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AIM: To report short-term outcomes of mitomycin C-augmented excisional bleb revision with capsulectomy (ERC) after Ahmed glaucoma valve (AGV) failure. METHODS: Patients who underwent ERC procedures between January 2017 and December 2019 with a minimum follow-up of 6mo were evaluated retrospectively for indications of AGV and AGV implantation to ERC interval. The number of anti-glaucoma medications (AGMs), intraocular pressure (IOP) and best corrected visual acuity (BCVA) were recorded at baseline, 1, 7, 30, 90, and 180d. Intra- and postoperative complications were also recorded. Positive outcome was defined as IOP≤21 mm Hg with or without AGMs. RESULTS: Fourteen eyes [14 patients, median age 69.5y, interquartile range (IQR) 61.3-80] were included. Pseudoexfoliative glaucoma (n=5, 36%) was the most common form of glaucoma. The median AGV implantation to ERC interval was 8.8mo (IQR 3.91-43.67). At 6mo, the median number of AGMs decreased from 3.0 (IQR 3.0-4.0) to 2.0 (IQR 1.5-3), the median IOP decreased from 26 mm Hg (IQR 22-29) to 16.5 mm Hg (IQR 13.75-20) and there was no significant change in BCVA. The success rate at 6mo was 92.9%. The Kaplan-Meier cumulative probability of survival was 93%, 79%, 64%, and 64% at 1wk, and 1, 3, and 6mo, respectively. No intraoperative complications were identified. Postoperative complications were identified in 5 eyes (36%), which were resolved spontaneously during the first week following ERC. CONCLUSION: ERC has a high success rate for short-term management of AGV failure. A longer follow-up study is required to determine long-term cumulative failure rates.

PurposeTo investigate the effect of change in body mass index (BMI) on intraocular pressure (IOP) in a large cohort of apparently healthy volunteers who underwent an annual comprehensive screening examinations.MethodsThis study included individuals who were enrolled in the Tel Aviv Medical Center Inflammation Survey (TAMCIS) and had IOP and BMI measurements at their baseline and follow up visits. Relationships between BMI and IOP and the effect of change in BMI on IOP were investigated.ResultsA total of 7,782 individuals had at least one IOP measurement at their baseline visit, and 2,985 individuals had ≥2 visits recorded. The mean (SD) IOP (right eye) was 14.6 (2.5) mm Hg and mean (SD) BMI was 26.4 (4.1) kg/m2. IOP positively correlated with BMI levels (r = 0.16, pConclusionsBMI loss correlated with reduction in IOP, and this correlation was more pronounced among morbidly obese individuals.

Abstract Background Diabetic retinopathy (DR) is a significant global public health and economic burden. DR accounts for approximately 15–17% of all cases of total blindness in the USA and Europe. Telemedicine is a new intervention for DR screening, however, there is not enough evidence to support its cost-effectiveness. The aim of this study is to review the most recent published literature on economic evaluations of telemedicine in DR screening and summarize the evidence on the cost-effectiveness of this technology. Methods A systematic search of PubMed, Embase and Google Scholar for relevant articles published between January 2010 and January 2020. Studies were included if they met the following criteria: (1) recruited subjects with either type 1, type 2 diabetes (2) evaluated telemedicine technology (3) patients underwent primary screening for DR (4) compared a telemedicine-based intervention with standard care (5) performed an economic evaluation or provided sufficient data for evaluating the cost-effectiveness of the technology used. Results Of 2238 articles screened, seven studies were included. Four of the studies were conducted in developed countries: The United States, Singapore and two studies in Canada. Three studies were conducted in developing countries: India, Brazil and South Africa. The patient populations in all studies were diabetic patients over the age of 18, previously not screened for DR. All seven studies used a telemedicine program which included capturing a retinal image and subsequently transmitting it to an ocular imaging center to assess the severity of DR. All studies compared telemedicine to a standard screening method for DR, including the option of no screening as standard of care. Although telemedicine requires initial and maintenance costs, it has the potential to provide significant cost savings by increasing patients’ working ability, increasing independent living ability, increasing quality of life and reducing travel costs. Conclusions Diabetic retinopathy telemedicine technology has the potential to provide significant cost savings, especially in low-income populations and rural patients with high transportation costs.

