glaucoma surgery - informa marketsimages2.advanstar.com/pixelmags/ot/pdf/2013-06-ote.pdf · dr...

June 2013 l Volume 9 Number 5 l www.oteurope.com

Glaucoma surgeryOptions to help slow down progression

RETINA

Imaging and diagnostics for

retinal problems

CATARACT & REFRACTIVE

Causes and treatments for ocular

surface diseases

GLAUCOMA

Updates on IOP monitoring in

glaucoma patients

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tafluprost

The first preservative-free prostaglandin

Effective IOP-lowering (1

Low risk of hyperaemia (2

For Glaucoma

Tough on IOP.Easy on Eyes.

June 2013 l Volume 9 Number 5 l www.oteurope.com

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Tough on IOP.Easy on Eyes.

tafluprost

Ma

y 2

01

3

Abbreviated Prescribing Information TAFLOTAN® (tafluprost 0.0015% eye drops, solution, single-dose container). Presentation: Low-density polyethylene single-dose containers packed in foil pouch. Each single-dose container has a fill volume of 0.3 ml and there are 10 containers in each foil pouch. The following pack sizes are available: 30 x 0.3 ml and 90 x 0.3 ml. One ml of eye drops contains 15 micrograms of tafluprost. Indication: Reduction of elevated intraocular pressure in open angle glaucoma and ocular hypertension in patients who would benefit from preservative-free eye drops or who are insufficiently responsive or intolerant or contra-indicated to first line therapy, as monotherapy or as adjunctive therapy to beta-blockers. Dosage and Administration: The recommended dose is one drop of TAFLOTAN® in the conjunctival sac of the affected eye(s) once daily in the evening. Not recom-mended in children or adolescents (under the age of 18). In renal or hepatic impairment use with caution. Contraindications: Hypersensitivity to tafluprost or to any of the excipients. Precautions: Before treatment is initiated, patients should be informed of the possibility of eyelash growth, darkening of the eyelid skin and increased iris pigmentation. Some of these changes may be permanent, and may lead to differences in appearance between the eyes when only one eye is treated. Caution is recommended when using tafluprost in aphakic patients, pseudophakic patients with torn posterior lens capsule or anterior chamber lenses, or in patients with known risk factors for cystoid macular oedema or iritis/uveitis. There is no experience in patients with severe asthma. Such patients should therefore be treated with caution. Interactions: Specific interaction studies with other medicinal products have not been performed with tafluprost. Pregnancy: Do not use in women of childbearing age/potential unless adequate contraceptive measures are in place. Driving: Tafluprost has no influence on the ability to drive. Undesirable Effects: The most frequently reported treatment-related adverse event was ocular hyperaemia. It occurred in approximately 13% of the patients treated with preserved tafluprost and 4.1% of the patients treated with preservative-free tafluprost. Other side effects include: Common (1% to 10%): eye pruritus, eye irritation, eye pain, changes in eyelashes, dry eye, eyelash discolouration, foreign body sensation in eyes, erythema of eye lid, blurred vision, increased lacrimation, blepharal pigmentation, eye discharge, reduced visual acuity, photophobia, eyelid oedema and increased iris pigmentation and headache. Uncommon (0.1% to <1%): superficial punctate keratitis (SPK), asthenopia, conjunctival oedema, blepharitis, ocular discomfort, anterior chamber flare, conjunctival follicles, allergic conjunctivitis, anterior chamber cell, conjunctival pigmentation and abnormal sensation in eye, hypertrichosis of eyelid. Overdose: If overdose occurs, treatment should be symptomatic. Special Precautions for Storage: Store in a refrigerator (2°C - 8°C). After opening the foil pouch keep the single-dose containers in the original foil pouch, do not store above 25°C, discard an opened single-dose container with any remaining solution immediately after use. MA Holder: Santen Oy, Niittyhaankatu 20, 33720 Tampere, Finland. Date of Preparation: 11/2012.1) Taflotan lowered IOP by 6.9 - 9.7 mmHg in masked, randomized studies 1-4. 1. Uusitalo H et al. Acta Ophthalmol 2010; 88: 12-19 2. Traverso C et al. J Ocul Pharmacol Ther 2010; 26: 97-104 3. Konstas AG et al. Comparison of 24-hour efficacy with Tafluprost compared with Latanoprost in patients with primary open-single glaucoma or ocular hypertension. Abstract 5104/A2458 4. Chabi A et al. Am J Ophthalmol 2012; 153: 1187-1196 2) SPC text of Taflotan 3) Zimmerman T et al. J Ocul Pharm and Ther 2009; 25: 49-56

Taflotan has a low risk of

hyperaemia!2

4,1%2

Hyperaemia contributes to >60% of adverse event related switches with prostaglandins.3

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3www.oteurope.com

Jorge L. Alió, MD, PhD

Instituto Oftalmologico de Alicante,

Alicante, Spain

Winfried Amoaku

University Hospital, Queen’s Medical

Centre, Nottingham, UK

Gerd Auffarth, MD

University of Heidelberg, Germany

Albert Augustin, MD

Klinikum Karlsruhe, Karlsruhe, Germany

Rafael Barraquer, MD

Institut Universitari Barraquer and Centro

de Oftalmología Barraquer, Barcelona,

Spain

Christophe Baudouin, MD

Quinze-Vingts National Ophthalmology

Hospital, Paris, France

Johan Blanckaert, MD

Eye & Refractive Centre, Ieper, Belgium

Burkhard Dick, MD

Center for Vision Science, Ruhr University

Eye Hospital, Bochum, Germany

Christoph Faschinger, MD

Medical University of Graz, Clinic of

Ophthalmology, Graz, Austria

Paolo Fazio, MD

Centro Catanese di Medicina e Chirurgia

(CCHC), Catania, Italy

Alessandro Franchini, MD

University of Florence, Eye Institute -

Azienda Ospedaliera Careggi, Florence,

Italy

Frank Goes, MD

Goes Eye Centre Left Bank, Antwerp,

Belgium

Günther Grabner, MD

University Eye Clinic Salzburg, Salzburg,

Austria

Zdenek Gregor, FRCS FRCOphth

Moorfelds Eye Hospital, London, UK

Gábor Holló ,MD, PhD, DSc

Semmelweis University, Budapest,

Hungary

Vikentia Katsanevaki, MD

Vardinogiannion Eye Institute, University

of Crete, Greece

Omid Kermani, MD

Augenklinik am Neumarkt,

Augenlaserzentrum Köln, Germany

Hans-Reinhard Koch, MD

Hochkreuz Augenklinik, Bonn, Germany

Anastasios G.P. Konstas, MD, PhD

1st University Department of

Ophthalmology, AHEPA Hospital,

Thessaloniki, Greece

Pavel Kuchynka, MD

Charles University, Prague, Czech

Republic

Erik L. Mertens, MD, FEBO

Antwerp Eye Center, Antwerp. Belgium

Norbert Pfeiffer, MD

University of Mainz, Mainz, Germany

Roberto Pinelli, MD

Istituto Laser Microchirurgia Oculare,

Brescia, Italy

Matteo Piovella, MD

C.M.A. srl Centro Microchirurgia

Ambulatoriale, Monza, Italy

Imola Ratkay-Traub, MD

Danube Band Medical Centre, Hungary

Herbert A. Reitsamer, MD

Paracelsus University Salzburg, SALK

University Eye Clinic, Salzburg, Austria

Gisbert Richard, MD

University Medical Center,

Hamburg-Eppendorf, Hamburg, Germany

Theo Seiler, MD

Institut für Refraktive & Ophthalmo-

Chirurgie (IROC) and University of Zurich,

Zurich, Switzerland

Tarek Shaarawy, MD

University of Geneva, Geneva,

Switzerland

Sunil Shah, FRCOphth, FRCSEd,

FBCLA

Birmingham and Midland Eye Centre,

Midland Eye Institute, Solihull, UK

Gisèle Soubrane, MD

University Paris XII, France

David Spalton, MD

St Thomas’ Hospital & King Edward VII’s

Hospital, London, UK

Einar Stéfansson, MD, PhD

University of Iceland, National University

Hospital, Reykjavik, Iceland

John Thygesen, MD

Rigshospitalet, University of

Copenhagen, Copenhagen, Denmark

Baha Toygar, MD

Dünya Eye Hospital, Istanbul, Turkey

Petja Vassileva, MD

National Eye Institute, Sofa, Bulgaria

Jan Venter, MD

Optimax UK & Croydon Clinics, UK

Carlos Vergés, MD, PhD

C.I.M.A. Universidad Politécnica de

Cataluña, Barcelona, Spain

Paolo Vinciguerra, MD

Istituto Clinico Humanitas, Rozzano,

Milan, Italy

Thierry Zeyen, MD

University Hospital, Leuven, Leuven,

Belgium

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4Ophthalmology Times Europe June 2013

Cover Features

7 Improving the glaucoma surgical armamentarium

In this article, Professor Buys discusses a contender in the

search for an improvement on trabeculectomy, revealing her

findings from a comparative review of published data.

10 Revisiting TSCPC as an option

According to Dr Ahmed this procedure has the ability to lower

IOP and preserve vision similar to trabeculectomy and tube

shunts.

12 Reducing IOP: A comparative analysis

Dr Lindstrom describes a minimally invasive surgical procedure,

which he believes has revolutionized treatment for glaucoma

patients.

14 Microstent reduces medication use

Results of a multinational study are revealed that demonstrate

the safety and efficacy of an investigational intracanalicular

microstent.

Cataract & Refractive

16 Effects of laser refractive surgery upon tear osmolarity

In this paper, the outcomes of a recent study examining the

effects of LASIK on the ocular surface are highlighted.

20 Treating MGD and evaporative dry eye

Dr Albou-Ganem offers her thoughts on a new system and

reveals the results of her recent study.

22 NSAIDs lower inflammation, CME

Comparative study results are discussed that support the use

of once-daily treatment.

24 OVDs ideal for microincision surgery

According to Dr Deidier, moderately cohesive OVDs offer

desired performance traits.

Retina

26 Identifying patients with autoimmune retinopathy

In this article, the authors examine the best practices for

patients with autoimmune retinopathy and reveal how imaging

technologies can help.

29 Confocal infrared RM imaging of macular diseases

Dr Diniz reports on a new, commercially available scanning

laser confocal ophthalmoscope that can perform multiple

functions.

32 Atypical presentation of acute macular

neuroretinopathy

A case report is presented in which imaging, visual acuity and

literature are used to diagnose acute macular neuroretinopathy

through exclusion.

Glaucoma

36 Continuous IOP monitoring

Dr Lorenz discusses her recent study investigating the

tolerability of a device that can continuously measure IOP in

glaucomatous and healthy patients.

38 Ocular surface disease exacerbated glaucoma

The authors describe the rationale for optimizing the ocular

surface in glaucoma patients.

41 Enhanced detection of open-angle glaucoma

Professor Chauhan summarizes a recent report on an

anatomically accurate OCT-derived neuroretinal rim parameter.

Regulars

6 News

42 Products

June 2013 l Volume 9 Number 5

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NEWS

NEWS IN BRIEF

Toric IOL improves QoLImplantation of a toric IOL results in

improved patient quality of life (QoL) and

better visual, refractive and aberrometric

results, states a new investigation in the

British Journal of Ophthalmology.

A team headed by Dr R. Mencucci,

Department of Specialised Surgical

Sciences-Eye Clinic, University of

Florence, Florence, Italy, assessed three

groups of subjects who underwent

unilateral cataract surgery with IOL

implantation.

Overall, the toric lens resulted in a

better post-op QoL compared to the

spherical SN60AT lens.

Digital devices good for AMDDigital devices may be used as a visual

rehabilitation technique for low-vision

AMD patients, according to a paper

featured in the journal Eye.

An investigation led by Dr K. Gill,

Department of Ophthalmology,University

of Western Ontario, London, Ontario,

Canada, included 27 stable wet AMD

patients in the study.

Devices with larger display screens

and high contrast ratios are benef cial to

AMD patients who require larger texts for

reading.

Three-plane CCI effectiveThe 2.75 mm three-plane clear corneal

incision (CCI) created with a femtosecond

laser produces comparable outcomes

to single-plane angled manual incision

for anterior and posterior corneal

topography, claims a new study in the

Journal of refractive Surgery.

Dr Marco Lombardo et al., Fondazione

G.B. Bietti IRCCS, Rome, Italy, performed

inf ation testing in 14 human eye globes

to assess the topographic response to

the cornea to CCIs.

The average change of the anterior

and posterior corneal astigmatism vector

magnitude was 0.17 D or less in both

groups.

Smoking decreases choroidal thicknessCigarette smoking signif cantly decreases choroidal thickness, claims the latest results published

in the British Journal of Ophthalmology.

The investigation, led by Dr Selçuk Sızmaz, Department of Ophthalmology, Baskent

Üniversitesi Adana Arastırma ve Uygulama Merkezi, Ankara, Turkey, included 17 otherwise

healthy smokers as the study group and 17 non-smokers as the control group. All smokers

underwent OCT scanning at baseline and one and three hours after smoking one standard

cigarette.

Participants in the control group underwent OCT scanning in the morning and then two

examinations at the f rst and third hours. Choroidal thickness measurements were recorded

from all participants in both groups.

At baseline, mean choroidal thickness at the fovea was 301.1 ± 63.1 μm for smokers and

decreased to 284.2 ± 56.7 μm at one hour and 270.8 ± 80.0 μm at three hours after smoking.

This demonstrated a signif cant decrease at all f ve extrafoveal points.

The control group presented with a mean baseline choroidal thickness at the fovea of

270.6 ± 57.9 μm, which was stable at 272.5 ± 52.4 μm at one hour and 273.8 ± 57.4 μm at three

hours.

Fourier domain OCT effectively identif es reductions in choroidal thickness due to cigarette

smoking.

Sagging eye syndrome causes diplopia Widespread rectus pulley displacement and extraocular muscle (EOM) elongation causes

acquired vertical and horizontal strabismus, according to a study in the Archives of

Ophthalmology.

