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Purpose: To determine the 5-year success rate for Baerveldt glaucoma implant (BGI) in patients who received the implant as a primary (primary BGI, used as the initial surgical procedure) or secondary (secondary BGI, used after trabeculectomy) by a single surgeon between year 1994 and 2010., Patients and Methods: A total of 117 eyes from patients who underwent BGI placement as a primary or secondary procedure were included in this study. Demographics, previous history, type of glaucoma, intraocular pressure (IOP), visual acuity (VA), glaucoma medication use, and early and late postoperative complications were collected. Postoperative data were collected at day 1, 30, 60, and every year until the last visit (minimum of 2 y). IOP was the main outcome measure. Secondary outcome measures included VA, glaucoma medication use, and early and late postoperative complications. Overall success rates were calculated for primary and secondary BGI using Kaplan-Meier survival analysis. Differences between survival curves were determined using log-rank test. Risk factors for success were defined by Cox proportional-hazards regression model., Results: At the 5-year follow-up, the overall success rates (determined as IOP between 6 and 21 mm Hg) in the primary and secondary BGI were 58% (49/79) and 53% (20/38), respectively (P=0.56). The overall success rate dropped by an average 10% and 13% per year for the primary and secondary BGI groups, respectively (P=0.05). The complete success rates at the 5-year follow-up for primary and secondary BGI were 24% (19/79) and 13% (5/38), respectively, whereas the qualified success rates were 34% (27/79) and 39% (15/38), respectively. There was a significant decrease in IOP [from 31.23 (±9.51) to 12.86 (±4.84) mm Hg (P<0.001) for the primary BGI group, and from 26.35 (±7.22) to 13.92 (±5.90) mm Hg (P<0.001) for the secondary BGI group]. There was also a significant drop in medication use but a significant worsening in VA in both groups (P<0.05) likely from cataract. The difference in the incidence of postoperative complications was not statistically significant between the groups., Conclusions: Although, the success rates were similar for the primary and secondary BGI at the 5-year follow-up, the drop in the success rate per year was significantly higher in the secondary BGI group. In contrast, both procedures had similar incidence of postoperative complications.

Impervious encapsulation around Ahmed glaucoma valve (AGV) results in surgical failure raising intraocular pressure (IOP). Dysregulation of extracellular matrix (ECM) molecules and cellular factors might contribute to increased hydraulic resistance to aqueous drainage. Therefore, we examined these molecules in failed AGV capsular tissue. Immunostaining for ECM molecules (collagen I, collagen III, decorin, lumican, chondroitin sulfate, aggrecan and keratan sulfate) and cellular factors (αSMA and TGFβ) was performed on excised capsules from failed AGVs and control tenon's tissue. Staining intensity of ECM molecules was assessed using Image J. Cellular factors were assessed based on positive cell counts. Histopathologically two distinct layers were visible in capsules. The inner layer (proximal to the AGV) showed significant decrease in most ECM molecules compared to outer layer. Furthermore, collagen III (p = 0.004), decorin (p = 0.02), lumican (p = 0.01) and chondroitin sulfate (p = 0.02) was significantly less in inner layer compared to tenon's tissue. Outer layer labelling however was similar to control tenon's for most ECM molecules. Significantly increased cellular expression of αSMA (p = 0.02) and TGFβ (p = 0.008) was detected within capsular tissue compared to controls. Our results suggest profibrotic activity indicated by increased αSMA and TGFβ expression and decreased expression of proteoglycan (decorin and lumican) and glycosaminoglycans (chondroitin sulfate). Additionally, we observed decreased collagen III which might reflect increased myofibroblast contractility when coupled with increased TGFβ and αSMA expression. Together these events lead to tissue dysfunction potentially resulting in hydraulic resistance that may affect aqueous flow through the capsular wall.

