Aim and background:To characterize the effects of glaucoma treatment on the corneal endothelium by quantifying corneal endothelial morphology in eyes with and without glaucoma using in vivo specular microscopy. Materials and methods:This is a case-control study of 304 eyes conducted at an ambulatory glaucoma clinic at a tertiary academic institution from August 2021 through July 2023. Primary outcomes include endothelial cell density (ECD), coefficient of variation (CV), and hexagonality (Hex). Images of the central corneal endothelium were obtained using a non-contact Konan NSP-9000 specular microscope (Konan Medical, Irvine, CA, United States). The highest quality image of each cornea was selected for analysis. Each corneal endothelial image was manually graded using the Center Method and analyzed using CellChek (Konan Medical, Irvine, CA, United States) software. Results:Glaucomatous eyes demonstrate significantly lower corneal ECD compared to control eyes and glaucoma suspect eyes. Topical glaucoma drop use, trabeculectomy, and glaucoma tube shunt surgery independently predict a significant reduction in corneal ECD. Alpha agonist, carbonic anhydrase inhibitor (CAI), and Rho-associated protein kinase (ROCK) inhibitor drops independently predict a significant reduction in corneal ECD, with ROCK inhibitors predicting the greatest absolute decrease. Conclusion:Eyes treated with topical drops, trabeculectomy, or glaucoma tube shunt implantation demonstrate lower corneal ECD compared to control eyes. Use of topical drops from the alpha agonist, CAI, and ROCK inhibitor classes predicts significant corneal endothelial cell loss. Clinical significance:These findings provide valuable clinical context for the medical management of glaucoma that may reduce adverse outcomes and preserve corneal function in patients receiving ocular hypotensive therapy. How to cite this article:Yang CD, Carbonell BAC, Hussey V, et al. Decoding Corneal Endothelial Loss from Glaucoma Treatment: A Case-Control Stratification Analysis. J Curr Glaucoma Pract 2025;19(2):68-74.

Purpose:To evaluate trends in fellow exposure to trabeculectomy, tube shunt, and minimally invasive glaucoma surgery (MIGS) procedures during glaucoma fellowship training. Methods:We analyzed fellowship surgical logs from 2013 to 2024 from the Association of University Professors of Ophthalmology (AUPO) Fellowship Compliance Committee to determine the frequency of trabeculectomy, tube shunt, and MIGS procedures within glaucoma fellowship programs. Results:Our analysis revealed a 55.9% decrease with significant correlative decline (r = -0.89, p = 0.0002) over the 11-year study period in total trabeculectomy exposure (primary and assistant surgeon), while total tube shunt surgeries underwent a modest 7.3% decrease with significant correlative decline (r = -0.80, p = 0.003) over the 11-year study period, and MIGS procedures showed a marked 128.6% increase with significant correlative increase (r = +0.72, p = 0.02) from 2016 to 2024. Conclusion:The declining exposure to trabeculectomy surgery, both as primary and assistant surgeon raises concerns about glaucoma fellowship graduate proficiency with this fundamental procedure. This may limit access to qualified care for specific glaucoma populations that may benefit most from this intervention, and for the continued care of patients that have previously undergone trabeculectomy surgery. These findings highlight the need to maintain proficiency in trabeculectomy to ensure optimal care for diverse glaucoma patient populations.