Dr Zia Chaudhuri et al., Jules Stein Eye Institute, University of California, Los Angeles,

California, USA, used magnetic resonance imaging to evaluate rectus EOMs, pulleys and the

lacteral rectus-superior rectus (LR-SR) band ligament on 56 orbits of 28 patients clinically

diagnosed with SES. Results were also gathered from 25 orbits of 14 control subjects.

The main outcome measures were rectus pulley locations compared with age-matched

norms and lengths of the LR-SR band ligament and rectus EOMs. This information was correlated

with facial features, binocular alignment and fundus torsion.

Blepharoptosis and superior sulcus defect was commonly exhibited in patients with SES.

Signif cant inferolateral LR pulley displacement was discovered in SES. However, the causes

extended to peripheral displacement of all other rectus pulleys and lateral displacement of the

inferior rectus pulley, with elongation of rectus EOMs.

Symmetrical LR sag was linked to divergence paralysis esotropia and asymmetrical LR sag

greater than 1 mm with cyclovertical strabismus. Small-angle esotropia or hypertropia could be

caused by common involutional changes in EOMs and orbital connective tissues.

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7www.oteurope.com

GLAUCOMA SURGERY

Landmark clinical trials have confirmed that

lowering intraocular pressure (IOP) slows

progression of glaucoma and that low target

pressures in many cases can halt progression. In

those individuals unable to achieve their target IOP

medically or unable to follow a medication regimen

(due to for example intolerance, lack of compliance or

cost), a variety of interventions are available.

Among the growing plethora of glaucoma surgical

procedures, trabeculectomy remains the most

commonly performed procedure due to its track

record of achieving low target pressures. Although

trabeculectomy has been performed for decades

the procedure has evolved over time including the

introduction of releasable sutures/suture lysis, the

use of anti-metabolites and conjunctival flap design

making the modern trabeculectomy very effective

at lowering IOP with reduced risks. Potential serious

complications exist, however, such as early and

late postoperative hypotony, reduced vision due to

accelerated cataract growth and bleb-associated

infections.

Glaucoma surgeons continue to search for an

improvement on the trabeculectomy; a procedure

that will deliver significant IOP reduction but with

fewer complications. One such contender is the

ExPRESS glaucoma shunt (Alcon Laboratories, Fort

Worth, Texas, USA — see Sidebar 1).

Similar to trabeculectomy

Originally the device was intended to be implanted

directly under the conjunctiva, however, due to high

rates of hypotony and device extrusion it is now

implanted under a scleral flap. This is essentially a

modification of a trabeculectomy, with the elimination

of manually creating an osteium and a peripheral

iridectomy.

Given the similarity to a trabeculectomy, the

procedure has a short learning curve specifically for

those familiar with trabeculectomy surgery. It was

also anticipated that the uniform internal lumen

diameter of the shunt would yield more consistent

reduction in IOP and specifically reduce rates of

early hypotony. Further proposed advantages over

conventional trabeculectomy include decreased

tissue manipulation by excluding the manual

creation of an osteium and peripheral iridectomy,

which could result in improved IOP lowering over a

trabeculectomy.

The procedure of implanting an ExPRESS shunt

under a scleral flap has been embraced by many

glaucoma surgeons with thousands of devices

implanted worldwide. Unfortunately, what is missing

in the literature are well-designed prospective

randomized controlled trials (RCTs) comparing

the device implanted under a scleral flap to a

trabeculectomy. Comparative data of this nature

would provide conclusive evidence to secure the

position of the ExPRESS shunt in the glaucoma

surgical armamentarium.

What the studies reveal

A recently published review1 comparing this device to

trabeculectomy found only two prospective RCTs in

the peer-reviewed literature and one additional RCT

with results presented at the 2012 and 2013 American

Glaucoma Society meeting. The first study, by de

Jong et al.,2 randomized 80 eyes to trabeculectomy

or ExPRESS and reported results up to 5 years.

Initially the ExPRESS group had statistically significant

lower IOP and better success than trabeculectomy,

however, after 3 years the differences were no longer

statistically significant.

Dahan et al.3 randomized fellow eyes of 15 subjects

to ExPRESS or trabeculectomy and followed these

subjects for a mean of 23.6 months. Three of the

By Prof. Yvonne M. Buys,

MD, FRCSC

Improving the glaucoma surgical armamentariumPositioning the ExPRESS shunt in the glaucoma surgeon’s practice

In short...Trabeculectomy remains the most commonly performed

procedure to surgically reduce IOP in glaucoma patients.

However, potential serious complications exist and as such

glaucoma surgeons continue to search for an improvement

on the trabeculectomy. In this article, Professor Buys

discusses a contender of this search, the ExPRESS

glaucoma shunt, revealing her findings from a comparative

review of published data.



GL AUCOMA SURGERY

subjects were lost to follow-up

after 1 year. In this small series they

reported significantly better success

with the shunt but no difference in

mean IOP between groups at last

follow-up.

In both of these studies there were

no differences in any of the other

reported outcomes between the

groups including number of glaucoma

medications and complications.

None of the retrospective studies

in this series reported a difference

in IOP, success rates or number of

glaucoma medications between the

device and trabeculectomy. In terms

of complications one retrospective

study reported significantly higher

rates of early hypotony and choroidal

effusions with trabeculectomy as

compared to ExPRESS. No other

studies reported differences in

complication rates between these

procedures.

When evaluating efficacy of

various glaucoma therapies the

focus has traditionally been on IOP.

The patient, however, is typically

concerned with visual function. In all

the studies included in this review

only one evaluated visual fields and

reported no difference between

the device and trabeculectomy.

Several studies compared visual

acuity with some finding decreased

vision following surgery with either

procedure however there was no

significant difference between the

groups. The rate of visual recovery

was evaluated in 3 studies and found

to be faster following implantation of

the shunt.4–6

Overall the clinical outcome

following ExPRESS appears to be

similar to trabeculectomy with

perhaps faster visual recovery.

Non-clinical outcomes, such as

economic factors should also be

considered. It was initially suggested

that this alternative filtration surgery

was faster than trabeculectomy,

however, a study that compared

surgical time did not find a difference

between these procedures. This

same study evaluated the one year

cost difference between ExPRESS

and trabeculectomy including surgical

costs, medications and follow-up and

found that the shunt was significantly

more expensive with the difference

primarily attributed to the cost of the

implant.7

Summary

In summary various metrics are

used in the decision process

when recommending a glaucoma

procedure to an individual patient.

The current evidence regarding

the device implanted under a

scleral flap suggests equivalency

to trabeculectomy in terms of IOP,

success, number of glaucoma

medications and complications. Final

visual acuity has also been reported

to be similar, however, the rate of

visual recovery may be faster with

trabeculectomy. Unknowns include

late device specific complications

including external device exposure,

erosion into the eye, and effects on

corneal clarity. All of these outcomes

also need to be considered in the

context of the increased cost of the

device and will ultimately determine

the position of the ExPRESS in the

armamentarium of glaucoma surgical

procedures.

References

1. Y.M. Buys, Curr. Opin. Ophthalmol.,

2013;24:111–118.

2. L. de John et al., Clin. Ophthalmol.,

2011;5:527–533.

3. E. Dahan et al., Eye, 2012;26:703–710.

4. T.J. Good and M.Y. Kahook, Am. J.

Ophthalmol., 2011;151:507–513.

5. T. Sugiyama et al., Clin. Ophthalmol.,

2011;5:1063–1066.

6. L. Beltran-Agullo et al., J. Glaucoma, In

press.

7. H.Y. Patel et al., J. Glaucoma, 2012. doi:

10.1097/IJG.0b013e31827a06f4.

8. N. Geffen et al., J. Glaucoma,

2010;19:116–118.

9. L.K. Seibold et al., Br. J. Ophthalmol.,

2011;95:251–254.

Author

Professor Yvonne M. Buys, MD,

FRCSC, is Professor at the Department

of Ophthalmology and Vision Sciences,

University of Toronto, Canada. She may be

reached by E-mail: [email protected]

Prof. Buys has indicated that some

ExPRESS shunts used in a study were

provided at no charge from IMed and

Alcon Canada. Also she has received

honorarium for speaking for Alcon Canada.

Do you agree?

www.oteurope.com/discuss

Sidebar 1: Details of the

ExPRESS shunt.

The ExPRESS shunt received

FDA approval in 2002. It basically

consists of a stainless steel tube

less than 3 mm in length. There

have been several design changes

with the P-50 model being the

most recent version. In addition

to the tube design there is a distal

footplate to prevent migration

of the tube into the anterior

chamber as well as a groove

in the footplate to promote

posterior drainage of aqueous and

a proximal spur to prevent device

extrusion. Together the footplate

and spur anchor the device to

the sclera. Tests have shown

that although the device does

have ferromagnetic properties

it is likely safe with MRI of up to

3 Telsa.8,9


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GLAUCOMA SURGERY

A variety of procedures are available for the

treatment of open-angle glaucoma, catering

to different degrees of severity. Microinvasive

glaucoma surgery is a relatively new category

aimed at mild-to-moderate glaucoma, and includes

the trabecular micro-bypass (iStent, Glaukos,

Laguna Hills, California, USA) and Trabectome

(NeoMedix, Tustin, California, USA). These

procedures use a clear-corneal microincision,

spare the conjunctiva and present only a minimal

disruption of the normal anatomy and physiology of

the eye. Their modest efficacy is combined with an

extremely high safety profile.

Blebless ab externo glaucoma surgeries, which

include canaloplasty and deep sclerectomy,

are successful at lowering high IOP while still

maintaining a good safety profile. Filtering

surgeries, such as trabeculectomy, ExPRESS shunt

(Alcon Laboratories, Fort Worth, Texas, USA), and

tubes, are the go-to options when a patient requires

an IOP lower than 10 to 12 mmHg.

Transscleral cyclophotocoagulation (TSCPC)

has typically been reserved for patients with

little hope of maintaining their vision. The

American Academy of Ophthalmology Ophthalmic

Technology Assessment Committee stated,

“Cyclophotocoagulation is indicated for patients

with refractory glaucoma who have failed

trabeculectomy or tube shunt procedures, patients

with minimal useful vision and elevated IOP,

patients who have no visual potential and need pain

relief, and patients with complicated glaucoma and

conjunctival scarring from previous surgery.”1

A few changes in technique combined

with a re-evaluation of the data merit a new

attitude toward this treatment option, however.

Cyclodestruction and later cryotherapy were

techniques associated with serious complications

including: substantial post-treatment visual loss,

sympathetic ophthalmia, and phthisis. Cryotherapy

has largely been replaced by TSCPC, which has a

vastly improved safety profile.

New techniques, such as the slow coagulation

method by Doug Gaasterland, are making TSCPC

safer. This approach uses a lower amount of energy

over a longer duration of time, leaving the eyes

quieter, and it reduces some of the complications,

such as inflammation, uveitis and cystoid macular

oedema.

On the cusp of development is a MicroPulse CPC

procedure, which is believed will further enhance

safety and allow more comfort in using the procedure

earlier in the treatment paradigm. In addition, the

use of steroids and non-steroidal anti-inflammatory

drugs perioperatively has helped mitigate some of the

complications.

A glaucoma device (G-Probe, Iridex, Mountain View,

California, USA) is designed to direct infrared energy

toward the ciliary body and I tend to err on the side of

posterior placement as well. In highly myopic eyes, I

often use transillumination to identify the exact location

of the ciliary body. This technique is effective anytime

extra confidence is needed with where to direct the

laser and more precise targeting of the ciliary processes

can reduce pain and inflammation after the procedure.

TSCPC in eyes with good visual acuity

Analysing the data on TSCPC will show that it

has historically been used in very sick eyes with

By Dr Ike K. Ahmed

Revisiting TSCPC as an optionProcedure has ability to lower IOP, preserve vision similar to trabeculectomy and tube

shunts

In short...Transscleral cyclophotocoagulation is not the same as

cryotherapy of the past; it has the ability to lower IOP and

preserve vision similar to trabeculectomy and tube shunts,

while avoiding a complicated filtering surgery.

“Instead of searching for one

ideal glaucoma procedure,

ophthalmologists should be

identifying the best option for

each patient.”


11www.oteurope.com/glaucoma

GL AUCOMA SURGERY

minimal visual acuity, contributing

to the idea that loss of visual acuity

is linked to TSCPC. However, more

recent studies of eyes with better

visual potential have shown that this

may not be fully accurate. Rotchford

and colleagues studied TSCPC in 49

eyes with a median pre-treatment

visual acuity of 20/60, and after

5 years of follow-up, the median

visual acuity remained 20/60.2

A loss of two or more lines was

recorded in 30.6% of eyes, a number

similar to other procedures.

The three-year follow-up for the

Tube Versus Trabeculectomy Study

showed an average decrease in

IOP of 48% for both randomized

groups, with surgical complications

related to re-operation or visual

acuity loss of greater than 2 Snellen

lines in 22% of the tube group and

27% of the trabeculectomy group.3

This is similar to the results of 74

eyes that underwent TSCPC and

were followed for 12 months.4 The

mean reduction in IOP was 43% and

mean visual acuity was preserved

in subgroups with good vision,

whereas 13% of patients lost vision

due to a progressive cataract or

glaucoma.

In another study comparing

TSCPC with a glaucoma valve

(Ahmed Glaucoma Valve, New

World Medical, Rancho Cucamonga,

California, USA), there was a 57%

decrease in IOP in the TSCPC group

and a 47% decrease in IOP in the

Ahmed group.5 Both groups had an

incidence of decreased vision of

about 25%, and predominantly in

patients with neovascular glaucoma

who are difficult to treat.

In my practice, I use TSCPC in

patients whose disease is often

advanced in nature, who may have

had previous glaucoma surgery

and who need IOP lowered to the

low teens or less. I expect that

patients will be taking one to two

medications after the procedure.

Patients for whom

trabeculectomy or tube shunts

would pre sent a significant risk are

often excellent TSCPC candidates.

This includes patients with a

previous failed subconjunctival

procedure or who have had a

previous incisional surgery, whether

or not they have good vision.

An example of a TSCPC patient in

my clinic is a 60-year-old male who

has high myopia, has split fixation

and vision around 20/25 with a small

tunnel of vision of 3° to 4°. His IOP

is low 20s mmHg with maximum

medical therapy, which is too high

for the optic nerve. This patient is

at very high risk for immediate snuff

out with a filtering procedure. In this

patient I would perform TSCPC with

a titrated, gentle approach, starting

modestly and then re-treating

again if necessary after a couple of

months.

