‑matched normal eyes. Enhanced depth imaging optical coherence tomography measurements of central macular and subfoveal choroidal thickness (CMT and SFCT) as well as optical coherence tomography angiography measurements such as retinal superficial capillary density (SCD), deep capillary density (DCD), and choriocapillaris density were documented.

Images of 2 eyes in the IVSC group and 8 eyes in the IAC group were excluded from the final image analysis due to severe retinal atrophy. Overall, 26 eyes with bilateral RB treated with IVSC and 4 eyes of 4 patients with unilateral RB treated with IAC were compared with the mentioned control groups. Best‑corrected visual acuity was 1.03 logMAR in the IAC patients compared to 0.46 logMAR in the IVSC group at the time of imaging. While the CMT and SFCT were lower in the IAC group in comparison with the IAC fellow eye and normal groups (P < 0.05 for all), no remarkable difference was observed between the IVSC group and the control groups based on the mentioned parameters. Although the SCD showed no significant difference between the IVSC and control groups, this parameter was significantly lower in the eyes receiving IAC relative to the corresponding fellow eye group (P = 0.042) and normal control eyes (P = 0.047). The mean DCD was considerably lower in both the treatment groups compared to the control groups (P < 0.05 for all).

Our study showed a substantial decrease in SCD, DCD, CMT, and choroidal thickness in the IAC group, which may explain the lower visual outcome in this group.

To study the risk factors of mucormycosis and analyze their association among nasal and orbital mucormycosis in Coronavirus disease 2019 (COVID‑19) infection.

All patients diagnosed of rhino‑orbito‑cerebral mucormycosis (ROCM) with previous COVID‑19 infection were included in the study. The details such as age, sex, presence of co‑morbidities, and serum ferritin levels were collected. ROCM patients were classified into two groups, nasal mucormycosis (stage 1 and 2 of ROCM) and orbital mucormycosis (stage 3 and 4 of ROCM), and data were collected. Duration of COVID‑19 symptoms, the time interval between COVID‑19 infection and onset of ROCM symptoms, computed tomography severity score (CTSS) and usage of steroids were collected accordingly. The collected data were compared between nasal group and orbital group.

Among 52 patients, 15 patients had nasal and 37 patients had orbital mucormycosis. Forty‑one patients were more than 40 years, 43 patients were males. Seven out of ten risk factors were found to be significant on comparing nasal and orbital group. Patients of age more than 40 years (P = 0.034), elderly diabetics (P = 0.014), poor control of diabetes (P = 0.003), high serum ferritin levels (P = 0.043), duration between COVID‑19 and mucormycosis of more than 20 days (P = 0.038), CTSS of more than 9/25 (P = 0.020), and steroid usage during COVID‑19 infection (P = 0.034) are prone to develop orbital mucormycosis. On multivariate logistic regression analysis, these variables did not emerge as independent risk factors.

Patients with severe COVID‑19 infection along with other associated risk factors can be prone to develop severe forms of mucormycosis. We did not find them to be statistically significant on multivariate analysis. In the future, large scale studies are needed to know their significance.

To assess consanguinity as a probable risk factor for congenital ptosis.

In this case–control study, 97 patients with congenital ptosis and 97 participants as the control group were included. The age, sex, and residence area of the control group were matched with the cases. The inbreeding coefficient (F) was calculated for each participant, and the mean of the inbreeding coefficient (α) was calculated for each group.

The prevalence of consanguineous marriage in parents of cases with congenital ptosis and those of the control group was 54.6% and 30.9%, respectively (P < 0.002). The mean of the inbreeding coefficient (α) in patients with ptosis was 0.026, whereas it was 0.016 in the control group (T = 2.51, degree of freedom = 192, P = 0.0129).

The rate of consanguineous marriage was significantly higher among the parents of patients with congenital ptosis. It implies a probable recessive pattern in the etiology of congenital ptosis.

To describe a case of bilateral acute iris transillumination (BAIT) with no history of systemic infections or antibiotics intake before the attack.

This study included the review of the clinical record of the patient.

A 29‑year‑old male was referred to the glaucoma clinic with presumed bilateral acute iridocyclitis with refractory glaucoma. Ophthalmic examination revealed bilateral pigment dispersion, marked iris transillumination, dense pigment deposition in the iridocorneal angle, and high intraocular pressure. The patient was diagnosed with BAIT and was followed for 5 months.