Background: This study compares the cost-utility, visual acuity, and humanistic outcomes of phacoemulsification surgery performed during international outreach campaigns to outcomes in the U.S. Objective: Humanitarian organizations frequently perform cataract surgeries in underserved regions, yet the outcomes of phacoemulsification in these settings remain unexplored. This study aims to compare the visual acuity outcomes, quality-of-life outcomes, and cost of phacoemulsification surgery during international outreach campaigns with those in the U.S. Methods: This retrospective review analyzed 344 cases from Women for World Health (W4WH) missions and 305 consecutive cases from the academic practice of the lead surgeon of W4WH in the US. The pre-operative (pre-op) visual acuity, post-operative (post-op) visual acuity at day 1, and best-corrected visual acuity (BCVA) at post-op month 1 were compared to baseline. The change in visual acuity was compared between the two groups. Complication rates, cost per case, and quality-of-life measures were evaluated for the mission group compared to cataract surgery outcomes in the developed world. Results: The mission cohort had worse baseline visual acuity than the U.S. cohort (1.36 logMAR vs. 0.50 logMAR, p < 0.0001) and showed greater mean improvement (1.24 logMAR vs. 0.35 logMAR, p < 0.0001). Both cohorts achieved similar BCVA at post-op month 1 (0.13 logMAR). The cost for the mission group was USD 276 per surgery. A total of 93.94% of patients in the mission group achieved a BCVA of 20/40 or better, which is comparable to the U.S. outcomes. Conclusions: The dramatic impact, immediacy, and enduring effect of cataract surgery using phacoemusification on quality of life, mental health, and economic return on investment make it the ideal procedure for humanitarian settings. Considering all of the available metrics, our data support the continued expansion of humanitarian efforts by cataract surgery organizations worldwide.

Purpose:To characterize clinical outcomes of canaloplasty and trabeculotomy using the OMNI Surgical System (Sight Sciences) as a standalone procedure in primary open-angle glaucoma (POAG) subgroups (phakic, pseudophakic; mild, moderate, severe disease). Design:Retrospective, observational cohort study utilizing the American Academy of Ophthalmology (Academy) IRIS® Registry (Intelligent Research in Sight). Methods:Patients with POAG undergoing standalone OMNI surgery with known laterality between January 2018 and December 2021 and followed for a minimum of 6 months and up to 36 months were included. Analyses divided the cohort into mild, moderate, and severe glaucoma subgroups (International Classification of Disease-10 coding), and lens status (phakic and pseudophakic) subgroups. Outcomes included changes in intraocular pressure (IOP) and glaucoma medication class use. Results:Data from 220 eyes of 187 patients were analyzed. Mean IOP reductions from baseline were clinically and statistically significant at every time point across disease severity groups; mild, 5.5-9.4 mmHg (p < 0.0026); moderate, 5.3-7.4 mmHg (p < 0.0001 at all time points); severe, 5.8-7.6 mmHg (p < 0.0004). Mean IOP reductions were 5.1-7.4 mmHg in phakic eyes and 5.8-6.7 mmHg in pseudophakic eyes; p < 0.0001 all time points, both subgroups. Mean medication reductions from baseline were clinically and statistically significant at month 6 and month 12 in the mild and severe groups, and insignificant at all other time points in the three groups. Medication reductions averaged 0.3-0.4 in phakic eyes (non-significant) and statistically significant reductions of 0.4-0.6 in pseudophakic eyes (months 6, 12, and 18 [p < 0.01]), with non-significant reductions (0.3-0.4 medications) at later time points. Conclusion:In this study, standalone OMNI surgery significantly decreased IOP for up to 3 years regardless of disease severity or lens status. This procedure may be considered for phakic or pseudophakic patients with all stages of glaucoma whose therapeutic goals fall within the ranges achievable with standalone surgery.

A patient with juvenile glaucoma status post 2 glaucoma drainage implants in each eye presents with painful vision loss in the left eye and is found to have streptococcus pneumoniae endophthalmitis from an exposed inferior glaucoma drainage implant. The infection is managed medically with intravitreal antibiotics and surgically with a glaucoma drainage device revision, anterior chamber washout and pars plana vitrectomy.