I start treatment at 1250 mW

of power for 4000 ms and apply

between 12 and 16 spots along the

limbus, with the G-probe. The goal

is to lower IOP to 13–14 mmHg and

it is common that the patient would

remain taking medication. It may be

necessary to re-treat this patient,

but the goal is to maintain central

vision.

Re-treatment with TSCPC is not

the same as re-treatment with

trabeculectomy or tube shunts. If

after two treatments the patient

needs additional IOP lowering, I

would increase the energy until I

hear audible pops that indicate the

explosion of the ciliary processes.

I avoid this endpoint because it

results in greater inflammation and

risk of cystoid macular oedema.

Individualized treatment

A variety of treatment options are

available today and it is necessary

to analyse which procedure is

optimal for each individual patient.

Trabeculectomy and tube shunts

definitely still have a place in my

practice, but there is a segment

of the population that does not

do well with these procedures.

Patients with failed filtering

surgeries, fixation defects, risk of

suprachoroidal haemorrhage, or

high risk in general will often lose

vision following trabeculectomy

or tube shunts. Losing vision after

undergoing such a procedure is

devastating.

TSCPC is not the same as

cryotherapy of the past; it has the

ability to lower IOP and preserve

vision similar to trabeculectomy

and tube shunts, while avoiding

a complicated filtering surgery.

Instead of searching for one

ideal glaucoma procedure,

ophthalmologists should be

identifying the best option for each

patient.

References

1. S.A. Pastor et al., Ophthalmology,

2001;108:2130–2138.

2. A. P. Rotchford et al., Br. J.

Ophthalmol., 2010;94:1180–1183.

3. N. Goldenberg-Cohen et al.,

Ophthalmic Surg. Lasers Imaging,

2005;36:272–279.

4. E. Ansari and J. Gandhewar, Eye,

2007;21:936–940.

5. N. Yildirim et al., J. Glaucoma,

2009;18:192–196.

Author

Dr Ike K. Ahmed is in practice

in Credit Valley Eye Care and

assistant professor at the

University of Toronto, Canada.

He is also fellowship director,

Glaucoma and Anterior

Segment Fellowship; University of Toronto

Research Fellowship Director; University

of Toronto, Department of Ophthalmology

and Vision Sciences Chief; and co-medical

director of TLC Laser Eye Center,

Mississauga, Ontario, Canada.

Dr Ahmed receives consultant/consulting

fees, speakers honoraria, or research

grant/support from numerous companies.

Would you consider

revisiting TSCPC?




GLAUCOMA SURGERY

The high comorbidity of cataracts and glaucoma

or ocular hypertension (OHT) has made it

expedient for ophthalmologists to determine how to

best treat this growing population. There have been

several different surgical therapies available, but

until now we have lacked a low-risk option to help

patients maintain controlled intraocular pressure

(IOP) and reduce their medication burden.

Phacoemulsification alone has been proven to

lower IOP a clinically significant amount over a

sustained period of time.1 Cataract surgery also has

the added benefit of being considered an extremely

safe and effective procedure with limited risks and

high quality of life value. With my patients presenting

with coexisting pathologies, I am often able to lower

their IOPs sufficiently with cataract surgery alone

that a combined procedure is not necessary.

When low pressures are needed to prevent

visual field loss in patients with moderate to severe

glaucoma, trabeculectomy or tube shunts are

optimum options. However, they have far more risks

associated with them than with cataract surgery

alone and studies have also shown that combining

these procedures with cataract surgery has a high

rate of failure.2

Glaucoma bleb surgeries, like trabeculectomies,

can be unpredictable and fraught with

complications. The success of a trabeculectomy

in lowering IOP hinges upon the size, shape and

contour of the sclerostomy and conjuctival bleb.

The bleb can fail if too much scarring occurs as

the operative site heals. Needling of the bleb can

reopen the outflow channel if scarring blocks it,

but if this is unsuccessful, IOP returns to high levels

and the treatment fails. An extended period of time

until IOP and vision stabilize and acceleration of

cataract formation are common symptoms following

trabeculectomy. A study of 1240 eyes found

46% of patients experienced early complications

and 42% had latent complications following a

trabeculectomy.2 The fickle nature of bleb surgeries

prompted the transition to treating patients with

cataract and glaucoma disease with cataract

surgery alone.

Cataract surgery alone

Transitioning from combined procedures to cataract

surgery alone resulted from findings that showed

significant reductions in IOP and medication burden

were achievable with cataract surgery alone. In a

retrospective review of 588 eyes that underwent

phacoemulsification and IOL implantation,

glaucomatous eyes with preoperative IOPs between

23 to 31 mmHg had a mean 4.8 mmHg reduction

in pressure sustained for 10 years.1 While this is

good news, additional lowering of IOP could mean a

patient is relieved of some medication burden. When

planning the treatment of patients with coexistent

pathologies, it is expedient to weigh the risk factors

and complication rates against the potential overall

reduction in pressure and determine what will be

maximally beneficial to the patient in the long run.

There is a 90% satisfaction rate in quality of life

issues with cataract surgery with a complication

rate of less than 5% and very few potential sight

threatening risks. In some patients, the greater risk

associated with a combined procedure is necessary

to take, because a greater pressure reduction is

By Dr Richard Lindstrom

Reducing IOP: A comparative analysisAn exciting new option in combination with cataract surgery

In short...The high comorbidity of cataracts and glaucoma or

OHT has meant it is advisable for ophthalmologists to

determine how best to treat this growing population.

Although there are a few options available, there has

not been, until now, a low risk option to lower IOP and

reduce the number of medications a patient requires.

Dr Lindstrom describes a minimally invasive surgical

procedure, which he believes has revolutionized treatment

for glaucoma patients.

“The optimal procedure for the

physician and the patient is a

minimally invasive glaucoma

surgery…”


13www.oteurope.com

GL AUCOMA SURGERY

needed, but many patients do not

need a drastic reduction in pressure

and can benefit from cataract

surgery alone.

Minimally invasive: The optimal

procedure

The optimal procedure for the

physician and the patient is a

minimally invasive glaucoma surgery

that can lower pressure greater

than cataract surgery alone, with

no or extremely low additional risk.

Recent advancements in glaucoma

procedures have changed the tide in

IOP management.

The Glaukos iStent (Glaukos,

Laguna Hills, California, USA), along

with other ab interno devices like

the Transcend CyPass (Transcend

Medical, Menlo Park, California,

USA) and AqueSys Zen (AqueSys,

Allison Viego, California, USA), have

changed the invasive nature of

glaucoma procedures. The iStent

stands out because it is the first

ab interno method that bypasses

trabecular resistance with the

placement of a micro-bypass stent

in Schlemm’s Canal. Additionally,

the stent is only 1 mm long. It is

inserted through the same corneal

incision used to remove the cataract

on a preloaded handle device with a

release button for easy insertion. In

US FDA clinical trials, a single stent

was implanted but in Canada and

Europe it has been found that with

the implantation of 2 or 3 stents

there is an even greater reduction

of IOP.

In the US pivotal trial, the mean

reduction of IOP after Phaco/IOL

with iStent insertion was 8.4 mmHg

in patients with a mean baseline

IOP of 24.4 mmHg.3 Fea found

that a single stent lowers the IOP

an additional 3 mm over cataract

surgery alone.4 Clinically, it has been

shown that every millimetre drop in

IOP reduces the risk of progressive

glaucoma damage by 10%.5 With the

iStent, one is able to reduce the risk

of progressive glaucoma damage

nearly 30% more than with cataract

surgery alone, without significant

additional risk.4

The Fea study also showed that

in addition to the reduction of IOP,

the medication burden was also

significantly reduced or eliminated

postoperatively. 67% of patients

who received iStent remained

medication free after 15 months

while maintaining IOPs of less than

21 mmHg at one-year post-op.4

In my own practice I went

from doing a lot of phaco

trabeculectomies to phaco alone

because while I could get a 13 mm

drop in pressure, there were a lot

of potential risks and complications

that had life-long implications for

the patient. I changed my method of

treatment to phaco alone and waited

to see patient progression and if

later it became necessary, I would

perform a trabeculectomy or a tube

shunt as a last resort procedure

due to the high complication rate.

The Glaukos iStent revolutionizes

the treatment of glaucoma because

the surgeon is able to lower IOP,

decrease the risk of glaucoma

progression, and reduce or eliminate

the need for medications with

little additional risk of surgical

complications. The iStent creates a

platform in which we can view the

treatment methodologies of patients

with cataract and glaucoma in a new

and innovative way.

References

1. B.J. Poley et al., J. Cataract Refract.

Surg., 2008;34:735–742.

2. B. Edmunds et al., Eye,

2002;16:297–303.

3. B. Shingleton, M. Tetz and N. Krober,

J. Cataract Refract. Surg.,

2008;34:433–440.

4. A.M. Fea, J. Cataract Refract. Surg.,

2010;36:407–412.

5. M.C. Leske et al., Curr. Opin.

Opthalmol., 2004;15(2):102–106.

Author

Dr Richard Lindstrom is

founder and attending surgeon

of Minnesota Eye Consultants

and Adjunct Clinical Professor

Emeritus at the University of

Minnesota of Ophthalmology,

Department of Ophthalmology, Minnesota,

USA. He is also the associate director

for the Minnesota Lions Eye Bank, board

member of the Minnesota Medical

Foundation, and a visiting professor

at UC Irvine: Gavin Herbert Eye. He is

a board-certified ophthalmologist and

internationally recognized leader in

corneal, cataract, refractive and laser

surgery.

Dr Lindstrom serves on the Board of

Directors of AcuFocus, TLC Vision, TearLab,

Refractec, Wavetec, Encore, RevitalVision

the Minnesota Medical Foundation, the

Eye Bank Association of Minnesota and

Inner City Tennis.

Do you use

a combined

approach? www.oteurope.com/discuss

“The Glaukos iStent revolutionizes the treatment

of glaucoma because the surgeon is able to

lower IOP, decrease the risk of glaucoma

progression, and reduce or eliminate the need for

medications with little additional risk of surgical

complications.”



GLAUCOMA SURGERY

Results from a multinational study demonstrate

the efficacy and safety of an investigational

intracanalicular microstent (Hydrus I, Ivantis, Irvine,

California, USA) implanted with an ab interno surgical

approach for reducing IOP in eyes with mild-to-moderate

primary open-angle glaucoma (POAG), announced Dr

Thomas W. Samuelson, at the annual meeting of the

American Academy of Ophthalmology (AAO).

The open study enrolled 69 patients at 7 centres.

Forty eyes underwent microinvasive glaucoma

surgery (MIGS) alone and 29 had combination

phacoemulsification. After one year of follow-up in both

subgroups, both mean IOP and mean medication use

were significantly reduced from baseline. No serious

complications occurred and there were no cases of

device migration or perforation.

“MIGS is an evolving therapeutic option conceived

to treat glaucoma surgically more safely than

trabeculectomy while still maintaining traditional

options,” claimed Dr Samuelson, founding partner,

Minnesota Eye Consultants, Minneapolis, Minnesota,

USA, and medical monitor for the multinational study.

“However, the MIGS procedures are often performed

in conjunction with cataract extraction, which makes

it difficult to know what is the pressure effect from the

MIGS procedure itself.

“Data from this investigation show benefit with and

without cataract surgery and IOP control appears to

be stable in patients who have been followed to 18

months,” he noted. “We look forward to further data

from this study and others under way, including the

US PMA trial of the intracanalicular microstent and

two trials outside the US comparing it with other MIGS

devices.”

The intracanalicular microstent is a nickel-titanium

(nitinol) device measuring 8 mm in length that is placed

ab interno into Schlemm’s canal through a clear corneal

incision (Figure 1). It features a small inlet that resides

within the anterior chamber and provides a path through

the trabecular meshwork. An open-window design

prevents obstruction of collector channels in Schlemm’s

canal.

“Not only does the stent occupy nearly 8 mm of

Schlemm’s canal, providing access for aqueous to

multiple collector channels, but it also dilates the

canal,” Dr Samuelson said. “Laboratory studies

have shown that this true stenting further improves

aqueous outflow.”

Study details

The multinational study included patients with POAG

or pseudoexfoliation glaucoma who had a visual

field mean deviation no worse than –12 dB, IOP of

By Cheryl Guttman

Krader

Reviewed by

Dr Thomas W. Samuelson

Microstent reduces medication useIntracanalicular device providing durable IOP reduction as standalone

procedure

In short...In a multinational study of eyes with mild-to-moderate

glaucoma, ab interno implantation of an intracanalicular

microstent (Hydrus I, Ivantis) resulted in significant

reductions in IOP and medication use whether performed

alone or combined with phacoemulsification.

Figure 1: The intracanalicular microstent is a nickel-titanium (nitinol) device measuring 8 mm in length that is placed ab interno into Schlemm’s canal through a clear corneal incision. It features a small inlet that resides within the anterior chamber and provides a path through the trabecular meshwork. (Photo courtesy of Ivantis.)


15www.oteurope.com

GL AUCOMA SURGERY

26 mmHg or less on medications and

IOP 21 to 32 mmHg if washed out on

medication.

“In this early trial of the stent,

the safety of glaucoma medication

washout was left to the investigator’s

discretion as was the decision to add

back medications,” Dr Samuelson

explained.

At baseline in the subgroup

of patients who had microstent

surgery only, average mean

deviation was –4.82 dB, mean

IOP was 21.6 mmHg and mean

medication use was 1.7.

Thirty-seven of the 40 patients

were seen at 12 months. Mean IOP

was reduced to 17.9 mmHg while

patients were taking an average of

0.2 medications. The results were

similar at 18 months at which time

32 patients were evaluated.

In the combined

phacoemulsification group, all

29 patients were evaluated at

12 months. Mean IOP was reduced

by 34% from 25.5 mmHg at baseline

to 16.9 mmHg; mean medication use

decreased from 2.2 at baseline to 0.1.

Safety review

The safety review identified a

single patient who lost two lines

of best-corrected visual acuity.