Purpose: Encapsulation of the Ahmed glaucoma valve (AGV) plate is a common cause for postoperative elevation of intraocular pressure, especially in children. Many reports have described the outcomes of AGV revision in adults. However, the outcomes of AGV revision in children are poorly documented. The aim of this study was to determine the outcomes of AGV revision in children., Design: Retrospective cross-sectional study., Methods: A retrospective chart review of patients less than 15 years of age who underwent AGV revision with a minimum postoperative follow-up of 6 months was conducted. Outcome measures included reduction in intraocular pressure from baseline, survival analysis, and reduction in the number of antiglaucoma medications. Postoperative complications were also noted. Complete success was defined as an IOP of 21 mm Hg or less without medications, while qualified success was defined as having an IOP of 21 mm Hg or less with medications., Results: A total of 44 eyes met the inclusion criteria. Primary congenital glaucoma was present in 39 eyes (88.6%), aphakic glaucoma in 4 eyes (9.1%), and Peters anomaly-associated glaucoma in 1 eye (2.3%). The mean number of previous surgeries was 1.4, and the mean age was 6.7 years (range, 1.9-13 years) with a median follow-up of 12 months (range, 6-24 months). The IOP was reduced from a preoperative mean of 30.4 (± 10.3) to 24.9 (± 10.6) mm Hg at 6 months postoperatively. Kaplan-Meier analysis showed that the complete success rate at 1 month was 100% followed by a rapid decline at 6 months to 38.6%, 27.7% at 1 year, and 5.5% at 2 years. Qualified success rate was 100% at 1 month followed by a 6-month and 1-year survival rate of approximately 50% and a 2-year survival rate of approximately 16%. The median survival time was 14 months. No specific risk factors for failure were identified. Visual acuity remained unchanged following revision. The most common complication was recurrence of encapsulation with elevated IOP (15.9%). Other complications included hyphema (n = 3; 6.8%), endophthalmitis (n = 1; 2.3%), wound leak (n = 1; 2.3%), and choroidal detachment (n = 2; 4.5%)., Conclusion: Although the short-term success rate of AGV revision in children is high, with longer follow-up the success rate decreases significantly., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: The aim is to present the incidence and determinants of neovascular glaucoma (NVG) in Saudi Arabia., Methods: A retrospective review of NVG cases (2002-2012) was included to estimate the incidence. The determinants included gender, age, comorbidities, lens status, type of NVG, and visual acuity on presentation. The impact of antiangiogenic therapy on NVG incidence was studied., Results: We studied 597 eyes with NVG. The incidence was 6.6/10,000. It declined from 13/10,000 in 2008-0.1/10,000 in 2012 (P < 0.001). The decline in 2008 coincided with the introduction of intravitreal injection bevacizumab in Saudi Arabia. Males had a significantly higher NVG risk (odds ratio [OR] = 2.2). Diabetes and hypertension were associated with NVG in 88% and 42.7% of cases, respectively. In 377 (72%) diabetic patients, the glycemic control was poor (HbA1C >7%). Visual acuity was 20/20-20/40 in 14 (2%), 20/50-20/200 in 79 (13%), 20/200-20/400 in 456 (76%), and <20/400 in 45 (7%) eyes. Intraocular pressure was higher than 30 mmHg in 438 (73%) eyes. The cup-to-disc (CD) ratio was >0.8 in 86 (14%) eyes. During the early period (2002-2007) and later period (2008-2012), CD ratio (χ2 = 4, P = 0.09) and anterior chamber angle (P = 0.8) were not different. The presence of NVG in contralateral eye (OR = 0.8, P = 0.3) in both periods was similar., Conclusions: NVG was associated with diabetes in a very large proportion of patients. It was significantly associated with males, and with poor glycemic control and poor vision at presentation. The incidence of NVG declined after the introduction of intravitreal bevacizumab.

Introduction: Glaucoma is a collection of optic neuropathies consisting of retinal ganglion cell death and corresponding visual field loss. Glaucoma is the leading cause of irreversible vision loss worldwide and is forecasted to precipitously increase in prevalence in the coming decades. Current treatment options aim to lower intraocular pressure (IOP) via topical or oral therapy, laser treatment to the trabecular meshwork or ciliary body, and incisional surgery. Despite increasing use of trabecular laser therapy, topical therapy remains first-line in the treatment of most forms of glaucoma. Areas covered: Novel glaucoma therapies are a long-standing focus of investigational study. More than two decades have passed since the last United States Food and Drug Administration (FDA) approval of a topical glaucoma drug. Here, the authors review established topical glaucoma drops as well as those currently in FDA phase 2 and 3 clinical trial, nearing clinical use. Expert opinion: Current investigational glaucoma drugs lower IOP, mainly through enhanced trabecular meshwork outflow. Although few emerging therapies show evidence of retinal ganglion cell and optic nerve neuroprotection in animal models, emerging drugs are focused on lowering IOP, similar to established medicines.