Purpose: To compare outcomes of ab-interno canaloplasty and trabeculotomy of the superior versus inferior angle. Patients and methods: This was a prospective, non-randomized, interventional comparison study done at the Veteran Affairs Hospital in Long Beach, California. All patients underwent cataract surgery with intraocular lens implantation combined with ab-interno canaloplasty and trabeculotomy with the OMNI Surgical System (SightSciences, Menlo Park, CA, USA), either superiorly or inferiorly. Pre- and post-operative intraocular pressure using Goldmann applanation tonometry and best corrected visual acuity were obtained and compared using paired t-tests. Patients were excluded if they had any prior intraocular surgery or prior laser trabeculoplasty procedures. Results: 38 eyes from 29 patients were analyzed. 19 eyes were included in the superior group and 19 eyes in the inferior group. Mean pre-operative IOP in the superior group was 17.6 +/- 5.2 mmHg and in the inferior group was 17.6 +/- 4.6 mmHg (p > 0.99). At 12 months, mean postoperative IOP for the superior group decreased 24% to 13.3 +/- 2.8 mmHg while the inferior group decreased 26% to 13.1 +/- 2.2 mmHg (p = 0.92). Mean preoperative medications in the superior group were 2.2 +/- 1.3 and in the inferior group was 2.4 +/- 1.3 (p = 0.88). At 12 months, this decreased to 1.3 +/- 1.5 post-operatively in the superior group and 2.2 +/- 1.6 post-operatively in the inferior group (p = 0.64). Conclusion: There was no statistical difference in efficacy between superior versus inferior canaloplasty/trabeculotomy with OMNI. Therefore, surgeons can perform the procedure in the direction that is most comfortable for them without affecting outcomes.

Introduction:Photodynamic therapy (PDT) has shown substantial benefit in the treatment of choroidal hemangioma (CH) in recent years. This report describes the use of PDT with overlapping spots in a patient with Sturge-Weber syndrome (SWS) and large circumscribed CH.Case Presentation:A 9-year-old girl with SWS and a history of glaucoma in her left eye was referred to a retina clinic for possible macular changes. Examination revealed decreased vision in the left eye, pigmentary changes in the macula, and choroidal thickening in the posterior pole. After being lost to follow-up for 2 years, the patient returned with further vision deterioration with best-corrected visual acuity (BCVA) of 20/150 and new subretinal fluid (SRF). Imaging findings were consistent with a diagnosis of CH and SRF. PDT with verteporfin was initiated on the entire area with multiple overlapping spots, resulting in resolution of SRF and improvement in visual acuity and choroidal contour. At 18-month post-treatment, the patient's BCVA was 20/25 with no recurrence of SRF or increased choroidal thickening. Significant pigmentary changes and subretinal hyper-reflective material were observed in the OCT of the treated area.Conclusion:Multiple overlapping laser spots of PDT can result in longstanding regression of large circumscribed CH in a patient with SWS with excellent final visual acuity. However, significant subretinal changes may also result following this method of treatment.

This video demonstrates two surgical cases where autologous tenon grafts are used to shut down leaking trabeculectomies. Variations in this technique with a rotational graft and a hinge graft are explored.

Purpose: To evaluate outcomes of new adopters of the OMNI (R) Surgical System (Sight Sciences, Inc.) by prospectively evaluating intermediate-term outcomes of patients operated by trainees.Patients and Methods: This was a prospective study of surgeries performed by trainees on patients with open angle glaucoma undergoing simultaneous cataract surgery and ab interno canaloplasty and trabeculotomy using the OMNI Surgical System. Preoperative intraocular pressure (IOP) and number of glaucoma medications were recorded. Only patients with a minimum of 6-month follow up were included. Baseline IOP was used to separate subjects into two groups: Group 1 (IOP >18 mmHg) and Group 2 (IOP <18 mmHg). Mean decrease in IOP and medications was calculated and compared with paired t-tests for the overall sample as well as the subgroups. Success was defined as those with a >20% reduction from pre-operative IOP or with an IOP <= 18 mmHg and >6 mmHg and on the same or fewer number of medications while not requiring additional surgery. Adverse events were also recorded.Results: Forty-two eyes of 31 patients were included. Mean pre-operative IOP was 17.2 +/- 4.8 mmHg and mean number of medications was 2.4 +/- 1.2. The primary endpoint was reached in 83.3% of patients at 12 months. IOP was reduced by 22.3% to 13.4 +/- 2.4 (p<0.001). Mean number of medications decreased to 1.7 +/- 1.6 (p<0.001). Group 1 mean IOP decreased 35.4% from 22.2 +/- 4.6 mmHg to 14.3 +/- 2.8 mmHg (p<0.001). Group 2 mean number of medications decreased from 2.3 +/- 1.1 to 1.6 +/- 1.5 (p<0.001). Conclusion: When operated on by the novice MIGS surgeon, the OMNI device provides effective IOP and glaucoma medication reduction with minimal adverse events. Efficacy and safety of the device in the hands of trainees was comparable to experienced glaucoma surgeons suggesting its ease of adoption.