AIM: To validate the ability of the Heidelberg Edge Perimeter (HEP) in detecting glaucomatous visual field (VF) defects compared to the Octopus Visual Field (OVF) Analyzer and to determine the test-retest repeatability of both modalities. METHODS: This prospective, cross-sectional study was conducted at Wills Eye Hospital, Philadelphia, PA. Glaucoma subjects and unaffected controls underwent VF testing using HEP standard automated perimetry (SAP) III 30-2 Adaptive Staircase Thresholding Algorithm (ASTA) FAST protocol and OVF G-TOP white-on-white strategy. Testing order was randomized. Pearson’s correlation coefficient was calculated for both mean deviation (MD) and pattern standard deviation/square root of loss of variance (PSD/sLV). Receiver operating characteristic (ROC) curves were used to determine the diagnostic abilities of both modalities. Glaucoma subjects returned for repeat testing and intraclass correlation coefficients (ICCs) were calculated to assess test-retest repeatability. RESULTS: Seventy-nine subjects with glaucoma and 36 unaffected controls were enrolled. HEP and OVF were significantly correlated for both MD (r=-0.84; P

Purpose: We compare the prevalence of glaucoma in professional wind versus non-wind instrument players in the Philadelphia Orchestra. Visual field changes in individuals with glaucoma and glaucoma suspects were evaluated, and the results were correlated with cumulative practice time. Methods: In this cross-sectional, observational study, fifty-one Philadelphia Orchestra musicians were enrolled and categorized as wind or non-wind instrument players. All study participants underwent screening fundus photography. Participants with optic discs suspicious for glaucoma underwent further evaluation, including standard automated visual field perimetry and a comprehensive eye examination by a glaucoma specialist. Results: Of the 51 musicians enrolled, 9 of the 21 wind instrument players (43%) and 8 of the 30 non-wind instrument players (27%) were suspected of developing glaucoma in at least one eye (P = 0.25), with examinations performed on 12 of the 17 returning musicians (71%) for further confirmation. Wind instrument players exhibited significantly higher Octopus visual field mean defect scores (1.08 ± 1.5 dB) than non-wind instrument players (−0.43 ± 0.7 dB; P < 0.001). There was a significant association between cumulative hours playing wind instruments and visual field mean defect (P < 0.001). Conclusion: Among members of the Philadelphia Orchestra, the difference in prevalence of glaucoma suspicious optic discs between wind and non-wind instrument players was not significant. The clinical significance of the greater visual field mean defect found in wind instrument players, and the association between the degree of visual field mean defect and the cumulative practice-time of playing wind instruments, needs further investigation.

AIM: To describe a novel technique of creating a landing strip within the trabecular meshwork to guide trabecular micro-bypass stent (iStent) implantation in patients who underwent phacoemulsification. METHODS: Thirty-four eyes from 30 patients who underwent iStent implantation after phacoemulsification from May 2014 to February 2015 were included in our retrospective study. All iStents were implanted via the “landing strip” technique. A 25-gauge microvitreoretinal blade was used to bisect the trabecular meshwork to less than 1 clock-hour, effectively creating a landing strip. The iStent applicator was pressed along the landing strip and then the stent was released into the trabecular meshwork. RESULTS: Of the 34 eyes with iStent implantation, 27 (79.4%) eyes had primary open-angle glaucoma, 6 (17.6%) eyes had pseudoexfoliation glaucoma, and 1 (2.9%) eye had ocular hypertension. At 6-month follow-up (n=17), the mean number of hypotensive medications decreased from 2.2±1.2 at baseline to 0.8±1.3 (P=0.05) and mean intraocular pressure decreased from 19.7±4.1 mm Hg at baseline to 16.7±2.1 mm Hg (P=0.58). Two eyes (5.9%) required subsequent trabeculectomy. CONCLUSION: The “landing strip” technique appears to be an effective way to assist with iStent implantation.