However, that was due to a retinal

vein occlusion that was judged not

to be device-related, Dr Samuelson

revealed.

“The patient never had high IOP,

and with this procedure, IOP cannot

get below episcleral venous pressure

so hypotony was not a factor in this

particular patient, or in the study in

general,” he concluded.

Transient hyphaema was the

most common adverse event (15%)

followed by peripheral anterior

synechia (9.5%).

Special contributor

Dr Thomas W. Samuelson

is a founding partner of

Minnesota Eye Consultants,

Minneapolis, Minnesota, USA.

He may be reached by E-mail:

[email protected]

Dr Samuelson is an advisor and

investigator to Ivantis and several other

companies developing MIGS procedures.

What do you think

the future holds for

MIGS? www.oteurope.com/discuss

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In short...Post-refractive dry eye is the most common postoperative

complaint by patients and can be extremely debilitating

but it has also been linked with a higher risk of post-LASIK

regression, according to the authors. In this paper, they

highlight the outcomes of their recent study examining the

effects of LASIK on the ocular surface.

Dr Ian Dooley and his colleagues at the Mater

Private Hospital in Dublin, Republic of Ireland,

have recently published a study in the Journal of

Cataract and Refractive Surgery examining the effects

of laser refractive surgery upon tear osmolarity.1

As you may be aware post-refractive surgery dry

eye is the most common postoperative complaint

by patients and can be extremely debilitating but it

has also been linked with a higher risk of post-LASIK

regression (laser in situ keratomileusis).2

Osmolarity is a marker for dry eye, which is central

to the current definition by the dry eye workshop

(DEWS):

“Dry eye is a multifactorial disease of the tears

and ocular surface that results in symptoms

of discomfort, visual disturbance, and tear

film instability with potential damage to the

ocular surface. It is accompanied by increased

osmolarity of the tear film and inflammation of

the ocular surface.”3

As the aqueous portion of tear is reduced, the

relative levels of dissolved materials increase, leading

to hyperosmolarity. This can induce apoptosis and

lead to further inflammation and result in permanent

damage to the ocular surface and degradation of

visual quality.4 Tear osmolarity has become increasing

recognized as a diagnostic and prognostic ‘bed side’

test.

It should be stressed that tear osmolarity is a highly

volatile parameter, which rises acutely if the patient

is staring for even a small period, as with visual acuity

testing, also recent topical drops (within 2 hours) will

also alter osmolarity readings. Thus, the sequencing

of the examination is important, where possible

tear osmolarity should be the first examination

performed.4

Post-LASIK dry eye

Post-LASIK dry eye affects up to half of patients at

1 week, 40% at 1 month, and 20–40% at 6 months.

While typically transient, a significant cohort of

patients experience severe symptoms. Surface

refractive laser, including LASEK (laser assisted

subepithelial keratectomy) and PRK (photorefractive

keratectomy), is associated with transient

postoperative dry eye symptoms. Patients with

extreme dry eye such with Sjogren’s syndrome should

not be considered for corneal procedures.4

Post-LASIK dry eye describes a spectrum of

diseases encompassing transient or persistent

postoperative neurotrophic disease, tear instability,

By Dr Ian John Dooley,

MSc, MRCOPHTH, and

Professor Michael

O’Keefe, MD, FRCOPHTH

Effects of laser refractive surgery upon tear osmolarity LASIK may pose a greater risk of post-op dry eye

Figure 1: Line series, showing mean Schirmer values (mm/5 min) at baseline, 3, 6 and 12 months post surgery in LASIK (bold line) versus LASEK patients (dashed line). Error bars depict ± 1 standard error of the mean (SEM).


The power of oneTwo types of incisions – one module

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regulatory requirements. Cataract procedures are not approved in the United States and in some other countries. Please contact Ziemer for details.

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CATAR ACT & REFR ACTIVE

true aqueous tear deficiency, corneal

and conjunctival epitheliopathy,

and neuropathic pain states.

Neural changes in the cornea and

neuropathic causes of ocular surface

discomfort may play a separate or

synergistic role in the development of

symptoms in some patients.

The post-LASIK neurotrophic effect

and damage to goblet cells, are

related to the corneal flap sectioning

and suction effect, respectively.

These effects may not be seen in

surface refractive laser patients,

so theoretically LASIK would have

a more profound effect on the

precorneal tear film and induce more

dry eye disease. This neurtophic

cornea is sometimes referred to

as LASIK-induced neurotrophic

epitheliopathy (LINE).4

Several factors are associated

with the development of post-

LASIK dry eye. Higher refractive

correction, deeper ablation depth,

narrow flap hinge and female gender

have been repeatedly reported to

be associated with an increased

incidence of post-LASIK dry eye. Flap

thickness has both been reported

to be directly related to dry eye post

LASIK and be unrelated.4 The dry

eye effects of LASIK seem to have

been comprehensively reported,

however there was a paucity of data

comparing LASIK and LASEK dry eye

rates and especially in relation to tear

osmolarity changes.

LASIK vs LASEK

Dooley et al. compared the one-year

postoperative changes in dry eye

metrics between thin flap LASIK

(120 microns, n = 50) and LASEK eyes

(n = 35).1

Pre- and postoperative levels of

tear osmolarity, Schirmer testing,

ocular surface disease index (OSDI),

modified dry eye workshop severity

score and rate of topical lubricant

use were compared between the two

groups.

Preoperatively the LASEK patients

had more dry eye features than the

LASIK group. This is explained in part

because, patients with moderate dry

eye were only offered LASEK, thus

preoperatively the LASEK group had

lower mean Schirmer test values

(Figure 1) and higher mean OSDI

(Figure 2). Interestingly they actually

had similar mean tear osmolarity

(Figure 3).1

The postoperative OSDI was

significantly higher in LASIK patients

than LASEK patients at 3 months,

suggesting that LASIK patients were

experiencing a greater increase in

level of dry eye symptoms compared

to LASEK patients.

At three and six months post-op

the LASIK group had more dry eye

features, with lower mean Schirmer

test values, higher mean OSDI and

higher mean tear osmolarity.1 By

12 months the gap was much less.

Thus the LASEK patients improved

postoperatively, despite having

worse parameters preoperatively,

while the LASIK patients transiently

deteriorated but recovered by 12

months. It would seem that LASEK

is a better procedure for patients

with dry eye features and the dry eye

effect of both procedures are usually

temporary.1,4

Conclusions

All laser refractive procedures are

associated with risk of dry eye.

LASIK may be associated with a

higher risk, due to the associated

neurotrophia, which is supported by

the data presented in the study by

Dooley et al.1 It is usually transient

but may prove problematic in some

patients. Preoperative discussion

regarding dry eye is essential and

early postoperative treatment is

advisable. Tear osmolarity helps the

clinician to provide the best care to

their patients.

Figure 2: Line series, showing mean ocular surface disease index (OSDI) values (%) at baseline, 3, 6 and 12 months post surgery in LASIK (bold line) versus LASEK patients (dashed line).

Figure 3: Line series, showing mean tear osmolarity values (mOsm/L) at baseline, 3, 6 and 12 months post surgery in LASIK (bold line) versus LASEK patients (dashed line). Error bars depict ± 1 standard error of the mean (SEM).


www.oteurope.com/cat_ref

References

1. I. Dooley, F. D’Arcy and M. O’Keefe,

J. Cataract Refract. Surg.,

2012;38(6):1058–1064.

2. J.M. Albietz, L.M. Lenton and S.G.

McLennan, J. Cataract Refract. Surg.,

2004;30(3):675–684.

3. The epidemiology of dry eye disease:

report of the Epidemiology Subcommittee

of the International Dry Eye WorkShop

(2007), Ocul. Surf., 2007;5(2):93–107.

4. I. Dooley, Dry eyes in patients undergoing

refractive surgery. In: M. O’Keefe,

ed. Current understanding and new

techniques in refractive surgery: Nova;

2013.

Authors

Dr Ian John Dooley, MSc MRCOPHTH, is

a Specialist Registrar in Ophthalmology in

the Irish Ophthalmology Higher Surgical

Training Scheme, currently working the Mater

Misericordiae University Hospital, Dublin,

Republic of Ireland. He may be reached by

E-mail: [email protected]

Professor Michael O’Keefe, MD,

FRCOPHTH, is Professor of Ophthalmology

at the University College, Dublin, and the

Director of Refractive Surgery at Mater

Private Hospital, Dublin, Republic of Ireland.

He may be reached by E-mail: mokeefe@

materprivate.ie

The authors have no financial interests in the

subject matter of this piece.

What are your

experiences?


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In short...Evaporative dry eye is caused by the loss of tear fluid

through evaporation. The functionality of the meibomian

glands is important in evaporative dry eye and in a

recent study, a new system was evaluated that has

been designed to treat patients with meibomian gland

dysfunction and evaporative dry eye. In this article, Dr

Albou‑Ganem discusses this study and her thoughts on

the benefits this system offers.

Evaporative dry eye is caused by the loss of tear fluid

through evaporation. It is known that this evaporation

occurs as a result of insufficient oil in the hybrid layer

coating the surface of the cornea. The meibomian

glands, located in the eyelids, contribute to the oils in

this hybrid layer and any obstructions or lack of function

of these glands will affect the composition of the tear

film and hence the rate of evaporation. Therefore, their

functionality plays an important role in evaporative dry

eye.

In a recent study,1 Dr Cati Albou‑Ganem (Centre

National d’Ophthalmologie des Quinze‑Vingts, Paris,

France) and Dr R. Amar evaluated a new system

(LipiFlow, TearScience, Morrisville, North Carolina, USA)

to treat patients with meibomian gland dysfunction

(MGD) and evaporative dry eye. “I was very interested by

the performance of the diagnostic platform and thought

that our dry eye patients desperately needed a solution

for their problem,” she said.

Evaluating a new system

To evaluate this new system, 16 eyes of 12 patients

were studied. These patients had been diagnosed with

MGD based on the results of a symptom questionnaire,

quantification of the lipid layer thickness and

standardized meibomian gland expression.

“We selected patients using the SPEED (Standard

Patient Evaluation of Eye Dryness) questionnaire,”

explained Dr Albou‑Ganem. “This questionnaire allows

the patient to describe their symptoms easily.” All

patients studied were suffering from dry eye without any

surgical impact and any patient that had a score higher

than 6 (out of 28) from the questionnaire were selected

to have the lipid layer of their eyes analysed.

“First, the LipiView (TearScience) exam allowed us to

measure the lipid layer thickness,” continued Dr Albou‑

Ganem. It has been demonstrated that a thin lipid layer

(below 70 nm) is correlated to the symptoms of dry eye,

she noted.

“When the lipid layer was below 70 we analysed

the functionality of the meibomian glands using the

Meibomian Gland Evaluator (MGE),” she said. “The MGE

allows us to apply a constant force to the lid, mimicking

the force of a deliberate blink. Therefore, we can observe

the secretions expressed at each blink. For the first time,

we were able to reproducibly look at secretions.”

If the number of meibomian glands capable of

secreting clear and liquid lipids was below 5 (out of 15

that were observed), Dr Albou‑Ganem and Dr Amar

confirmed diagnosis that the patient was experiencing

evaporative dry eye as a result of MGD. A direct

correlation between the number of functioning glands

and the symptoms of dry eye has also been previously

demonstrated.2,3

LipiFlow treatment

Once the patient had been confirmed as having

evaporative dry eye as a result of MGD, the team used

the LipiFlow treatment, which has been designed

to unblock the meibomian glands and restore their

function. “This system applies a constant heat to the

posterior face of the lids during 12 minutes and a series

of pulsations on the outer face of the lids in order to

massage them,” added Dr Albou‑Ganem.

“By applying the right temperature and a moderate

pressure, it is not painful for the patients and very

efficient,” she continued. “Post‑treatment we could

observe a significant improvement in the gland function.”

Application of a constant temperature is also

important, she explained as a temperature of 42.5 ºC is

necessary to liquefy the secretions that block the glands.

“It is important to note that this temperature is not only

applied to the lid margin but to the whole surface of the

posterior lids, unblocking the glands in their depth,” Dr

Albou‑Ganem asserted.

By Felicity Thomas

Reviewed by

Dr Cati Albou-Ganem

Treating MGD and evaporative dry eyeEvaluation of a new system

ES253800_OTE0613_020.pgs 05.22.2013 22:36 ADV blackmagentacyan


Decrease in symptoms

It was found that through the use of this system all patients

experienced a decrease in symptoms at 12–18 months

post‑treatment. “Symptoms decreased at 1 month for most of the

patients,” revealed Dr Albou‑Ganem. “What was very astonishing,

was that we observed symptomatic control at 12–18 months.”

These results are inline with the multicentric randomized

study that had been conducted in the US to gain FDA approval

for the treatment and Dr Albou‑Ganem noted that further results

from a study by Dr Greiner (published at the AAO last year) has

also demonstrated similar outcomes after 3 years.4 “This is very

encouraging and creates a lot of hope for the patients and the

ophthalmologists using this technology,” she said.

A great improvement

“This new system is a great improvement in the way we can treat

MGD patients,” stressed Dr Albou‑Ganem. “For the first time, we

can propose something to them that will free them from their daily

warm compress therapy and symptoms.”

The system also provides an effective and, importantly, a quick

treatment for patients. “When you see a patient who has been

suffering from dry eye for several months and who tells you after

1 month ‘I don’t feel my eyes anymore’, as an ophthalmologist, you

feel very grateful,” she said.

“The TearScience system is revolutionizing our approach of dry

eye because it creates satisfaction for patients and practitioners,”

Dr Albou‑Ganem concluded. “We now know that 86% of dry eye

patients are suffering from MGD related dry eye. I am very confident

that this system will become the standard of care for evaporative

dry eye in the near future.”

References

1. C. Albou‑Ganem and R. Amar, A novel system for the treatment of

meibomian gland dysfunction and evaporative dry eye with a 12 to 18

month follow-up, Poster presentation, ESCRS 2012, Milan, Italy.

2. D.R. Korb and C.A. Blackie, Cornea, 2008;27(10):1142–1147.

3. C.A. Blackie and D.R. Korb, Cornea, 2009;28(3):293–297.

4. J.V. Greiner, DO, PhD, Long-Term (3 Year) Effects of A Single LipiFlow

Thermal Pulsation System Treatment on Meibomian Gland Function

and Dry Eye Symptoms, Poster presentation, ASCRS 2012, Chicago,

Illinois, USA.