Background Δ9-tetrahydrocannabinol (THC) has been shown to decreased intraocular pressure (IOP). This project aims to define the relationship between plasma THC levels and IOP in healthy adult subjects. Methods Eleven healthy subjects received a single dose of inhaled cannabis that was self-administered in negative pressure rooms. Measurements of IOP and plasma THC levels were taken at baseline and every 30 min for 1 h and afterwards every hour for 4 h. IOP reduction and percent change in IOP over time were calculated. Linear regression models were used to measure the relationship between IOP and plasma THC levels. Two line linear regression models with F-tests were used to detect change points in the regression. Then, Pearson correlations were computed based on the change point. Results Twenty-two eyes met inclusion criteria. The average peak percentage decrease in IOP was 16% at 60 min. Percent IOP reduction as well as total IOP reduction demonstrated a negative correlation with THC plasma levels showing r-values of −0.81 and −0.70, respectively. F-tests revealed a change point in the regression for plasma levels >20 ng/ml. For levels >20 ng/ml, the correlation coefficients changed significantly with r-values of 0.21 and 0.29 (p < 0.01). Conclusion Plasma THC levels are significantly correlated with IOP reduction up to plasma levels of 20 ng/ml. Plasma levels >20 ng/ml were not correlated with further decrease in IOP. More research is needed to determine the efficacy of THC in reducing IOP for eyes with ocular hypertension and glaucoma.

Background Capnocytophaga canimorsus is a facultative anaerobic, slow-growing, capnophilic, Gram-negative bacillus, that is commonly found in the microflora of canine and feline oral cavities. Capnocytophaga infections are an emerging zoonotic disease that can cause fatal systemic infections in immunocompromised individuals. Localized ocular Capnocytophaga infections, including keratitis, blepharitis, and endophthalmitis, can lead to severe eye threatening situations. To our knowledge, there is currently no documented case of Capnocytophaga canimorsus blebitis with bleb perforation after trabeculectomy. Case presentation Our case report and literature review features a novel case of Capnocytophaga blebitis that occurred after trabeculectomy, associated with close dog contact (i.e. face licking). The patient had underwent trabeculectomy 10 years prior and presented with conjunctival injection, perforated bleb, and hypotony. Overall, patient was medically treated subconjunctival vancomycin, gentamicin and moxifloxacin drops. Trabeculectomy revision was performed with good visual outcome. Bacterial cultures grew Capnocytophaga canimorsus . Conclusions We discuss the strategies for diagnosis, treatment, and common risk factors for ocular Capnocytophaga infections. At-risk patients with ocular infections should be asked about close contact with dogs and cats; and treated promptly with the proper antibiotic regimen.

