This review aims to provide an update on therapeutic techniques and a recommended approach to angle closure management. The concept of angle closure management is based on reversing the angle closure process while taking into account the disease’s etiology, clinical presentation, and staging of the disease. Recent data show that lens extraction, whether for visually significant cataract or clear lens, is becoming more common in angle closure management. In addition, traditional management to prevent occludable angle eyes from progressing to a more advanced stage of primary angle closure disease may not be necessary in all cases. A variety of new glaucoma therapies have been shown to be effective and may play a significant role in angle closure management. An initial step in angle closure management is to widen the angle. The procedures chosen are determined by the underlying mechanism of angle closure. Lens extraction is one of the most effective methods to widen the angle. Procedures that increase aqueous outflow or decrease aqueous inflow are required for eyes with low target IOP or synechial angle closure.

The crystalline lens plays an important role in the pathophysiology of primary angle closure and primary angle-closure glaucoma. The aging process is associated with a progressive enlargement of the lens, resulting in greater iridolenticular and iridotrabecular contact, which exacerbates both pupillary block and appositional angle closure, irrespective of the cataract status of the lens. Cataract surgery has been shown to widen the angle and reduce intraocular pressure in eyes with primary angle closure or primary angle-closure glaucoma. Recently, clear lens phacoemulsification has been suggested as a treatment modality in such eyes. We review the literature on clear lens extraction in eyes with angle closure and discuss its efficacy, safety, and indications. Although it is evident that clear lens extraction is beneficial in eyes with primary angle closure and primary angle-closure glaucoma, it is technically challenging and should be performed by experienced surgeons who not only master the procedure but are also able to deal with potential complications. Since the follow-up of the reviewed studies is relatively short, long-term follow-up (>10 years) of patients who undergo this procedure is needed to evaluate the safety and confirm the early benefits reported.

Purpose of review Although reducing the intraocular pressure (IOP) through medications, laser or surgery remains the primary means of glaucoma treatment, there is increasing evidence during the last decade that environmentally modifiable factors may help to prevent glaucoma or its progression through different mechanisms that may or may not involve lowering IOP. Additionally, patients are increasingly interested in maintaining a healthy lifestyle and taking an active role in the management of their disease. Therefore, the aim of this review is to summarize the current evidence regarding environmentally modifiable factors such as lifestyle, exercise, and nutrition in the pathogenesis of glaucoma. Recent findings In the last decade, large population-based studies have helped to identify possible environmentally modifiable protective and risk factors with regard to glaucomatous disease. Smoking cessation; moderate aerobic exercise; recommended weight; and a balanced diet including green leafy vegetables, omega fatty-acids, and moderate intake of hot tea and coffee have been reported to be possibly protective against developing glaucoma or its progression. Summary Modifiable environmental factors such as lifestyle, exercise, and nutrition may play a role in glaucoma pathogenesis. Large prospective studies with long-term follow-up should be encouraged to corroborate these findings, which may guide future treatments for our patients, some of which may not be limited to IOP reduction.

*University Favaloro School of Medical Sciences, and Foundation for the Study of Glaucoma, Buenos Aires, Argentina †Glaucoma Research Center, Montchoisi Clinic, Swiss Vision Network, Lausanne, Switzerland ‡Department of Ophthalmology, University of Colorado School of Medicine, Denver, CO §Glaucoma Center of San Francisco, San Francisco, CA Disclosure: S.F.L.: Alcon (S), Iridex (S), Glaukos (C), Novartis (C, S). K.M.: Santen (C), Sensimed (C), Topcon (S), Alcon (S), Allergan (S), Optovue (S), ImplanData (C). S.C.L.: Aerie (C), Allergan (C), Bausch and Lomb (C), Iridex (C). Reprints: S. Fabian Lerner, MD, Marcelo T. de Alvear 2010-2A, Buenos Aires 1122AAF, Argentina (e-mail: [email protected]).