The diagnosis of BAIT can be elicited even without a prior history of systemic infection or antibiotics intake.

To describe a particular form of posterior microphthalmos pigmentary retinopathy syndrome (PMPRS) with an atypical clinical presentation of pigment retinal dystrophy and an association to an inconstant complication which is angle‑closure glaucoma (ACG).

A 40‑year‑old male patient with ACG on maximal topical treatment was referred to our department for uncontrolled intraocular pressure. Best‑corrected visual acuity was 2/10 in the right eye and light perception in the left eye. Intraocular pressure was 36 mmHg bilaterally. He had 360° peripheral anterior synechiae on gonioscopy. Fundus examination revealed total cupping with pale retinal lesions in both eyes and a few pigment deposits in the midperiphery of the right eye. Multimodal imaging was done.

Fundus autofluorescence revealed patchy areas of hypoautofluorescence. Optical coherence tomography (OCT) showed bilateral foveoschisis and macular folds. Anterior segment OCT showed a circumferential iridocorneal angle closure. Axial length measured with ultrasound biomicroscopy was 18.4 mm in the right eye and 18.1 in the left eye. Electroretinogram revealed attenuated scotopic responses. The patient was diagnosed with nanophthalmos–retinitis pigmentosa (RP)–foveoschisis syndrome complicated with ACG. A combined surgery with phacoemulsification - anterior vitrectomy - intraocular lens implantation and trabeculectomy was performed in both eyes with a satisfactory outcome.

In its typical forms, PMPR syndrome is an association of nanophthalmos - RP - foveoschisis and optic nerve head (ONH) drusen. Incomplete phenotypes may lack ONH drusen or foveoschisis. Patients with PMPRS have to be screened for iridocorneal angle synechia and ACG.

To describe the case of a 67‑year‑old female with proliferative retinopathy secondary to uncontrolled hypertension.

Retrospective case report including multimodal imaging.

A 67‑year‑old female presented with mild vitreous hemorrhage, retinal hemorrhage, hard exudate of the left eye and hard exudate, copper wiring of vessels, and retinal hemorrhages in the right eye. Optical coherence tomography depicted macular edema of both eyes. Fluorescein angiography revealed large areas of peripheral retinal ischemia and neovascularization with multiple areas of vascular leakage in both eyes.

Proliferative hypertensive retinopathy has been rarely reported in the literature. Our patient exhibited findings consistent with proliferative retinopathy secondary to hypertensive retinopathy.

To report a case of medial rectus plication for the management of dissociated horizontal deviation (DHD).

We introduce medial rectus plication for improving the control of exoshift of DHD.

A 20‑year‑old woman with a chief complaint of left eye outward deviation since childhood was referred to the strabismus clinic. The diagnosis of DHD was made according to the detection of asymmetric slow abduction of the left eye (50 prism diopter) during visual inattention or cover testing. The left lateral rectus (LR) was recessed 8 mm with a posterior fixation suture (PFS). In the early postoperative period, the control of DHD improved; however, after 6 months, the patient and her parents complained of frequent observation of the exoshift of the left eye (30 prism diopter). For better control of DHD, medial rectus plication (5 mm) of the left eye was considered the second operation. After 12 months of follow‑up, the control of deviation improved, and there was no manifest deviation.

The literature’s recommended procedure for unilateral DHD without a duction deficit is to perform a unilateral LR muscle recession. Some authors have proposed adding PFS to augment the effect of LR recessions. Although recurrence may occur, medial rectus plication can be considered one of the reversible options and can be used in recurrences of DHD after the first surgical procedure.

To describe superficial temporal artery graft as a new autologous tissue to reconstruct the upper lacrimal drainage system.

We explain the history of a 30‑year‑old female with upper lacrimal drainage system obstruction, in whom conjunctivodacryocystorhinostomy (CDCR) failed to resolve epiphora. Asuperficial temporal artery graft was harvested, intubated with Masterka tube, and implanted between the conjunctiva and nasal cavity. Masterka was replaced with a thicker dummy tube 12 weeks postoperatively. The adequacy of the graft was checked with irrigation tests in follow‑up visits from 1 to 26 months after the procedure.

Superficial temporal artery autograft successfully eliminated epiphora of the patient in whom (CDCR) with Jones tube failed to make her symptom free.

Superficial temporal artery autograft as an autogenous tissue with adequate characteristics can be considered in selective patients of upper lacrimal obstruction to reconstruct the lacrimal drainage system.