It has been 15 years since the first study on ab interno trabulotomy results with the Trabectome system were published by Minckler et al. This procedure was the pioneer that ushered in the minimally invasive glaucoma surgery (MIGS) era. Times have certainly changed in terms of peoples' perceptions and attitudes towards the MIGS category. What has not changed throughout these years are the consistent outcomes seen with the Trabectome procedure. That initial publication studied patients with primary open-angle glaucoma and reported an intraocular pressure (IOP) reduction from a baseline of 28.2 mmHg down to 16.3 mmHg at 12-month follow-up. Interestingly, the results of the study by Swamy et al in this issue of CEO mirror those early findings almost exactly. This study was performed on patients with uveitic glaucoma and the IOP at 12-month follow-up was 16.7 mmHg, reduced from a baseline of 29.2 mmHg. In the years between that first study and the current one, dozens of papers have been published on ab interno trabeculotomy in various subtypes and severities of glaucoma, by hundreds of investigators, and from all corners of the globe. Given that the highest success rates have been reported in pseudoexfoliative glaucoma, steroid-induced glaucoma and pigmentary glaucoma, it can be safely concluded that ab interno trabeculotomy can be used successfully in patients in whom the pathological basis for the elevated IOP is at the level of the trabecular meshwork. This is particularly true for patients with uveitic glaucoma. As the investigators in the Swamy et al paper indicate, uveitic glaucoma is a complex disease with contributions from inflammatory debris congesting the trabecular meshwork, trabeculitis, synechial closure of the angle from chronic inflammation and steroid response. All of the above-mentioned mechanisms are at the level of the trabecularmeshwork, and common sense indicate that bypassing this bottle-neck via a small clear corneal incision is a more targeted approach than performing a trabeculectomy or tube shunt implant. Historically, uveitic glaucoma is one of the most challenging of the glaucomas to treat surgically, owing to the high risk of hypotony and scarring. The success rate seen in this study was 91% at 12 months. This exceeds the typical reported success rates of either the tube shunt or the trabeculectomy in uveitic glaucoma. It can be theorized that by targeting the site of pathology directly, there is less possibility of recruiting traditional mechanisms for failure such as scarring of conjunctiva/ tenon/sclera, overfiltration, hypotony and implant erosion. Many studies have indicated that ongoing uncontrolled inflammation at the time of glaucoma surgery and recurrent uveitis are negative prognostic indicators for surgical success with trabeculectomy and tube shunt surgery. In the Swamy et al study, no comment was made on the proportion of patients that had uncontrolled uveitis at the time of enrolment or recurrent inflammation during the follow-up period. It would indeed be interesting to see if this had any impact on Trabectome outcomes, and should be the subject of future investigation. The remarkable success rate reported in this study is somewhat a function of the intermediate-term follow-up. As uveitis tends to be a relapsing and remitting condition with recurrent needs for steroid use, it is likely that some of these patients may go on to fail trabecular bypass and require more invasive surgery. The authors here acknowledge that longer-term follow-up is preferred and warrants revisiting the data when additional follow-up and a larger cohort are available for analysis. Despite the risks of enthusiasm for new technologies, it seems that the early adopters of the Trabectome have not been penalized by the judgements of time, but rather rewarded with an enduring alternative that has allowed for success rates such as these in the most challenging of conditions.

Abstract Purpose To present an association between acquired pits of the optic nerve (APON) and prior laser-assisted in situ keratomileusis (LASIK). Materials and methods A retrospective case series of patients with an optic disc pit on clinical exam and a history of LASIK. Spectralis Optical Coherence Tomography images and Humphrey Visual Fields were reviewed from prior visits. Extended-depth optical coherence tomography was performed of the optic nerve head at subsequent visits after patients were identified. Results Seven patients, aged 45–73 years, were identified each with unilateral optic disc pits. Optic disc pits were located inferior in six patients and centrally in one patient. All demonstrated thinning on optical coherence tomography and six patients had corresponding visual field defects. Four patients identified these defects after their LASIK procedure while two patients were unaware of their reproducible visual field defects. All patients were treated with drops initially. One patient underwent laser trabeculoplasty, and three underwent a trabeculectomy after demonstrating progression on maximum tolerated medical therapy. Conclusion This series describes a possible association between LASIK and APON. Given the similarity and severity of vision loss associated with the optic nerve pits in these patients after LASIK, increased awareness and caution is suggested while considering LASIK in susceptible individuals. How to cite this article Smith AK, Bussel I, Ling J, et al. Acquired Optic Pits Associated with Laser-assisted In Situ Keratomileusis: A Case Series. J Curr Glaucoma Pract 2020;14(3):106–108.