Special contributor

Dr Cati Albou-Ganem is a cataract and refractive surgeon practising in

the Centre National d’Ophthalmologie des Quinze‑Vingts, and in private

practice, in Paris, France. She is one of the founders of the first private

refractive surgery clinic in France and is the president of the French Society

of Cataract and Refractive Surgery (SAFIR). She is also a board member of

the French Society of Ophthalmology (SFO). She may be reached by E‑mail:

[email protected]

Dr Albou‑Ganem has indicated no financial disclosures.




In short...Two studies were conducted to compare outcomes of

patients undergoing cataract surgery using two different

nonsteroidal anti-inflammatory drugs for controlling pain

and postoperative inflammation. The results support the

efficacy of both products, but suggest some potential

benefits for once-daily bromfenac 0.09% (Bromday, Bausch

+ Lomb, Rochester, New York, USA).

Both bromfenac 0.09% once daily (Bromday,

Bausch + Lomb, Rochester, New York, USA) and

nepafenac 0.1% (Nevanac, Alcon Laboratories, Fort

Worth, Texas, USA) appear to be safe and effective

in preventing anterior segment inflammation and

clinical cystoid macular edema (CME) after cataract

surgery, even in high-risk patients. However, results

from retrospective and prospective comparative

studies suggest there may be an advantage for

using bromfenac, noted Dr Melissa Morrison

Toyos, private practice, Discover Vision Centre,

Independence, Missouri, USA.

“Both nepafenac and bromfenac are

newer-generation nonsteroidal anti-inflammatory

drugs (NSAIDs) with molecular structural

modifications that confer enhanced potency

relative to older-generation NSAIDs,” explained

Dr Toyos. “Bromfenac offers the convenience of

once-daily dosing, but both products are known

to be efficacious and well-tolerated based on

placebo-controlled pivotal trials. However, to my

knowledge, these two products had never been

compared in a head-to-head trial.

“I was struck to find that the results of a small

pilot prospective study suggested advantages

of bromfenac and a benefit of bromfenac was

also observed in a subsequently conducted

retrospective analysis comparing these NSAIDs in a

much larger patient cohort,” she claimed.

Prospective study

The prospective study1 randomly assigned 20

patients under going unilateral cataract surgery

to treatment with nepafenac three times daily or

bromfenac once daily. Both NSAIDs were started

3 days before cataract surgery and continued

for 21 days after the procedure. Patients with

diabetes were eligible for the study unless they had

pre-existing macular or retinal oedema or two or

more microaneurysms within the fundus. Primary

endpoints assessed included ETDRS best-corrected

visual acuity (BCVA), summed ocular inflammation

score and OCT-measured macular volume and

retinal thickness. Evaluations were conducted at

one day and one, three and six weeks after surgery.

The two treatment groups were well-matched

at baseline and there were no statistically

significant differences between them for any

endpoints at any follow-up visits. However,

findings from intragroup analyses of changes from

baseline showed some evidence of better clinical

outcomes in the bromfenac group compared with

the nepafenac-treated patients in terms of less

retinal thickening, more stable macular volumes

in the immediate postoperative period, and a

trend toward greater improvements in BCVA from

baseline, Dr Toyos stressed.

Retrospective study

The retrospective study included data for 600

patients who were treated postoperatively with

bromfenac once daily and 591 patients treated

postoperatively with nepafenac. Reported

frequency of dosing with nepafenac varied from

By Cheryl Guttman

Krader

Reviewed by Dr Melissa

Morrison Toyos

NSAIDs lower inflammation, CMEComparative study results support use of once-daily treatment, but

both satisfactory

“…findings from intragroup

analyses of changes from baseline

showed some evidence of

better clinical outcomes in the

bromfenac group…”

ES253831_OTE0613_022.pgs 05.22.2013 22:40 ADV blackmagentacyan


one to four times daily, but nearly all

patients (93.5%) used nepafenac three

times daily. The two groups had similar

proportions of patients with diabetic

retinopathy (10%) and proliferative

diabetic retinopathy (5%), but the rate

of pre-existing epiretinal membranes

was about two-fold higher in the

bromfenac group compared with the

nepafenac group (15% versus 7%).

Clinical CME occurred in just one

patient in the bromfenac group (0.15%)

and in five patients using nepafenac

(0.8%). The bromfenac-treated patient

who developed clinical CME had a

pre-existing epiretinal membrane.

Among the five nepafenac-treated

patients who developed clinical CME,

one had mild diabetic retinopathy

and one had proliferative diabetic

retinopathy, but three had no

risk factors. All five patients used

nepafenac three times daily.

Reference

1. M. Cable, Clin. Ophthalmol.,

2012;6:997–1004.

Special contributor

Dr Melissa Morrison Toyos is in

private practice, Discover Vision Centre,

Independence, Missouri, USA. She may be

reached by E-mail: mcable@discovervision.

com

Dr Toyos is a speaker and consultant for Alcon

Laboratories and ISTA Pharmaceuticals and

received research funding from Bausch + Lomb

and ISTA.

Would you use

bromfenac?


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A retrospective analysis of cataract surgery

procedures performed with three different

moderately cohesive ophthalmic viscosurgical

devices (OVDs) show that these products are

well-suited to use in microincision procedures,

according to Dr Danielle Deidier, St Vincent Clinic,

Toulon, France.

She presented findings from a study evaluating

the OVD behaviour and endothelial cell loss

in groups of 20 eyes each operated on using

PhysioVisc Integral (PhysIOL, Liège, Belgium),

Amvisc Plus (Bausch + Lomb Surgical, Greater

London, UK) or Z-Hyalin Plus (Carl Zeiss Meditec,

Jena, Germany). All surgeries were performed using

the same phacoemulsification platform (Stellaris,

Bausch + Lomb) and a bimanual microincision

technique involving two 1.2 mm incisions and with

enlargement of one incision to 1.7 mm for IOL

implantation.

Observations

Surgeon observations showed the anterior

chamber remained deep and stable and the OVDs

allowed perfect control and visualization during

capsulorhexis, hydrodissection and IOL injection.

There were no cases of capsular rupture, complete

OVD removal was achieved at the end of the

procedure and endothelial cell count (ECC) loss was

similarly low across all three groups, revealed Dr

Deidier.

“When surgeons perform cataract surgery

through self-sealing incisions, the OVD is expected

to maintain the anterior chamber depth so as

to facilitate the capsulorhexis,” she explained.

“However, while the OVD needs to provide space

and tissue protection, if it is not spontaneously

expelled during surgical manoeuvers, particularly

during hydrodissection, there is a risk of

overpressurisation that can lead to capsule rupture.

“The study results show that each of these OVDs

offers behaviour that is in line with [the] surgeon’s

expectations and that the OVDs provided good

protection for the corneal endothelium,” Dr Deidier

added.

By Cheryl Guttman

Krader

Reviewed by

Dr Danielle Deidier

OVDs ideal for microincision surgeryModerately cohesive ophthalmic viscosurgical devices offer desired performance traits

Special contributor

Dr Danielle Deidier is ophthalmologist at St

Vincent Clinic, Toulon, France. She may be

contacted by E-mail: [email protected]

Dr Deidier has no financial interests in the

subject matter.

Do you use OVDs in

microincision surgery?


As moderately cohesive OVDs, all three products

evaluated in the study have high viscosity, strong

elasticity and strong pseudoplasticity that allow

easy injection through a 27-gauge cannula and

removal at the end of the procedure, even with

1.2 mm microincision instruments, noted Dr Deidier.

The three study groups were similar with respect

to mean patient age (72 to 76 years), cataract grade

(about LOCS III) and preoperative ECC measured by

specular microscopy (about 2400 cells/mm2). Based

on measurements performed at a month after

surgery, mean ECC loss was 1% in eyes operated on

with PhysioVisc Integral, 1.09% in the Amvisc Plus

group and 1.01% for the Z-Hyalin Plus procedures.

In short...The intraoperative behaviour and endothelial protection

performance of three moderately cohesive ophthalmic

viscosurgical devices were compared in a retrospective

study with favourable results for all products.


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RETINA

The term autoimmune retinopathy refers to a

group of rare acquired retinal degeneration

syndromes characterized by acute or subacute

vision loss in combination with an abnormal (often

unrecordable) electroretinogram (ERG) and anti‑retinal

serum antibodies.1 The diagnosis encompasses

the paraneoplastic presentations known as Cancer

Associated retinopathy (CAR) and Melanoma Associated

Retinopathy (MAR) as well as non‑paraneoplastic

retinopathies.

CAR was first reported in association with small cell

lung cancer, but can occur with other malignancies

including prostate, breast, and colon cancer.2 Prompt

diagnosis is important due to the possibility of an

underlying malignancy in patients with CAR or MAR, and

the correct diagnosis can lead to initiation of potentially

life saving systemic treatment.

The classic anti‑retinal antibody associated with CAR

is directed against the 23 kDa protein, and detection of

this antibody in the serum of a patient with acute vision

loss should prompt a thorough systemic evaluation

for an occult malignancy. However, in most case

series the majority of patients with an autoimmune

retinopathy will not have anti‑recoverin antibodies or

an underlying malignancy so the extent of the workup

is controversial.

Easily overlooked

Autoimmune retinopathies are easily overlooked

and can be difficult to diagnose. Patients classically

present with acute to sub‑acute vision loss, nyctalopia,

scotomas and photopsias. However, visual complaints

can be vague and nonspecific. The physical exam is

often unremarkable with the most common findings

being optic nerve pallor and vascular attenuation.

So how does the clinician decide when to pursue a

patient’s non‑specific visual complaints with expensive

and sometimes difficult to obtain tests like ERG and

serum antibody analysis?

The first step is to expand the history. Some patients

will have a recent diagnosis of cancer, or a history of

prior malignancy. In patients with a non‑paraneoplastic

retinopathy, a personal or family history of

autoimmunity can often be elicited.

Then a review of systems should be obtained

to identify any pertinent positives that suggest an

underlying malignancy such as unexplained weight

loss or dyspnea. In addition, visual field testing is

important for establishing an objective measure of

vision loss. Concentric constriction is a classic finding,

but the presence of any scotomata should heighten

clinical suspicion.

Importance of imaging

Imaging technologies such as fundus

autofluorescence (AF) and spectral domain optical

coherence tomography (SD‑OCT) are quickly

becoming the most frequently ordered studies in

ophthalmology, and they can provide important

diagnostic information in conditions where the

conventional exam is unremarkable. Using these

imaging modalities, our group described fundus

abnormalities in a group of seven patients with an

autoimmune retinopathy.3

Using SD‑OCT we found loss of outer retinal layers

including the outer nuclear layer (ONL), the inner

segment and outer segment junction (IS/OS) and

external limiting membrane (ELM). The loss of these

outer retinal structures was found within the macula,

but spared the fovea. In one patient with CAR followed

over eight months, these retinal changes progressed

centripetally with a corresponding loss of vision by

Goldman visual field testing. Lima et al. reported

similar findings in a series of four patients with an

autoimmune retinopathy.4 They also demonstrated a

functional consequence associated with these imaging

changes by microperimetry.

By Dr Kathryn L. Pepple,

PhD, and Dr Prithvi

Mruthyunjaya

Identifying patients with autoimmune retinopathyImaging with autofluorescence and SD‑OCT can help

In short...Autoimmune retinopathies are easily overlooked and

can be difficult to diagnose. Moreover, visual complaints

can be vague and non‑specific. In this article, the

authors examine the best practices for these patients

and reveal how imaging technologies, such as fundus

autofluorescence and SD‑OCT, are offering clinicians a new

tool to help identify patients requiring expeditious follow

up testing and further systemic evaluation.


www.oteurope.com/retina

RETINA

Another similar finding in both

studies was the presence of abnormal

fundus autofluorescence that

corresponded with the boundaries

of the structural changes noted on

SD‑OCT. In the areas of outer retinal

loss, abnormal hyper‑autofluorescence

was seen acutely, but over

time evolved to mottled

hypo‑autofluorescence. Typically, the

area of hyper‑autofluorescence formed

a ring around the central area of

preserved retinal architecture, but this

was not a uniform finding.

Case examples

The following case example highlights

how these imaging modalities can

be used to suggest the diagnosis

of an autoimmune retinopathy. A

46 year‑old woman presented for

glasses due to ‘poor vision’. Her

central vision was 6/6 in both eyes,

but her visual fields were severely

constricted in both eyes (see Figure 1).

Her fundus exam was unremarkable

without peripheral pigmentary

changes, but OCT revealed the loss of

outer retinal layers sparing the fovea

and peri‑fovea, with corresponding

hyper‑autofluorescence.

She was sent immediately for

further testing, and was found to have

an unrecordable ERG and anti‑retinal

antibodies in her serum. A systemic

evaluation was also initiated in

coordination with her PCP, but no

malignancy or other autoimmune

condition has been detected.

Despite the utility SD‑OCT and

AF demonstrated in diagnosing

this patient, not all patients with

an autoimmune retinopathy will

have abnormalities that can be

identified with imaging. A patient

with melanoma from our case

series highlights this point. This

patient had constricted visual fields,

an unrecordable ERG, and serum

autoantibodies targeting bipolar

cells and the outer plexiform layer

by immunohistochemistry to human

retinal sections.

This combination of history, exam

and lab findings is strongly consistent

with the diagnosis of MAR, and yet his

SD‑OCT and AF imaging studies were

completely normal.

Thus, the take home message is

that these imaging modalities can be

helpful in suggesting the diagnosis

of an autoimmune retinopathy, but

the absence of imaging findings

should not be a reason to exclude

an autoimmune retinopathy from

your differential in the proper clinical

context.

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RET INA

No definitive test

Currently, there is no definitive test

that can distinguish autoimmune

retinopathy from other retinal

degenerative diagnoses such as

acute zonal occult outer retinopathy

(AZOOR), retinitis pigmentosa, cone

dystrophy, Vitamin A deficiency

and toxic retinopathy (chloroquine,

hydroxychloroquine). For each

suspected case of an autoimmune

retinopathy, the clinician will

continue to need to use all the

clinical and laboratory data available

to them to make the correct

diagnosis.