Supplemental Digital Content is available in the text. Precis: We found no evidence of an increase in the number of Americans using topical intraocular pressure (IOP) medication or a number of drops used per patient from 1999 to 2014, although there were significant changes in the class of medications used. Purpose: The purpose of this study was to determine changes in topical IOP-lowering medication use in the United States from 1999 to 2014. Materials and Methods: A series of 8 nationally representative, weighted cross-sectional surveys of United States residents were performed every 2 years from 1999 to 2014. On 2-year cycles, professional interviewers performed in-home interviews of a representative sample of the nation as part of the National Health and Nutrition Examination Survey study. Participants were asked, “In the past month, have you used or taken medication for which a prescription is needed?” Adults over age 40 who responded to this question were included in the analysis. The primary outcome was number of US adults using topical IOP–lowering medication. Secondary outcomes included the number and types of medications used. Results: There was no change in the number of adults using topical IOP–lowering medications over the time period studied (P=0.74) with 1.4% (95% confidence interval: 0.9%-1.8%) of US residents on IOP-lowering medications in 1999 to 2000 and 1.4% of US residents (95% confidence interval: 1.1%-1.8%) on topical medications in 2013 to 2014. There was no change in the number of medications per patient over the period of the study (P=0.14). There was a significant increase in the use of prostaglandin analogs and combination medications and a decrease in the use of β-blockers (all P<0.01). Conclusions: In contrast to the increase in glaucoma medication use seen in several other developed nations, use in the United States remained stable from 1999 to 2014. This may be due to differential use of other procedures. Future studies of IOP-lowering medications incorporating the effect of new agents and minimally invasive surgeries are warranted.

Purpose/Aim: To evaluate the best formula to predict intraocular pressure (IOP) reduction after cataract surgery.Materials and methods: In this prospective longitudinal study, we included consecutive patients with or without glaucoma, either with open or with narrow angles but without peripheral anterior synechiae, who underwent phacoemulsification. Clinical factors and anterior segment parameters measured with optical biometry and optical coherence tomography were evaluated as preoperative predictors for IOP reduction at 6months postoperatively. To find the best combinations of predictors, model selection was conducted using least absolute selection and shrinkage operator regression with cross-validation.Results: A total of 156 eyes from 109 patients were enrolled. The mean age of the patients was 74.89 (8.54) years and the average preoperative IOP was 15.6 (+/- 3.68) mmHg with 0.7 (range 0-4) glaucoma medications. The mean IOP reduction after phaco was 3.1 (+/- 2.49) mmHg at postoperative month 6. After multivariate analysis, preoperative IOP (=0.49 [0.4-0.59] P <.0001), gonioscopy score (=-0.14 [-0.23 to -0.06] P =.0001), anterior chamber depth (=-0.85 [-1.64 to -0.07] P =0.033), lens thickness (LT) (=0.87 [0.12-1.62] P =.024), and angle open distance 750 (=-2.2 [-3.96 to -0.44] P =0.014) were associated with IOP reduction. The best formula to correlate with IOP reduction was -4.76+(0.46xpreoperative IOP) -(0.42xLT) -(0.1xgonioscopy score) -(0.66xglaucoma status).Conclusion: Different formulas were developed and were able to improve the predictive value of the preoperative IOP. When used in combination, these formulas may help the clinician to know how much IOP reduction to expect after cataract surgery at 6months postoperatively.

Purpose: To evaluate a novel gonioscopy score as a potential predictor for intraocular pressure (IOP) reduction after cataract surgery. Materials and Methods: This was a prospective study that included consecutive patients with or without glaucoma, either with open or narrow angles but without peripheral anterior synechiae, who underwent phacoemulsification. Eyes with intraoperative complications and secondary glaucoma were excluded. A preoperative gonioscopy score was created, summing the Shaffer gonioscopy grading in 4 quadrants (range, 0 to 16). To determine variables associated with IOP change at 6 months, univariate and multivariate linear mixed-effects regression analysis was performed adjusting for age, sex, and preoperative IOP. Results: In total, 188 eyes from 137 patients were enrolled. The mean age of the patients was 75.0 (±8.5) years and the average preoperative IOP was 15.6 (±3.6) mm Hg with 0.7 (range, 0 to 4) glaucoma medications. The mean IOP reduction after phacoemulsification was 3.0 (±2.6) mm Hg at postoperative month 6. After multivariate analysis, preoperative IOP [&bgr;=0.49 (0.41-0.58), P<0.0001], gonioscopy score [&bgr;=−0.17 (−0.24 to −0.09), P<0.0001], anterior chamber depth (ACD) [&bgr;=−0.88 (−1.64 to −0.14), P=0.02], and IOP/ACD ratio [&bgr;=0.45 (0.07 to 0.83) P=0.021] were associated with IOP reduction at 6 months. Conclusions: Preoperative predictors for IOP reduction after cataract surgery were preoperative IOP, ACD, gonioscopy score, and IOP/ACD ratio. The IOP/ACD ratio and gonioscopy score can be easy parameters to obtain and may help clinicians to estimate the IOP reduction after phacoemulsification.