Journal of Cataract & Refractive Surgery: January 2020 - Volume 46 - Issue 1 - p 154-155 doi: 10.1097/01.j.jcrs.0000668260.00212.05

Purpose: There is a growing interest in targeting minimally invasive surgery devices to the aqueous outflow system to optimize treatment outcomes. However, methods to visualize functioning, large-caliber aqueous and episcleral veins in-vivo are lacking. This pilot study establishes an ex-vivo system to evaluate the use of a confocal laser microendoscope to noninvasively image episcleral vessels and quantify regional flow variation along the limbal circumference. Methods: A fiber-optic confocal laser endomicroscopy (CLE) system with lateral and axial resolution of 3.5 μ m and 15 μ m, respectively, was used on three porcine and four human eyes. Diluted fluorescein (0.04%) was injected into eyes kept under constant infusion. The microprobe was applied to the sclera 1 mm behind the limbus to acquire real-time video. Image acquisition was performed at 15-degree intervals along the limbal circumference to quantify regional flow variation in human eyes. Results: Vascular structures were visualized in whole human eyes without processing. Schlemm's canal was visualized only after a scleral flap was created. Fluorescent signal intensity and vessel diameter variation were observed along the limbal circumference, with the inferior quadrant having a statistically higher fluorescein signal compared to the other quadrants in human eyes ( P < 0.05). Conclusion: This study demonstrates for the first time that the fiber-optic CLE platform can visualize the episcleral vasculature with high resolution ex-vivo with minimal tissue manipulation. Intravascular signal intensities and vessel diameters were acquired in real-time; such information can help select target areas for minimally invasive glaucoma surgery (MIGS) to achieve greater intraocular pressure reduction.

We present a case series describing a unique entity as it relates to plateau iris. There have been many established risk factors for plateau iris, but we present the following cases that describe patients with plateau iris in the setting of prematurity and/or retinopathy of prematurity as well as high myopia or emmetropia. We believe this to be a distinct form of plateau iris resulting from abnormal ciliary body and angle development in the preterm infant. Subjects were treated according to standard of care, with laser peripheral iridotomies, laser iridoplasty, and even glaucoma drainage implants, as indicated.

Objective: To determine the efficacy and safety of ab interno trabeculectomy with Trabectome in juvenile open-angle glaucoma (JOAG) patients. Design: Prospective cohort study. Methods: Evaluation of the 12-month results of 2 patient groups receiving ab interno trabeculectomy: group 1, eyes with no prior incisional surgery; group 2, eyes that had prior incisional cataract or glaucoma surgery. Results: Group 1, 40 eyes (average age 31 +/- 7 years), had a significant reduction in intraocular pressure (10P) of 10.6 mm Hg at 12 months from a baseline of 27.4 mm Hg (p = 0.01), and the number of glaucoma medications reduced by 0.4 (p = 0.80). Four eyes (10%) within the study period required a secondary glaucoma surgery. Group 2, 20 eyes (average age 27 +/- 8 years), had a significant reduction in !OP of 8.8 mm Hg from a baseline of 27.1 mm Hg (p = 0.06), and the number of glaucoma medications reduced by 1.4 (p = 0.36). Five eyes (25%) from this group underwent a secondary glaucoma surgery within 12 months. Conclusion: After 1 year of follow-up, ab interno trabeculectomy appears to be an effective and safe intervention for patients with JOAG; however, a reduction in use of topical medications may not be observed in those receiving ab interno trabeculectomy as a primary procedure.