However, with the increasing use

of fundus autofluorescence and

SD‑OCT imaging, the clinician has

an new tool to help them quickly

identify patients that require

expeditious follow up testing and

further systemic evaluation.

References

1. J.R. Heckenlively and H.A. Ferreyra,

Semin. Immunopathol.,

2008;30(2):127–134.

2. Y. Shildkrot, L. Sobrin and E.S.

Gragoudas, Semin. Ophthalmol.,

2011;26(4–5):321–328.

3. K.L. Pepple et al., Br. J. Ophthalmol.,

2013;97(2):139–144.

4. L.H. Lima et al., Retina,

2012;32(7):1385–1394.

Authors

Dr Kathryn L. Pepple, MD, PhD, is a medical

retina fellow at the Duke University Eye

Center, Durham, North Carolina, USA.

Dr Prithvi Mruthyunjaya, MD, is an

associate professor of ophthalmology at the

Duke University Eye Center in the division of

Ocular Oncology and Vitreoretinal Surgery,

Durham, North Carolina, USA. He may be

reached by E‑mail: [email protected]

Neither author has any financial interests.

Figure 1: Autofuorescence and SD‑OCT imaging identify fundus abnormalities in a patient with an autoimmune retinopathy.

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29www.oteurope.com/retina

RETINA

The F10 (Nidek, Gamagori, Japan) is a new,

commercially available scanning laser confocal

ophthalmoscope (SLO) that can perform multiple

functions including fluorescein angiography,

indocyanine green angiography, fundus

autofluorescence, and infrared retromode (RM)

imaging.

The RM imaging enables investigators to observe

the details of deep retinal structures, noninvasively

and clearly, by illuminating the fundus with an

infrared laser and collecting the scattered light

reflected from the retina and choroid through a

semicircular and pericentral aperture by a new

confocal technique. This allows for a clearer pseudo

three-dimensional image, which is a new method of

detecting abnormalities in the macula.1

Some advantages of using the F10 SLO to

examine the macula are: non-invasive procedure,

short testing time and the entire extent of the

macula can be obtained in one image under non-

mydriatic conditions.

Optical coherence tomography (OCT) is a valuable

way to provide morphologic features and diagnose

macular diseases, but sometimes it can be difficult

to detect the entire extent of the lesion.

This report aims to show some macular diseases

features in which this imaging method could be

helpful.

Drusen

RM imaging has been reported to detect

more drusen then conventional color fundus

photography.2 The drusen borders, by this imaging

method are well highlighted, making them easier to

manually segment and grade.

A recent study evaluated the detection of drusen

using the different infrared confocal apertures of

the Nidek F10.3 The standard confocal infrared

imaging system uses a central aperture (CA), while

the RM images are obtained using lateral (right or

left) aperture positions.

The measurements of drusen number and

area obtained by RM were compared with

those obtained using standard colour fundus

photography. Drusen number grades were found

to be significantly higher using the right (AR) and

left (AL) lateral apertures in which the laterally

scattered light is captured.

The mean drusen number detection with the AR

retromode was almost two times greater than for

the colour photographs. Small drusen, as well as

drusen more distant from the fovea, were more

easily visualized with the AR and AL retromodes.

The AR retromode would probably be preferred

and recommended in further comparative studies;

while drusen appear in an elevated convex shape

in the AR, in the AL the conformation seems to be

inverted.

Another study reports that RM imaging might

be superior even to OCT in detection of very small

drusen.4 These findings suggest that RM imaging

may be more sensitive for detection of drusen,

particularly early in the disease course and/or

when the drusen are small or subtle. Larger and

longitudinal studies will be critical for validating

these approaches.

Pigment epithelial detachment

The F10 confocal optical arrangement allows

investigators to observe the details of the retinal

pigment epithelium (RPE), such as drusen and

pigment epithelial detachments (PED). PEDs and

RPE protrusions are identified as well- to ill-defined,

flat to lowly convex, slightly irregular, translucent

to opaque prominences with a dark shadow.5 In

OCT they may appear as a regular, dome-shaped

elevation of the band of the RPE.

SLO in the RM imaging modality and OCT have a

mild intermethod agreement (k = 0.51) in detecting

By Dr Bruno Diniz

Confocal infrared RM imaging of macular diseasesAbility to observe details of deep retinal structures noninvasively and clearly

In short...Dr Diniz reports on a new, commercially available scanning

laser confocal ophthalmoscope that can perform multiple

functions, discussing specific macular disease features

that could benefit from the technology.



RET INA

PEDs in patients with retinal

changes secondary to exudative

age related macular degeneration

(AMD).6 Another imaging study

detected polypoidal vessels and

network vessels of polypoidal

choroidal vasculopathy (PCV) as

vascular indentations of the RPE

on RM.7 In that study, the vessels

were identified by RM in 70% of all

patients with the disease.

Subretinal fluid

Subretinal fluid (SRF) is identified

in RM as a well-defined, lowly to

moderately convex, circular to

ovoid, translucent prominence

with a dark shadow.5 Intermethod

agreement with OCT was poor

for the RM modality (k = 0.29)

in patients with retinal changes

secondary to AMD.6 The multiple

features in AMD eyes (SRF,

PED, cysts) may be related to a

difficult interpretation of the RM

image and the low agreement

found. In patients with SRF and

diabetic macular edema (DME) this

agreement was almost perfect

(k = 0.83).8

Cystoid macular oedema

In the RM, scattered light that

passed the aperture and deviated

laterally, give a shadow to the

silhouetted cystoid spaces, and

enable visualization of the cystoid

macular oedema (CME).9 It can show

each cystoid space located in any

layer of the retina, and can allow

to detect the extent of the CME in

PCV, AMD and DME.

The agreement between RM and

OCT in evaluating cystoid pattern

was excellent (k = 0.80) in patients

with DME and almost perfect

(k = 0.88) in patients with retinal

changes secondary to AMD.6,8

The combined use of non-invasive

imaging techniques could improve

the diagnostic interpretation of

different aspects of CME.

Retinoschisis

OCT and RM examinations show a

perfect agreement in myopic eyes

that have macular retinoschisis.

Retromode imaging by F10 showed

a characteristic fingerprint pattern

at the corresponding area of the

macular retinoschisis.1 This pattern

Figure 2: (a) RM imaging reveals a large PED that appears as a well defned, convex, and translucent prominence with a dark shadow; (b) OCT image of the same patient.

(a) (b)

Figure 3: Patient with central serous chorioretinopathy, acute phase. (a) Subretinal fuid appears as a well-defned, convex, circular and translucent prominence with a dark shadow in RM images; (b) fuid accumulation anterior to the RPE appreciated on OCT.

(a) (b)

Figure 1: Drusen detection by each F10 image modality: (a) Digital colour photograph; (b) central aperture infrared (CA); (c) infrared RM with aperture on the right side (AR); (d) aperture on the left side (AL).

(a)

(c)

(b)

(d)



RETINA

consists of radiating retinal striae

centered on the fovea and many

light dots and lines that run in

parallel to the striae or form a

whorled pattern surrounding the

radiating striae.

Sites of laser application

It has been reported that retromode

with infrared light can delineate

sites of laser application, even when

using subthreshold micropulse.10

No obvious laser scars affecting

the treated area was noticed in any

of the patients on color images,

but the RM images obtained

immediately after subthreshold

laser photocoagulation showed

dark spots at the sites where the

laser had been applied. Those dark

spots detected by RM are believed

to be related to swelling of the

pigment epithelium after laser

application. This method may be

useful to confirm the invisible spots

created by subthreshold micropulse

photocoagulation.

Macular hole

Changes around macular holes

were recorded by SLO and it was

observed retinal wrinkling and

radiating striae around the holes.

Those radiating retinal folds

disappeared after successful

vitreous surgery. The retinal folds

may indicate the presence of

traction on the macula and hence

may be good a marker for macular

repair after vitreous surgery.11

Conclusion

We propose RM imaging as another

noninvasive diagnostic tool for

use in detecting macular diseases.

RM may be capable of providing

comprehensive topographic

information related to the deep

retina and RPE alterations.

However, the investigation and

interpretation of RM imaging is in

its earliest stages.

References

1. Y. Tanaka et al., Am. J. Ophthalmol.,

2010;149:635–40.

2. J.H. Acton et al., Acta Ophthalmol.,

2011;89:404–11.

3. B. Diniz et al., Br. J. Ophthalmol.,

2013;97:285–90.

4. M. Takeda et al., Nihon Ganka Gakkai

Zasshi, 2012;116:635-42.

5. Y.U. Shin and B.R. Lee, Am. J.

Ophthalmol., 2012;154:155–63.

6. E. Pilotto et al., Graefes Arch. Clin.

Exp. Ophthalmol., 2013;251:27–34.

7. M. Takeda and Y. Sato, Nihon Ganka

Gakkai Zasshi, 2012;116:946-54.

8. S. Vujosevi et al., Acta Ophthalmol.,

2012;90:e374–80.

9. M. Yamamoto et al., Int. Ophthalmol.,

2009;29:503-6.

10. K. Ohkoshi et al., Am. J. Ophthalmol.,

2010;150:856–62.

11. A. Yoshida et al., Graefes Arch. Clin.

Exp. Ophthalmol., 1998;236:445–450.

Author

Dr Bruno Diniz is postdoctoral associate

at the Ophthalmology Department,

Universidade Federal de São Paulo, São

Paulo, Brazil. He may be reached by E-mail:

[email protected]

Dr Diniz has no conflicts of interest to

disclosure.

Have you used RM

imaging in this

way? www.oteurope.com/discuss

Figure 5: (a) Circular depression corresponding to macular hole and perilesional elevated edges; (b) full thickness, stage IV macular hole.

(a) (b)

Figure 4: (a) RM shows a large central cyst with smaller adjacent cysts; (b) OCT scan of the same patient.

(a)

(b)



RETINA

“When you have eliminated the impossible,

whatever remains, however improbable, must

be the truth.”

S. Holmes

A 31 year old caucasian female was referred to

us with the sudden appearance of superior

paracentral scotoma over the course of a 24 hour

period. The patient’s clinical history didn’t reveal

any systemic disease or drug consumption with the

exception of the birth control pill. The patient herself

also described previous flu symptoms, which had

since resolved.

The clinical examination

BCVA: 10/10 (0.0 LogMar) with sf –1.00 = cyl –3.50 (90)

Anterior segment: Dioptres transparent, photomotor

reflex normal, anterior chamber empty and its depth

normal

Ocular pressure: 11 mmHg

Fundus oculi: Presence of a rounded shape white

lesion, inferior to the fovea, across the papillo-

macular bundle vessels (Figure 1). Remaining

sectors of the retina were unharmed. Vitreous body

transparent.

No sure diagnosis

We immediately performed an OCT (TOPCON OCT

3D-1000), finding a focal zone of thickening of

neurosensorial retina corresponding to the lesion

observed with biomicroscopy and involving the

inner plexiform layer, the inner nuclear layer, the

IS/OS junction and the inner limiting membrane,

By Dr Fabrizio G. Puce,

Dr P. Lvezzari and

Dr Fabrizio Neri

Atypical presentation of acute macular neuroretinopathyA case report

In short...The authors describe a case report in which they use

imaging, visual acuity and literature references to

diagnose, through exclusion, a case of atypical acute

macular neuroretinitis.

Figure 1: Colour retinography performed at the time of the f rst visit.

Figure 2: OCT of the lesion.

Figure 3: OCT of the foveal region.



RETINA

without involving the RPE-Bruch

membrane-choroid complex

(Figure 2). Additionally, the foveal

region appeared unharmed (Figure 3).

Initially, suspecting a vasculitis or a

self-immune or an infectious retinitis,

we decided to perform a fluorescein

angiography. The following day we

programmed infectious disease and

rheumatologic consulting consisting

of the following laboratory exams:

• CBC, coagulation, hepatic and

kidney function, urinalysis,

anti-streptolysin title, angiotensin

converting enzyme, CRP.

• Generic inflammation indexes:

c-reactive protein, alpha-1-acid

glicoprotein, erythrocyte

sedimentation speed.

• Reumathic diseases exams:

reumathoid factor, antinucleus

antibodies, anti-DNA native

antibodies (ANA), extractable

nucleus antigens antibodies

(ENA), anti neutrophils cytoplasm

antibodies (ANCA), anti

mytocondria antibodies (AMA), anti

smooth muscle antibodies (ASMA),

sieric crioglobulines antibodies,

complement fractions C3 and C4

antibodies, immunoglobulins and

lysozyme serum dosage, (LZM).

• Infectious diseases exams:

anticorpal immunity determination

for Herpes viruses (simplex, zoster,

Epstein-Barr, citomegalovirus), HIV,

Hepatitis B and C, Toxoplasmosis

and tests for tuberculosis and

syphilis.

• Chest and sacroiliac joint X-ray.

• Gallium scintigraphy.

Fluorescein retinal angiography

showed a normal filling of

chorioretinal circulation without

leakage or ‘window-effect’ or ‘shield

effect’ areas (Figure 4).

Visual field analysis, performed by

computerized Humphrey HFA-II-I, with

‘full threshold 30-2’ strategy, didn’t

show any negative scotoma (Figure 5).

Infectious disease and

reumathological consulting didn’t

reveal any pathological conditions

or diseases to explain the clinical

findings and the symptoms described

by the patient.

As we couldn’t make a sure

diagnosis, the patient was closely

monitored without any therapy to

evaluate the evolution of the clinical

picture that remained unchanged for

about 2 weeks. Then the patient went

abroad owing to work commitments

and came back for a visit after a

further 2 weeks.

At the new visit, which was about

1 month after the first observation,

the patient described subjective

visual improvement with a reduction

of the scotoma. Visual acuity was

unchanged and the retinal lesion,

previously observed at the fundus

oculi examination, had disappeared

(Figure 6). The OCT images, however,

demonstrated an important reduction

of the retinal thickening and only a

slight hyper-reflective band persist on

the inner plexiform and nuclear layers

(Figure 7).