Background/Aims. Epigenetic mechanisms via DNA methylation may be related to glaucoma pathogenesis. This study aimed to determine the global DNA methylation level of the trabeculectomy specimens among patients with different types of glaucoma and normal subjects. Methods. Trabeculectomy sections from 16 primary open-angle glaucoma (POAG), 12 primary angle-closure glaucoma (PACG), 16 secondary glaucoma patients, and 10 normal controls were assessed for DNA methylation using combined-bisulfite restriction analysis. The percentage of global methylation level of the interspersed repetitive sequences for LINE-1, Alu, HERV-E, and HERV-K were compared between the 4 groups. Results. There were no significant differences in the methylation for LINE-1 and HERV-E between patients and normal controls. For the Alu marker, the methylation was significantly lower in all types of glaucoma patients compared to controls (POAG 52.19% versus control 52.83%, p=0.021; PACG 51.50% versus control, p=0.005; secondary glaucoma 51.95% versus control, p=0.014), whereas the methylation level of HERV-K was statistically higher in POAG patients compared to controls (POAG 49.22% versus control 48.09%, p=0.017). Conclusions. The trabeculectomy sections had relative DNA hypomethylation of Alu in all glaucoma subtypes and relative DNA hypermethylation of HERV-K in POAG patients. These methylation changes may lead to the fibrotic phenotype in the trabecular meshwork.

Purpose: To compare optic nerve head, peripapillary retinal nerve fiber layer (pRNFL), and ganglion cell complex (GCC) parameters between Caucasian and ethnic Chinese. Materials and Methods: Normal subjects above 40 years old and self-identified as being Caucasian and Chinese were recruited. They were evaluated with spectral-domain optical coherence tomography (RTVue-100). Parameters related to the optic nerve head, pRNFL, and GCC analysis protocols were acquired. Multivariable linear regression was performed adjusting for potential confounders. Results: Data from 116 Caucasian and 130 Chinese subjects were available for analysis. Mean age of all participants was 66.72 (SD 10.82) years. There were statistically significant differences for disc area (DA), area cup-to-disc, vertical cup-to-disc, and cup volume (P=0.02, 0.004, 0.02, and 0.03, respectively), greater in Chinese. After adjusting for age, sex, axial length (AL), intraocular pressure (IOP), DA, and GCC thickness, Chinese subjects had significantly greater thickness in all pRNFL parameters (mean differences ranged between 4.29 and 9.93 &mgr;m; all P<0.001) except the nasal quadrant. GCC outcomes were also adjusted for DA and pRNFL; Caucasians had significantly higher average GCC and inferior GCC (mean difference 2.97 and 3.45 &mgr;m, respectively; P<0.01), whereas the Chinese group had significantly higher ganglion cell global loss volume (mean difference 2.47 %, P<0.001). Conclusions: This study suggests there is significantly greater pRNFL thickness in Chinese, which were independent of age, AL, IOP, and DA, and possibly greater GCC in Caucasians after adjustment for age, AL, IOP, DA, and pRNFL thickness.

PURPOSE:Evaluate the distribution and the color probability codes of the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thickness in a healthy Vietnamese population and compare them with the original color-codes provided by the Cirrus spectral domain-optical coherence tomography. METHODS:This is a cross-sectional study. We recruited nonglaucomatous Vietnamese subjects and constructed a normative database for peripapillary RNFL and macular GCIPL thickness. The probability color-codes for each decade of age were calculated. We evaluated the agreement with κ coefficient between optical coherence tomography color probability codes with Cirrus built-in original normative database and the Vietnamese normative database. RESULTS:In total, 149 eyes of 149 subjects were included. The mean age of enrollees was 60.77 (±11.09) years, with a mean spherical equivalent of +0.65 (±1.58) D and mean axial length of 23.4 (±0.87) mm. Average RNFL thickness was 97.86 (±9.19) µm and average macular GCIPL was 82.49 (±6.09) µm. Agreement between original and adjusted normative database for RNFL was fair for average and inferior quadrant (κ=0.25 and 0.2, respectively); and good for other quadrants (range, κ=0.63 to 0.73). For macular GCIPL κ agreement ranged between 0.39 and 0.69. After adjusting with the normative Vietnamese database, the percent of yellow and red color-codes increased significantly for peripapillary RNFL thickness. CONCLUSIONS:Vietnamese population has a thicker RNFL in comparison with Cirrus normative database. This leads to a poor color-code agreement in average and inferior quadrant between the original and adjusted database. These findings should encourage to create a peripapillary RNFL normative database for each ethnicity.