Purpose: The purpose of this study was to compare outcomes of transscleral diode cyclophotocoagulation using short duration (SD) versus longer duration (LD) treatment., Patients and Methods: Data were collected retrospectively on patients with glaucoma who underwent cyclophotocoagulation with LD (4000 ms) treatment with variable power ≤1000 mW versus SD using 1500 ms with variable power ≤2000 mW. The outcome measures included: intraocular pressure (IOP) at 12 months, decrease in number of antiglaucoma medications, complications and visual acuity (VA) at the final follow-up visit., Results: There were 71 patients and 70 patients in the SD and LD groups, respectively. The mean IOP±SD pretreatment baseline was 33±10 versus 36±10 mm Hg for SD and LD groups, respectively (P>0.05). At 1 year postoperatively, the IOP decreased significantly in both groups (16.7 vs. 17.4 mm Hg for SD and LD, respectively; P<0.0001). This decrease in IOP was comparable between groups (P=0.5). The average number of IOP lowering medications were 2.5 and 2.9 at baseline in the SD and LD groups, respectively, and decreased to 1.3 in both groups (P=0.83). The mean LogMAR VA decreased significantly from 1.87 at baseline to 1.96 at 1 year in the SD group (P=0.276), and 2.03 to 2.3 (P≤0.001) in the LD group, this change was comparable (0.19; P=0.075) between the 2 groups. Complications were also comparable., Conclusions: Both LD and SD burns during cyclophotocoagulation effectively lowered IOP at 1 year. Neither treatment resulted in a greater reduction of IOP. LD treatment appeared to result in a decrease in VA and greater postoperative inflammation.

The purpose of this study is to present the causes and visual acuity outcomes in patients with elevated intraocular pressure (IOP) following implantable collamer lens (ICL) implantation. A chart review identified patients who developed high IOP at any postoperative examination and a minimum follow-up period of 3 months after ICL implantation. Data are reported out to 6 months postoperatively. Outcome measures included causes of elevated IOP, best-corrected visual acuity (BCVA) at last visit, number of glaucoma medications, other interventions, and glaucomatous damage. Elevated IOP occurred in 58 (10.8 %) of 534 eyes that received ICL. The mean age was 28 ± 7.2 years. The preoperative IOP was 16.3 ± 1.2 mmHg. Elevated IOP most commonly occurred on the first postoperative day (23/58 (39.7 %) eyes) due to retained viscoelastic. This was followed by steroid response in 22/58 (37.9 %) eyes at 2-4 weeks postoperatively. IOP elevation in 6 (10.3 %) eyes was related to high ICL vault and pupillary block, and in 4 (6.9 %) eyes due to synechial angle closure. At last visit, BCVA was 20/40 or better in 56/58 (96.6 %) eyes, and 5/58 (8.6 %) eyes remained on glaucoma medications due to persistent steroid response (2 eyes), synechial angle closure glaucoma (1 eye), and other causes (2 eyes). One eye showed glaucomatous damage. Two eyes with high vault and elevated IOP underwent ICL explantation. There is a moderate risk of transiently developing elevated IOP after ICL implantation. Thorough removal of viscoelastic and use of anti-glaucoma medications during steroid use will reduce the majority of cases with postoperative IOP elevation.