Suspected idiopathic posterior uveitis

As the blood exams and the expert

advice were negative, using only the

ophthalmoscopic pattern, gender and

age of the patient, we suspected a

form of idiopathic posterior uveitis.

We particularly focused our diagnosis

on three forms of this disease —

multiple evanescent dot syndrome,

acute pigmentosus retinal epithelitis

and acute macular neuroretinopathy.

These three diseases have many

common features, such as retinal

involvement without involving the

anterior segment or the vitreous

body, retinal ophthalmoscopy and

visual field pattern.

Acute macular neuroretinopathy,

however, may present with either

multiple or single retinal lesions. In a

great number of cases monolateral

lesions occur within the neurosensorial

Figure 4: Fluorescein retinal angiography: normal fnding.

Figure 5: Visual feld analysis, ‘full threshold 30-2’ strategy.

Figure 6: Colour retinography after 1 month.

Figure 7: Corresponding OCT scan.



RET INA

retina, visual impairment is lower

and the visual field analysis shows a

paracentral scotoma corresponding

to the retinal lesion and the retinal

fluorescein angiography is normal.1

Typically lesions in acute macular

neuroretinopathy are round or oval

shaped, brown or dark red and, when

multiple, they surround the macula

in a flower petal pattern (Figures 8

and 9).

Many other atypical forms of

this disease are described in the

literature.2,3 The first description

of this disease dates back to 1975

from Bos and Deutman4 and so far

only 60 cases have been reported in

the UK.5 Usually the patient, more

often a woman, around 30 years

old, will describe sudden onset of a

paracentral scotoma, which is often

monolateral. Sometimes the scotoma

can be preceded by previous flu

syndrome or hypotensive episodes.

No risk factors have been detected

but many authors suspect excessive

caffeine consumption, birth control

pill, epinephrine or hormone therapy

as potential factors. Yannuzzi has

found a correlation with certain

drugs.6 Aetiology is still unknown but

some authors speculate a vascular

based mechanism.

In many cases after 7–8 days from

the onset of the first scotoma, the

patient will describe the appearance

of a second scotoma, always

paracentral. Usually with time, the

scotoma tends to diminish gradually

but never completely disappears.7

However, it must be noted that

electrophysiological tests (electro-

retinogram and electro-oculogram) are

not helpful because they measure the

whole physiological response and are

not sensible for pathological process

involving the macula.8

Atypical acute macular neuroretinopathy

In our case the observed lesion did

not have the classical features of

acute macular neuroretinopathy but

of ‘the multiple evanescent white

dot syndrome’ for which we did a

differential diagnosis.9

Gass and Hamed, in this regard,

reported an association between

these two aforementioned diseases,

suggesting that these two rare

syndromes could be related by

pathogenesis and aetiology. The

lightest forms, where the macular

lesions are lower, can be confused

with retinal pigment epithelium

inflammation because both these

diseases can cause a sudden central

visual loss in young adults.10,11 In

these cases, OCT can be very useful

because it reveals the exact location

of the lesion and allows an accurate

follow-up.12,13

After around 6 months from the

first observation, the OCT showed an

atrophic area of the neurosensorial

retina where it had previously appeared

thickened (Figure 10). Ophthalmoscopy

appeared normal (Figure 11).

So we performed another visual

field analysis, this time using the

‘macula-threshold’ program of the

computerized perimeter Humphrey

HFA-II-I. This revealed an absolute

negative scotoma in the upper area of

the macular region (Figure 12). Visual

acuity was unchanged and the patient

referred to a subjective reduction of

the scotoma.

The clinical course of this disease

reflects what has been described in

the literature about acute macular

neuroretinopathy: the scotoma

Figure 8: Colour retinal retinography in typical acute macular neuroretinopathy (from: J. Donald and M. Gass, “Stereoscopic Atlas of macular diseases”, Mosby 1997).

Figure 9: OCT scan in a typical acute macular neuroretinopathy.

Figure 10: OCT after 6 months.

Figure 11: Colour retinography after 6 months.

Figure 12: ‘Macula-threshold’ visual feld analysis.



RETINA

persists but sometimes tends to

diminish. There has only been one

case, where the disease was bilateral,

when a complete visual recovery

has been reported in one eye and

persistent severe visual loss in the

other eye.14

Now, our patient is subjected to

regular controls with visit, OCT and

computerized perimetry that have

not changed. Moreover she lives a

normal life feeling the presence of the

scotoma less as time goes on.

References

1. M. Yanoff and J.S. Duker,

Ophthalmology: Expert Consult

Premium Edition: Enhanced

Online Features and Print (Yanoff,

Ophthalmology), 2008.

2. S.K. Vance et al., Retina, 2011;31:441–450.

3. H.D. Corver et al., Eye,

2007;21:1226–1229.

4. P.J.M. Bos and A.F. Deutmann, Am. J.

Ophthalmol., 1975;80:573.

5. S.D. Turbeville, L.D. Cowan and J.D.

Gass, Surv. Ophthalmol., 2003;48:1–11.

6. A.L. Yannuzzi, R.D. Guyer and W.R.

Green, Retina atlas; Medical Books,

1988.

7. D.M. O’Brien et al., Retina, 1989;9:281.

8. C. Maschi et al., Graefes Arch. Clin. Exp.

Ophthalmol., 2011;249:827–831.

9. N. Mamalis and M.J. Daily,

Ophthalmology, 1984;94:1209–1212.

10. J.D.M. Gaz and L.M. Hamed, Arch.

Ophthalmol., 1989;107:189.

11. A.E. Krill and A.F. Deutmann, Am. J.

Ophthalmol., 1972;74:193–205.

12. I.M. Neuhann et al., Graefes

Arch. Clin. Exp. Ophthalmol.,

2010;248:1041–1044.

13. G. Azar et al., Eur. J. Ophthalmol., 2012;

14 [Epub ahead of print]

14. M.H. Miller et al., Ophthalmology,

1989;96:265.

Authors

Dr Fabrizio Puce is a resident doctor

in the Ophthalmology Department at

S. Bartholomew Hospital, Sarzana, La

Spezia, Italy. He can be reached by E-mail:

[email protected]

Dr P. Lavezzari is a resident doctor

in the Ophthalmology Department at

S.Bartholomew Hospital, Sarzana, La

Spezia, Italy.

Dr Fabrizio Neri is chief of the

Ophthalmology Department at S.

Bartholomew Hospital, Sarzana, La Spezia,

Italy.

The authors do not have any commercial

or financial interest in any of the materials

or methods used in this study.

Have you

had similar

experiences? www.oteurope.com/discuss

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GLAUCOMA

“Elevated IOP is an important risk factor for

glaucoma1–3 and glaucoma progression,”4 according

to Dr Katrin Lorenz (Department of Ophthalmology,

University Medical Center, Johannes Gutenberg-

University Mainz, Germany) when discussing the study

she recently led that investigated the tolerability and

safety of a 24-hour intraocular pressure (IOP) monitoring

diagnostic device.5

“The role of IOP fluctuation as an independent

predictive factor for glaucoma progression is still

controversial,”6–10 she added. “Goldmann applanation

tonometry (GAT) has been the most widely established

indirect method for measuring IOP for many decades and

is the gold standard.”11–14

The SENSIMED Triggerfish (Sensimed, Lausanne,

Switzerland) is a novel device that comprises a soft

disposible contact lens embedded with a telemetry

chip and strain gauge sensor for measurement of

circumferential changes close to the corneoscleral

junction correlated to variations in IOP, regardless of

the patient’s position and activity (Figure 1). “A 24-hour

monitoring device for use in patients would be helpful

to better understand IOP fluctuation in normals and

in glaucoma patients. Also, measurements could be

obtained with continuation of normal daily activities,” Dr

Lorenz said.

Testing tolerability

“We tested the first model for use in humans for the

first time in healthy subjects and in glaucoma patients

with the primary objective to investigate tolerability and

side effects of the device during and after a 24-hour

IOP monitoring period,” explained Dr Lorenz. Taking

both healthy subjects and glaucoma patients and

excluding anyone who had worn contact lenses before,

the team placed one sensor in each patient’s test eye

and performed examinations both before and after the

24 hour wearing period.

“To evaluate the level of discomfort of the device

in the study eye at 24 hours, a visual analogue scale

(VAS) was presented to the subject. VAS for each

subject was scored between 0 and 100 mm, the

number corresponding to the distance in millimetres

of the subject’s mark on the VAS line from the left

end. Secondary endpoints included best corrected

visual acuity (BCVA), pachymetry, epithelial defects,

conjunctival erythema and corneal topography,” she said.

“Additionally, subjects were asked to fill in a diary which

was collected at the end of the study.”

A test was also performed initially to ensure that

healthy and glaucoma patients could be analysed

together, as the device had never been formally tested in

healthy subjects before. Dr Lorenz explained that if the

glaucoma patients had demonstrated severe discomfort

in this trial there would have been some difficulty in

proving that it was not significantly associated with

ocular surface disease, therefore, healthy subjects were

required to be used as controls. “However, contrary to

our expectations, no significant differences between

the two groups could be demonstrated and both groups

were combined for analysis,” she asserted.

Good tolerability

“The level of discomfort while wearing the contact lens

was measured by VAS and was 24.3 for all subjects,

which we define as a good level of tolerability for a

contact lens,” said Dr Lorenz. “Most subjects were using

artificial tears and noticed red eyes when they woke up in

the morning, but felt quite comfortable.”

Slightly more discomfort was found in the glaucoma

patients as compared to healthy subjects (26.8 versus

21.8), however, this difference was not found to be

statistically significant. “These results may be explained

by the higher frequency of dry eye syndrome in glaucoma

patients and the regular use of anti-glaucomatous eye

drops.15 Previous studies show that ocular surface

disease is present in more than 50% of glaucoma

patients,”16 she continued.

There were statistically significant changes found after

the patients had worn the device in corneal topography

for horizontal radii, objective and subjective refraction

By Felicity Thomas

Reviewed by Dr Katrin Lorenz

Continous IOP monitoringInvestigating tolerability of a diagnostic device in healthy and glaucomatous patients

In short...Elevated IOP is an important risk factor for glaucoma and

glaucoma progression, however, measurement of IOP

in a continuous 24-hour period has until now only been

possible in costly specialized centres. A novel device

comprising a soft disposible contact lens embedded with a

telemetry chip and strain gauge sensor has been developed

to enable continuous monitoring of IOP while the patient

is performing everyday activities. In this article, Dr Lorenz

discusses her recent study investigating the tolerability of

this device in glaucomatous and healthy patients.



GLAUCOMA

(sphere, cylinder and degree), BCVA,

conjunctival oedema, conjunctival

erythema, epithelial micro-defects

and lid oedema.5 “Deterioration of

BCVA probably results from changes

in epithelial micro-defects and corneal

topography and also due to irritation by

removal of the device. All these changes

are transient and may be considered

as not clinically significant,” Dr Lorenz

explained.

“Most of these changes may also

occur during 24-hour IOP profiles in a

sleep laboratory due to repeated topical

anaesthesia and GAT,” she added. “One

glaucoma patient received a 24-hour

IOP profile in the non-study eye in

our sleep laboratory during the study.

Epithelial defects changed from grade 1

(both eyes) to grade 2 in the non-study

eye while it remained stable in the study

eye. Worsening of epithelial defects is

quite common after repeated topical

anaesthesia and GAT.”

Additionally, Dr Lorenz revealed

that in this study the vast majority of

glaucoma patients (95%) would agree

to use the device again, which may

indicate a preference for this method

over analyses performed in a sleep

laboratory.

Increasing interest

“Twenty-four-hour IOP profiles are of

increasing interest. However, they are

only possible in specialized centres

with a sleep laboratory,” said Dr Lorenz.

“These profiles are not only associated

with high costs, they only partially

reflect IOP measurements in everyday

life.”17,18

Based on the results of this study,

the VAS scores and the willingness

of the glaucoma patients to repeat

the IOP profile with this device, the

subjective tolerability was shown to be

good in healthy subjects and glaucoma

patients. However, Dr Lorenz asserted

that further studies are needed to

investigate if this device is helpful

in daily routine. “Verification of the

relationship between the device output

and IOP is still an unsolved problem. This

validation is needed,” she said.

“Although researchers and clinicians

recognize the need for continuous IOP

monitoring of patients with glaucoma,

no clinical tool has been available until

now.19 The SENSIMED Triggerfish offers

the possibility to monitor IOP in daily life,

including office hours, sports and sleep.

No other devices are commercially

available so far,” Dr Lorenz concluded.

Acknowledgments

This editorial has been written based on

a recently published study:

Katrin Lorenz, MD, FEBO, Christina

Korb, MD, Nicola Herzog, MD, Jan M.

Vetter, MD, FEBO, Heike Elflein, MD,

Munir M. Keilani, MD, and Norbert

Pfeiffer, MD, Journal of Glaucoma,

2013;22(4):311–316. Dr Lorenz also

revealed that a further monocentric

study has been completed comparing

48-hour IOP monitoring with this device

with the gold standard. In this trial

the contact lens sensor was placed in

one eye and Goldmann applanation

tonometry (sitting measurements) and

Perkins tonometry (supine position)

were performed in the fellow eye

every two hours in a crossover design.

The initial results of this study were

presented at the ARVO meeting in

Seattle, Washington, USA.

References

1. A. Sommer, Curr. Opin. Ophthalmol.,

1996;7:93–98.

2. M.C. Leske et al., Arch. Ophthalmol.,

2002;120:954–959.

3. M.O. Gordon et al., Arch. Ophthalmol.,

2002;120:714–720; discussion 829–730.

4. M.C. Leske et al., Arch. Ophthalmol.,

2003;121:48–56.

5. K. Lorenz et al., J. Glaucoma,

2013;22(4):311–316.

6. B. Bergea, L. Bodin and B. Svedbergh,

Ophthalmology, 1999;106:997–1004;

discussion 1004–1005.

7. S. Asrani et al., J. Glaucoma,

2000;9:134–142.

8. B. Bengtsson and A. Heijl, Graefes Arch.

Clin. Exp. Ophthalmol.,2005;243:513–518.

9. L. Daugeliene, T. Yamamoto and Y.

Kitazawa, Graefes Arch. Clin. Exp.

Ophthalmol., 1999;237:105–108.