PURPOSE:To report the first case of Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser use to recanalize a CyPass occluded with a clot in the early postoperative follow-up.OBSERVATIONS:A 66 year-old woman with primary open angle glaucoma and cataract received combined cataract surgery plus CyPass in the right eye. Surgery was uneventful, however, there was a small amount of hyphema related to bleeding around the site of Cypass insertion. Intraocular pressure (IOP) was between 6 and 7 mmHg in the first week on no glaucoma medications. At the second postoperative week, IOP jumped to 30 mmHg and a clot was observed obstructing the CyPass lumen. We disrupted the clot with a single shot from a Nd:YAG laser. Twenty minutes after the laser, the IOP was 8 mmHg. CyPass was recanalized without complications. IOP was 11 mmHg at 1 month postoperatively with timolol 0.5% twice a day.CONCLUSIONS AND IMPORTANCE:It is important to perform gonioscopy to evaluate for CyPass obstruction in cases of IOP spike. Nd:YAG laser may be a useful approach to recanalize the CyPass in the early postoperative follow-up.

PURPOSE:This prospective study used anterior segment optical coherence tomography (AS-OCT) to determine how phacoemulsification (phaco) changes iris parameters in eyes with glaucoma or glaucoma suspect status. METHODS:Using Visante AS-OCT (Carl Zeiss Meditec AG), the following pre- and post-phaco parameters were measured: IT750 = iris thickness at 750 μm from the scleral spur; IT2000 = iris thickness 2000 μm from the scleral spur; ITCM = the maximum iris thickness at the middle one third of the iris; ICURV = iris curvature; IAREA = iris area; and pupil size = pupil diameter (mm). Only high-quality images with an identifiable scleral spur were included, and only the nasal quadrant was analyzed. A single glaucoma specialist analyzed the parameters according to the Zhongshan Angle Assessment Program (ZAAP, Guangzhou, China). Multivariate analysis was performed using mixed effects regression correcting for age, gender, and ethnicity. RESULTS:89 subjects and 110 eyes were included in this study. The mean age of subjects was 74.83 {+/-} 8.69 years old. Most common diagnoses were POAG and glaucoma suspect (23% and 52%, respectively), and 16% of subjects had an LPI. In multivariate analysis of AS-OCT parameters, decreases in IT750, IT2000, ITCM, ICURV, and pupil size were statistically significant (p<0.05). CONCLUSIONS:After phacoemulsification, eyes with glaucoma as well as glaucoma suspect eyes have thinner irises and smaller pupils. This may lead to less iris-mediated aqueous outflow obstruction, providing support for early phacoemulsification glaucoma treatment. TRANSLATIONAL RELEVANCE:Our AS-OCT imaging findings may guide clinical practice as iris parameters become increasingly relevant in preoperative phaco planning.

PURPOSE:To provide the reader with information on the principal techniques of optical coherence tomography angiography (OCTA); the current literature on OCTA reproducibility; its applications to glaucoma detection and monitoring of progression; and the role of OCTA in the assessment of the vascular component in glaucoma pathogenesis.METHODS:A literature review of the pertinent publications for the OCTA in relation to the development, techniques, and its use in glaucoma was carried out.RESULTS:Rapid improvements in optical coherence tomography (OCT) technology have allowed for enhancement of both image resolution and scanning speed, and the development of vascular assessment modality. OCTA is the non-invasive in vivo imaging of the vasculature located within the retina and optic nerve head area. The principle of OCTA is to use the variations in OCT signals caused by moving particles as the contrast mechanism for imaging of flow. Several algorithms which aim to maximize the contrast signal and minimize the noise have been developed including the phase-based techniques, intensity-based techniques (e.g., split-spectrum amplitude decorrelation angiography (SSADA)), and complex-based techniques (e.g., optical microangiography (OMAG)). With its reliable technique, high image resolution, and current availability, OCTA has been widely used in the assessment of posterior segment diseases including glaucoma in which ocular perfusion dysfunction has been proposed as a pathophysiological mechanism.CONCLUSION:OCTA may enhance our knowledge of glaucoma pathogenesis and offer an improvement in our ability to detect glaucomatous change.