Purpose: To compare intraocular pressure (IOP) measurements by rebound tonometry (Icare PRO; Icare Finland Oy, Helsinki, Finland) to measurements by indentation tonometry (Pneumotonometer Model 30 classic and Tono-Pen XL; Reichert, Buffalo, NY, USA) in supine sedated children with glaucoma., Methods: Prospective comparative observational study of Saudi Arabian children with glaucoma undergoing chloral hydrate sedation for ophthalmic examination (February 2012 - February 2013). Nonglaucomatous eyes were included as controls. Eyes with corneal scars or prior corneal transplant or lamellar surgery were excluded., Results: Fifty-two eyes (26 OD, 26 OS) of 28 children were included. Thirty-six eyes had glaucoma (32 primary congenital glaucoma, two Sturge-Weber related, and two aphakia related). Sixteen eyes did not have glaucoma (six with pediatric cataract, five normal eyes, two strabismic eyes, two eyes with simple megalocornea, and one eye had peripheral corneal laceration repair. In the glaucoma group, the mean IOP was 17.55 ± 5.97 mmHg (range, 8-31.5 mmHg) with the Icare PRO and 20 ± 6.4 mmHg (range, 8-35.5 mmHg) with the Pneumotonometer from 20.47 ± 6.81 mmHg (range, 10-43 mmHg) with the Tono-Pen XL. The Icare PRO readings were significantly lower than each of the indentation tonometers. For the control group, there was no statistically significant difference in IOP measured by the Icare PRO and the indentation tonometers., Conclusions: In this population of supine sedated children with glaucoma, IOP measurements with the Icare PRO tend to be lower than readings from the Pneumotonometer and Tono-Pen XL.

Purpose: To evaluate changes in intraocular pressure (IOP), vision, and medications at least 1 year after phacoemulsification combined with endocyclophotocoagulation for advanced glaucoma and cataract., Methods: A retrospective chart review was conducted on patients with advanced glaucoma who underwent phacoemulsification combined with endocyclophotocoagulation at King Khaled Eye Specialist Hospital between 2005 and 2012. Data were collected on patient demographics, type of glaucoma, IOP over time, best-corrected visual acuity, number of glaucoma medications, comorbidities, and previous surgeries. Absolute success was defined as IOP≤15 mm Hg without medication and qualified success was IOP≤15 mm Hg with medications. Statistical significance was indicated by P<0.05., Results: The study sample comprised 104 eyes (104 patients). Mean follow-up was 17.3±1.8 months. Mean IOP decreased from 17±1.4 mm Hg preoperatively to 14.7±1.3 mm Hg at the last postoperative visit. Absolute success was achieved in 11.9% (95% confidence interval, 5.6-18.2) of the eyes. Qualified success was achieved in 72.3% (95% confidence interval, 63.5-81.0) of the eyes. Best-corrected visual acuity improved by ≥2 lines in 76 (73%) eyes. Eyes with primary open-angle glaucoma had the higher absolute and qualified success rates compared with primary angle-closure and pseudoexfoliation glaucoma (P>0.05). Only 48 (46%) patients required >3 medications for IOP control compared with 78 (75%) patients before surgery., Conclusions: At ≥1 year postoperatively, the absolute success rate of treating advanced glaucoma by endocyclophotocoagulation and phacoemulsification was low. However, medication burden was reduced. Owing to the significant variation in the success rate based on the type of glaucoma, patients with advanced glaucoma should be carefully selected and counseled.

Purpose: To study the relationship of ocular pulse amplitude (OPA) and intraocular pressure (IOP) in eyes that have undergone successful Descemet stripping endothelial keratoplasty (DSEK)., Patients and Methods: Fifty eyes of 38 patients with successful DSEK at a single tertiary referral center were followed up for at least 3 months. At the time of the study all patients were carefully examined to rule out any clinically detectable corneal edema. IOP was measured by Goldmann applanation tonometry (GAT), pneumotonometry (PT), and dynamic contour tonometry (DCT). IOP, OPA, and quality measurements were recorded. Central corneal thickness (CCT) was measured by ultrasonic pachymetry., Results: Mean IOP was 15.9±4.9 mm Hg by GAT, 20.3±4.6 mm Hg by PT, and 19.8±4.4 mm Hg by DCT. Mean OPA was 2.53±1.24 mm Hg. OPA was correlated with GAT (r=0.357, P=0.011) and PT (r=0.316, P=0.026). The correlation of OPA and DCT approached significance (r=0.270, P=0.058). Mean CCT was 701±65 µm (range, 529 to 928 µm). OPA was not associated with CCT (r=0.238, P=0.096)., Conclusions: In eyes with DSEK, our results showed that OPA was similar to that reported in normal eyes. Comparable with results in normal eyes, OPA was not associated with CCT but was associated with increasing IOP in DSEK eyes.