AIM:To determine the long-term effects of selective laser trabeculoplasty (SLT) on intraocular pressure (IOP) and the number of medications used up to 5y following treatment in glaucoma patients receiving maximally tolerated medical therapy (MTMT).METHODS:The Wills Eye Hospital Glaucoma Research Center retrospectively reviewed the charts of glaucoma patients who underwent SLT after receiving MTMT. Eyes that did not achieve their target pressure within 3mo following SLT were excluded from the study. Changes in mean IOP and number of glaucoma medications used were analyzed at 1, 3, and 5y following SLT.RESULTS:Seventy-five eyes of 67 patients were included in the study. Fifteen eyes that received SLT failed to achieve their target pressure within 3mo and were excluded from the study. The average follow-up time was 37.4mo (±14.4). Mean IOP was significantly reduced 1y after treatment (P=0.005). It was also reduced 3, 5y after treatment without reaching statistical significance (P=0.20 and P=0.072, respectively). There was a significant decrease in mean number of medications used 1, 3, 5y after treatment (PPP=0.039, respectively). In the span of 5y, 2 eyes (2.7%) underwent repeat SLT, 7 eyes (9.3%) underwent glaucoma surgery and an additional 3 eyes (4.0%) underwent both.CONCLUSION:SLT significantly reduced the number of glaucoma medications used 5y following treatment in glaucoma patients receiving MTMT. SLT may delay operating-room surgery.

Abstract Background Over the past 50 years, there has been a decline in the number of physicians pursuing careers in clinical research. In ophthalmology, the need for clinician-investigators continues to grow with the increasing eye-care demands of the aging population. Expert panels have recommended exposing medical students early in their training to structured, didactic curricula with clinical research experience and mentoring opportunities. Methods To address this need, the Department of Research, Wills Eye Hospital, developed an 8-week Clinical Vision Research Training and Mentoring Program for undergraduate and medical students. The curriculum included an 11-hour lecture series on topics in research methods in ophthalmology and a 10-hour scientific writing workshop series. The program also involved hands-on participation in vision research projects and shadowing in one of Wills' subspecialty services. Students completed 40-question pre- and posttests on ophthalmology and research methodology. Scores were analyzed using a paired-sample t-test. The program also utilized a satisfaction survey. Results During 2014 and 2015, a total of 34 students out of 56 applicants were accepted to the Clinical Vision Research Training and Mentoring Program. Students scored significantly higher on the posttest (mean [M] = 79.78%, standard deviation [SD] = 6.25) than on the pretest (M = 71.43%, SD = 8.43); p< 0.001. Using a satisfaction survey, students strongly agreed that they were satisfied with the program and that the lecture series and manuscript writing workshops enhanced their learning. Conclusions The Wills Eye Clinical Vision Research Training and Mentoring Program provided an evidence-based foundation in research methods and manuscript development for students interested in careers in ophthalmology. Students emerged with clinical research skills and an increased understanding and appreciation of vision research. Results of the pre- and posttest analysis indicate that lecture material supplemented with hands-on experience can lead to better understanding of ophthalmology. This pilot program can serve as a research training and mentoring model for ophthalmology and other medical and surgical specialties.

Due to the high rates of complications and failure experienced with current glaucoma procedures, there is a continuous search for a safer and more effective glaucoma surgery. A new class of procedures termed minimally invasive glaucoma surgeries (MIGS) aim to fill this void by offering an alternative method of IOP reduction associated with markedly reduced complication rates and shorter recovery times. The iStent, a trabecular microbypass stent, is a MIGS device that has quickly gained popularity. The device allows aqueous humor to directly drain from the anterior chamber into Schlemm’s canal by bypassing an obstructed trabecular meshwork. This review examines publications about the iStent, focusing on the device’s efficacy, safety, and cost when a single iStent or multiple iStents are implanted in combination with cataract surgery or as a solo procedure. Current data suggest that the iStent is a safe and effective tool in the management of mild-to-moderate glaucoma, notable for its limited complications and absence of serious adverse events following implantation. As valuable experience is gained performing ab interno MIGS, increasing familiarity with angle anatomy and iStent placement, and as newer stent designs are developed, there is promise of continual improvement in the surgical management of glaucoma.