The purpose of this study is to assess the relationship between self-reported uveitis and purported demographic and clinical risk factors, using an American adult population extracted from the National Health and Nutrition Examination Survey (NHANES) for the years 2009 and 2010. This is a cross-sectional, population-based study using a sample of 5106 subjects between 20 and 69 years old. The main outcome for our study was the self-report of a diagnosis of uveitis. The demographic analysis included age, gender, and ethnicity. Potential predictors were having a diagnosis of ankylosing spondylitis (AS), ulcerative colitis (UC), or Crohn’s disease (CD); a history of cigarette smoking; vitamin D deficiency; and different mental health measures. Univariate and multivariate analyses were conducted using RStudio.

Cataract extraction is a safe and effective surgery that has been performed in its modern form for several decades. Many studies have noted that cataract extraction could also have a clinically significant role in the control of comorbid glaucoma. Lens extraction decreases the pressure within the eye, and intraocular pressure (IOP) is the only controllable risk factor in glaucoma proven to be effective. A systematic analysis of current evidence is needed to establish strong practice patterns and identify areas where further research is required. We performed systematic review and meta-analysis of the clinical data to estimate the net effect of cataract surgery on IOP. A total of 37 treatment arms from 32 different studies from January 1997 to January 2017 were included. IOP reduction was highly correlated across follow-up periods. For angle-closure glaucoma, results showed an IOP decrease of -6.4 mmHg (95% CI: -9.4 to -3.4) at final follow-up (12 months and longer). For the open-angle glaucoma group, there was an overall IOP change of -2.7 mmHg (95% CI -3.7 to -1.7) from baseline. For pseudoexfoliation glaucoma further research is needed to reach an adequate evidence-based conclusion. The influence of inherent sources of bias, including loss to follow-up, washout and medication use, and lack of a control group, was evaluated numerically. These sources of bias pulled the IOP estimate in opposite directions and are therefore unlikely to affect the main conclusions substantially. Future prospective clinical trials, including other outcomes such as quality of life, clinical severity information, and cost-effectiveness analysis, are needed to determine the role of phacoemulsification alone within the glaucoma treatment algorithm. (C) 2017 Elsevier Inc. All rights reserved.

Purpose:The purpose of this article is to investigate the association between body mass index (BMI) and open-angle glaucoma (OAG) in a sample of the South Korean population.Materials and Methods:The sample consisted of a cross-sectional, population-based sample of 10,978 participants, 40 years of age and older, enrolled in the 2008 to 2011 Korean National Health and Nutrition Examination Survey. All participants had measured intraocular pressure <22mmHg and open anterior chamber angles. OAG was defined using disc and visual field criteria established by the International Society for Geographical and Epidemiological Ophthalmology. Multivariable analyses were performed to determine the association between BMI and OAG. These analyses were also performed in a sex-stratified and age-stratified manner.Results:After adjusting for potential confounding variables, lower BMI (<19kg/m(2)) was associated with greater risk of OAG compared with normal BMI (19 to 24.9kg/m(2)) [odds ratio (OR), 2.28; 95% confidence interval (CI), 1.22-4.26]. In sex-stratified analyses, low BMI remained adversely related to glaucoma in women (OR, 3.45; 95% CI, 1.42-8.38) but not in men (OR, 1.72; 95% CI, 0.71-4.20). In age-stratified analyses, lower BMI was adversely related to glaucoma among subjects 40- to 49-year old (OR, 5.16; 95% CI, 1.86-14.36) but differences in glaucoma prevalence were not statistically significant between those with low versus normal BMI in other age strata.Conclusions:Lower BMI was associated with increased odds of OAG in a sample of the South Korean population. Multivariate analysis revealed the association to be statistically significant in women and those in the youngest age stratum.