Purpose: To compare the demographic and clinical distribution of primary and secondary congenital glaucoma from a registry at King Khaled Eye Specialist Hospital., Design: Registry-based cohort study., Methods: Review of registry data that included new patients with congenital glaucoma seen between 2001 and 2003 (29 months); analysis of the demographic data and clinical features of primary and secondary congenital glaucoma at presentation., Results: A total of 325 eyes of 180 patients were included. Most patients had primary congenital glaucoma (80%). The mean (± SD) age at presentation for primary congenital glaucoma was 3.8 ± 10.7 months and for secondary congenital glaucoma was 4.3 ± 7.9 months. Most primary congenital glaucoma and secondary congenital glaucoma patients had bilateral disease (82.6%; 74.3%). Primary congenital glaucoma was equally distributed by sex but secondary congenital glaucoma was 1.5-fold more common in male patients. A positive family history was elicited in 30%, and almost 60% had a history of consanguinity in both groups. The mean intraocular pressure and corneal diameter were comparable in both groups but the axial length was significantly longer in primary congenital glaucoma and cup-to-disc (C/D) ratio greater in secondary congenital glaucoma. In the primary congenital glaucoma group, corneal haze showed a significant relationship with most clinical parameters. In primary congenital glaucoma, a positive correlation was noted between age at presentation and increasing corneal diameter and axial length but a negative relationship was noted with C/D ratio and corneal haze, whereas for secondary congenital glaucoma only axial length was positively correlated., Conclusion: The congenital glaucoma registry provides unique baseline data on primary congenital glaucoma and secondary congenital glaucoma in Saudi Arabia that will enable us to better understand the disease in the Kingdom and region., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: (1) To characterize the pattern of intraocular pressure (IOP) changes after Descemet's stripping endothelial keratoplasty (DSEK) in patients without preexisting glaucoma and in those with preexisting glaucoma, with and without prior glaucoma surgery. (2) To compare vision and IOP outcomes among the 3 groups., Design: A retrospective chart review., Participants: A total of 805 DSEK cases performed in 641 patients by a single surgeon from December 2003 to August 2007 were available in the database. Only the first-treated eye of each patient with at least 1-year follow-up was included. Four hundred cases qualified: 315 eyes had no glaucoma (C); 64 eyes had glaucoma with no previous glaucoma surgery (G); and 21 eyes had prior glaucoma surgery (GS). Eyes with preexisting retinal problems were included in the analysis., Methods: Data analysis included calculation of incidence of postoperative IOP elevation. The study criteria for postoperative IOP elevation were IOP > or =24 mmHg or IOP increase > or =10 mmHg from baseline. Kruskal-Wallis test was used to compare visual acuity (VA) and IOP among the 3 groups preoperatively and at 1-, 3-, 6-, and 12-month postoperative visits., Main Outcome Measures: Visual acuity (Snellen) and IOP (millimeters of mercury)., Results: The incidence of postoperative IOP elevation by the study criteria was 35%, 45%, and 43% for groups C, G, and GS, respectively. Elevated IOP was medically managed by initiating or increasing glaucoma medications or reducing steroids in 27%, 44%, and 38% of the patients in groups C, G, and GS, respectively. A subsequent glaucoma procedure was performed in 0.3%, 5%, and 19% of patients in groups C, G, and GS, respectively. Only the control group had statistically significant IOP elevation at 12 months (median increase of 2 mmHg) when compared with baseline (P<0.0001). All 3 groups had statistically significant improvement in vision at 12 months when compared with baseline (12-month median VA = 20/40 for C and G; and 20/50 for GS, P<0.0001)., Conclusions: All groups had a substantial incidence of IOP elevation after DSEK. Close monitoring of IOP is warranted. In this cohort, preexisting glaucoma did not seem to have a negative effect on VA after DSEK., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Purpose: The effect of increased corneal thickness after Descemet stripping endothelial keratoplasty (DSEK) on intraocular pressure (IOP) measurement has not been previously studied. It is uncertain if this increase in corneal thickness would artificially elevate IOP reading by Goldmann tonometry [GAT] (Haag-Streit, Konig, Switzerland). Therefore the effect of DSEK-related thick cornea on IOP measurement was investigated using three different techniques., Design: Prospective cross-sectional study., Methods: Participants were recruited from a single tertiary referral center. Fifty eyes of 38 patients with successful DSEK at least three months prior to testing were evaluated. At the time of the study, none of the participants had clinically detectable corneal edema. IOP was measured with GAT, pneumatonometry, and dynamic contour tonometry (DCT) in an unmasked randomized sequence. Central corneal thickness (CCT) was measured by ultrasonic pachymetry., Results: Mean CCT was 701 +/- 68 microm. The mean IOP +/- standard deviation (SD) was 15.9 +/- 4.9 mm Hg for GAT, 20.3 +/- 4.5 mm Hg for pneumatonometry, and 19.8 +/- 4.4 mm Hg for DCT. Pneumatonometry and DCT IOP measurements were significant higher than GAT (P < .01). In contrast, the difference between pneumatonometry and DCT readings was not statistically significant (P = .28). The correlations between IOP and corneal thickness were not significant in this cohort (P > .05)., Conclusions: Falsely elevated GAT, as expected in thick corneas, was not demonstrated after DSEK. High IOP reading by GAT therefore should raise suspicion of elevated IOP in DSEK eyes.