10. K. Nouri-Mahdavi et al., Ophthalmology,

2004;111:1627–1635.

11. J.D. Brandt, Curr. Opin. Ophthalmol.,

2004;15:85–89.

12. I. Dielemans et al., Graefes Arch. Clin. Exp.

Ophthalmol.,

1994;232:141–144.

13. H. Goldmann and T. Schmidt,

Ophthalmologica, 1957;134:221–242.

14. I.F. Wessels and Y. Oh, Arch. Ophthalmol.,

1990;108:1709–1712.

15. H. Uusitalo et al., Acta Ophthalmol.,

2010;88:329–336.

16. E.W. Leung, F.A. Medeiros and R.N.

Weinreb, J. Glaucoma, 2008;17:350–355.

17. P. Fogagnolo et al., Invest. Ophthalmol.

Vis. Sci., 2009;50:2209–2215.

18. T. Haufschild, S. Orgul and J. Flammer,

Am. J. Ophthalmol., 2006;142:179–181.

19. A.J. Sit, J. Glaucoma, 2009;18:272–279.

Figure 1: A patient wearing the device.

Special contributor

Dr Katrin Lorenz is head of the

clinical trial site in the Department of

Ophthalmology, University Medical Center,

Johannes Gutenberg-University Mainz,

Germany, and specialized in clinical trials.

She may be reached by E-mail:

[email protected]

Dr Lorenz stated that for the study discussed

in this article the authors received a research

grant and travel support by Sensimed AG.

Have you used this

device?




GLAUCOMA

Ocular surface disease (OSD) comprises dry

eye, lid disease, conjunctivitis and keratitis.

The high prevalence of OSD in glaucoma patients1

is primarily attributed to the use of the commonly

used preservative Benzalkonium Chloride (BAK),2

and hence the severity of OSD increases with

the cumulative number of medications.3 Not only

does OSD cause significant morbidity,2 but is also

compromises treatment compliance,4 quality of

life5 and surgical outcomes.6

Case series

We describe a series of four patients, referred

to our tertiary surgical glaucoma service, with

inadequately controlled POAG and symptomatic

OSD. All of the patients reported good compliance

with their glaucoma treatment prior to referral

to the glaucoma service. A combination

approach was used to manage the OSD (Table 1).

Preservative-free topical anti-glaucoma

medications were used as deemed appropriate

by the clinician. The latter three interventions, in

Table 1, were used in all patients.

Treatment resulted in improved intraocular

pressure (IOP) control in all four patients (Table 2).

There was no deterioration in visual field or

change in optic disc appearance throughout the

study period. Furthermore, a marked symptomatic

and clinical improvement in the ocular surface

with reduction in hyperaemia, meibomian gland

dysfunction and superficial keratopathy was noted

following treatment.

Discussion

OSD caused by the long-term use of topical

anti-glaucoma medication, can lead to

conjunctival inflammation, foreshortening

and shrinkage12 and severe symptomatic

cicatrisation, which is indistinguishable from

ocular cicatricial pemphigoid (OCP). The terms

drug-induced cicatricial conjunctivitis (DICC) and

pseudopemphigoid have been used.13

As discussed glaucoma therapy causes OSD,

however, it is also apparent that severe OSD in

turn exacerbates glaucoma. The prevalence of

glaucoma in patients with severe OSD has been

found to be 65.7%.14 Proposed mechanisms for

raised IOP in patients with OSD are increased

conjunctival inflammation in patients using

anti-glaucoma medications, vascular aetiologies

and inflammation of the trabecular meshwork,

and in addition inflammation and scarring of

the episclera and sclera thereby impairing the

outflow facility of the eye.15 In support of this

inflammatory theory, a higher rate of inflammatory

cell infiltrates and fibroblasts have been found in

conjunctival and trabeculectomy tissue samples

from patients who are chronically exposed to

preserved glaucoma medications.16

The aim of our treatment approach was to

break the destructive cycle of events (OSD may

potentiate glaucoma and vice versa) and achieve

improved IOP control and a healthy ocular surface.

In all four patients an improvement in the OSD

By Ruchika Batra,

MRCOphth, Rajen Tailor,

FRCOphth, and Shabbir

Mohamed, FRCSEd

Ocular surface disease exacerbated glaucomaThe rationale for optimizing the ocular surface in glaucoma patients

In short...The authors describe a case series of four patients

with inadequately controlled POAG and symptomatic

OSD in whom management of the OSD led to improved

IOP control, raising a new argument for maintaining

increased awareness of the signs and symptoms of

OSD in patients with glaucoma.

“Not only does OSD cause

significant morbidity, but is

also compromises treatment

compliance, quality of life and

surgical outcomes.”



GLAUCOMA

Table 1: Interventions to treat the OSD.

Intervention Rationale

1. Anti-glaucoma medications were changed to preservative-free preparations.

• BAKproducesseverechangesinepithelialcells,includingloss of microvilli, disruption of plasma membranes and desquamation of the top two layers of cells.7

Reducing BAK may improve OSD.8

2. Oral doxycycline (50 mg once daily for 3 months).

• Anti-inflammatoryactionduetotheinhibitionofT-cellactivation and chemotaxis, the downregulation of proinflammatory cytokines (TNFa and IL-1b) and the inhibition of matrix metalloproteinases that have been pathologically activated.9

• Doxycyclinecausesdestructionofmigratorykeratocytesorfibroblasts responsible for scar tissue formation, promoting epithelialization.10

3. Topical carmellose sodium (celluvisc) 0.5% 4–6 times daily for continued use.

• Topicalpreservativefreelubricationusedregularlymayimprove ocular surface health.11

4. Lid hygiene measures comprising twice daily lid margin massage using a hot moist face towel.

• Lidmassageanecdotallyimprovesmeibomianglandfunctionand may improve ocular surface blood flow.

Table 2: IOPs before and after treatment.

Case Range of IOPs 1 year prior to referral

(mmHg)

Highest recorded IOP

IOP at presentation to tertiary glaucoma clinic (mmHg)

Post treatment IOP (mmHg) at number of months (m) after intervention

1 R 15–20

L 15–20

R 28

L 42

R 14

L 19

R 13

L 13

3 m

R 10

L 11

8 m

R 8

L 11

14 m

R 9

L 9

19 m

2 R 24–30

L 24–28

R 26

L 28

R 24

L 24

R 16

L 16

3 m

R 14

L 10

9 m

R 15

L 14

17 m

3 Unknown Unknown R 20

L 19

R 12

L 13

3 m

R 12

L 12

8 m

R 15

L 15

12 m

4 R 16–30

L 16–26

R 34

L 36

R 30

L 20

R 18

L 18

2 m



GL AUCOMA

resulted in an improvement in the

IOP control and stabilization of the

visual field. This obviated the need

for surgical intervention, during the

study period. We feel our approach

was successful possibly due to

decreased inflammation of the

trabecular meshwork, conjunctiva,

episclera and sclera leading to

improved outflow facility of the eye.

If glaucoma filtration surgery

is subsequently required in our

patients, the improvement in the

ocular surface may contribute

to the increased likelihood of a

successful surgical outcome.

It may be argued that the

reduction in IOP may have been

due to improved compliance with

treatment for two reasons; firstly

as patient care was transferred

to a specialist consultant-led

glaucoma service and secondly due

to a reduction in ocular discomfort

following treatment of the OSD.

We feel that these scenarios are

unlikely because all four patients

reported good compliance with

treatment prior to being referred

to the service. Furthermore, we

recognize the limitations of our

small retrospective clinic-based

observation and the need for large

robust randomized studies to test

our hypothesis.

Nevertheless, we feel that this is

an important finding in a group of

patients in whom management can

be challenging; glaucoma in patients

with severe OSD is often refractive

to medical therapy14 and the surgical

success of glaucoma filtering surgery

is compromised in this group.17 Our

study raises a new argument for

maintaining increased awareness

of the signs and symptoms of OSD

in patients with glaucoma and

emphasizes the importance of

timely diagnosis and treatment of a

phenomenon we describe as ‘OSD

exacerbated glaucoma’.

References

1. E.W. Leung, F.A. Medeiros and R.N.

Weinreb, J. Glaucoma,

2008;17:350–355.

2. P.J. Pisella, P. Pouliquen and C.

Baudouin, Br. J. Ophthalmol.,

2002;86:418–423.

3. R.D. Fechtner et al., Cornea,

2010;29(6):618–621.

4. A. Chawla, J.N. McGalliard and M.

Batterbury, Acta Ophthalmol. Scand.,

2007;85:464.

5. B. Pouyeh et al., Am. J. Ophthalmol.,

2012;153(6): 1061–1066.

6. D.C. Broadway et al., Arch.

Ophthalmol., 1994;112:1446–1454.

7. M.B. Sherwood et al., Ophthalmol.,

1989;96:327–335.

8. N. Jaenen et al., Eur. J. Ophthalmol.,

2007;17:341–349.

9. A.N. Sapadin and R. Fleischmajer,

J. Am. Acad. Dermatol.,

2006;54(2):258–265.

10. V.A. Smith and S.D. Cook, Br. J.

Ophthalmol., 2004;88:619–625.

11. M.A. Sanchez et al., Cornea,

2010;29(2):167–171.

12. I.R. Schwab et al., Ophthalmol.,

1992;99:197–202.

13. T.J. Liesegang, Cornea,

1998;17(6):574–583.

14. J.H. Tsai et al., Cornea,

2006;25(5):530–532.

15. J. Tauber, A. Melamed and S. Foster,

Ophthalmol., 1989;96:33–37.

16. C. Baudouin et al., Ophthalmol.,

1999;106:556–563.

17. M.J. Lavin et al., Arch. Ophthalmol.,

1990;108:1543–1548.

Authors

Ruchika Batra, MRCOphth, is a speciality

registrar at the University Hospital

Birmingham, UK. She may be reached by

E-mail: [email protected]

Rajen Tailor, FRCOphth, is a speciality

registrar in ophthalmology at the

University Hopsital Birmingham, UK.

Shabbir Mohamed, FRCSEd, is a

consultant ophthalmologist at the

University Hospital Birmingham, UK.

None of the authors have any financial

disclosures pertaining to the subject

matter of this article.

Do you agree?


“The aim of our

treatment approach

was to break the

destructive cycle

of events (OSD may

potentiate glaucoma

and vice versa) and

achieve improved IOP

control and a healthy

ocular surface.”

“Our study raises a

new argument for

maintaining increased

awareness of the signs

and symptoms of OSD in

patients with glaucoma

and emphasizes the

importance of timely

diagnosis and treatment

of a phenomenon

we describe as ‘OSD

exacerbated glaucoma’.”

“…glaucoma therapy

causes OSD, however,

it is also apparent

that severe OSD in

turn exacerbates

glaucoma.”



GLAUCOMA

An estimated 79.6 million people will have

glaucoma by 2020,1 and the disease already

accounts for over 10 million visits to physicians

each year.2 Primary open-angle glaucoma is a

slowly progressive disease characterized by

degeneration of retinal ganglion cells with loss of

the retinal nerve fibre layer (RNFL) and thinning

of the neuroretinal rim of the optic nerve head.

However, new information indicates that current

rim measurements lack a solid anatomical

foundation and may not accurately reflect rim

width.

Current optic disc margin-based neuroretinal rim

estimates assume that the clinically visible disc

margin is the true anatomic border of the rim tissue

from which width, area or volume measurements

can be made. Professor Claude Burgoyne, myself,

and colleagues3,4,5 recently co-localized stereo

optic disc photographs to spectral-domain optical

coherence tomography (SD-OCT) and found that:

1) the clinically identified disc margin is rarely

a single anatomic entity or an identifiable

anatomic junction;

2) in some regions, Bruch’s Membrane extends

internally toward the centre of the optic nerve

head and is clinically and photographically

invisible; and

3) rim width measurements made in the plane

of the perceived disc margin are inaccurate

compared to those that take into account the

orientation of the overlying rim tissue.

The scientists developed a new, objective

method for measuring the rim that uses the Bruch’s

Membrane opening (BMO), a logical anatomical

outer border of the rim. With the Spectralis SD-OCT

(Heidelberg Engineering GmbH, Heidelberg,

Germany), a measurement is made from the BMO to

the nearest point on the internal limiting membrane

(ILM) quantifying the cross section of the nerve

fibres exiting the eye also referred to as BMO-based

minimum rim width (BMO-MRW).

Other studies by the same group found that

BMO-MRW measurements deviated regionally

and significantly from conventional rim margin

measurement.4 The BMO-MRW measurements

are more accurate because they are based on an

identifiable border of the rim and take into account

its varying trajectory relative to the point of

measurement. The investigators also demonstrated

that use of the BMO-MRW measurement translates

into significantly enhanced diagnostic precision

compared to the currently used cSLO or SD

OCT-based optic nerve head and RNFL thickness

parameters. At 95% specificity, the sensitivity of

RNFLT measurements ranged from 31% to 59%,

compared to the BMO-MRW measurement, whose

sensitivity ranged from 54% to 79%, a significant

improvement.

Heidelberg Engineering is currently working

with the investigators to develop software for the

Spectralis that will employ this new neuroretinal

rim analysis.

References

1. H.A. Quigley and A.T. Broman, Br. J. Ophthalmol.,

2006;90(3):262–267.

2. Center for Disease Control and Prevention/National

Center for Health Statistics, 2010 & 1995. Viewed April 20,

2013 at http://www.cdc.gov/nchs/data/hus/hus10.pdf

3. B.C. Chauhan et al., Ophthalmology, 2013;120:535–543.

4. A.S. Reis et al., Invest. Ophthalmol. Vis. Sci.,

2012;53:1852–1860.

5. A.S. Reis et al., Ophthalmology, 2012;119:738–747.

By Professor

Balwantray Chauhan

Enhanced detection of open-angle glaucomaUsing an anatomically accurate OCT-derived neuroretinal rim

parameter

Author

Professor Balwantray C. Chauhan, PhD, is Mathers

Professor and Research Director, Department of

Ophthalmology and Visual Sciences,Dalhousie University,

Halifax, Nova Scotia,Canada. He may be reached by E-mail:

[email protected]



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© 2011 Novartis AG 7/11 EXP10587JAD-EU


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