Purpose: To investigate brimonidine-related side effects and the efficacy of brimonidine in lowering intraocular pressure (IOP) in children with primary infantile and secondary glaucoma., Study Design: Single-center, prospective, interventional, noncomparative case series., Participants: Eighty-three children (mean age, 7.84 years) met the inclusion criteria., Methods: Medical records were reviewed to identify children with primary infantile or other forms of secondary pediatric glaucoma from birth to 15 years who received brimonidine as adjunctive therapy for glaucoma. The parents of the children who met the inclusion criteria completed a detailed questionnaire-based interview. The children were examined to assess weight, major systemic effects, and efficacy of adjunctive brimonidine therapy., Main Outcome Measures: Questionnaire-based interview of parents to assess side effects of brimonidine and IOP-lowering effect of adjunctive brimonidine., Results: Parents reported symptoms in 70 of 83 children (84%). The most common side effects were excessive sleepiness and lethargy (76%), eye itching and rubbing (49%), and stinging and burning of the eyes (39%). Logistic regression analysis showed a statistically significant independent association between age and weight with lethargy and sleepiness. In symptomatic patients, symptoms' frequency increased with low weight (<20 kg) and in the young (<6 years). Mean IOP reduction after initiation of brimonidine, mainly as an adjunct, was 5+/-6.7 mmHg (P<0.001)., Conclusions: Side effects after the use of brimonidine in children were frequent. The weight and age of the child were important factors in predicting central nervous system side effects, especially excessive sleepiness and lethargy. Although brimonidine is effective in lowering IOP in children, alternative glaucoma therapy should be considered especially in children weighing <20 kg and those younger than 6 years.

Purpose: To discuss a case in which melanocytoma of the ciliary body presented with widespread pigment dispersion and elevated intraocular pressure (IOP)., Methods: A 64-year old woman presented with increased IOP and persistent anterior segment inflammation in her right eye. She had undergone a trabeculectomy for uncontrolled IOP before presentation. Slit-lamp examination, gonioscopy, and ultrasound biomicroscopy revealed a ciliary body mass with extension into the subconjunctiva in addition to widespread pigmentary dispersion in the anterior segment. Enucleation of the right eye was performed for histopathologic evaluation, as a diagnosis of ciliary body melanoma was made on clinical examination., Results: Histopathologic findings were diagnostic of a melanocytoma of the ciliary body with necrosis and focal malignant transformation with extension of melanocytoma cells and melanophages into the subconjunctival space, trabecular meshwork, and anterior chamber angle., Conclusion: Melanocytoma of the ciliary body is a rare intraocular tumor that may present with pigment dispersion and secondary elevated IOP. Careful examination of the anterior segment is imperative in such cases.