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The circumpapillary retinal nerve fiber layer (RNFL) thickness was assessed by spectral domain optical coherent tomography (SD-OCT) before and after surgical reduction of intraocular pressure in an eye with primary infantile glaucoma. In this case, a postoperative reduction of cupping and a subsequent increase in neuroretinal rim area is associated with a paradoxical thinning of the RNFL. This is the first-known characterization of cupping reversal using SD-OCT. [ABSTRACT FROM AUTHOR]

: PurposeTo determine the organ at risk and the maximum tolerated dose (MTD) of radiation that could be delivered to lung cancer using small-volume, image-guided radiotherapy (IGRT) using hypofractionated, coplanar, and noncoplanar multiple fields.: Methods and materialsPatients with measurable lung cancer (except small-cell lung cancer) 6 cm or less in diameter for whom surgery was not indicated were eligible for this study. Internal target volume was determined using averaged CT under normal breathing, and for patients with large respiratory motion, using two additional CT scans with breath-holding at the expiratory and inspiratory phases in the same table position. Patients were localized at the isocenter after three-dimensional treatment planning. Their setup was corrected by comparing two linacographies that were orthogonal at the isocenter with corresponding digitally reconstructed images. Megavoltage X-rays using noncoplanar multiple static ports or arcs were used to cover the parenchymal tumor mass. Prophylactic nodal irradiation was not performed. The radiation dose was started at 60 Gy in 8 fractions over 2 weeks (60 Gy/8 Fr/2 weeks) for peripheral lesions 3.0 cm or less, and at 48 Gy/8 Fr/2 weeks at the isocenter for central lesions or tumors more than 3.0 cm at their greatest dimension.: ResultsFifty-seven lesions in 45 patients were treated. Tumor size ranged from 0.6 to 6.0 cm, with a median of 2.6 cm. Using the starting dose, 1 patient with a central lesion died of a radiation-induced ulcer in the esophagus after receiving 48 Gy/8 Fr at isocenter. Although the contour of esophagus received 80% or less of the prescribed dose in the planning, recontouring of esophagus in retrospective review revealed that 1 cc of esophagus might have received 42.5 Gy, with the maximum dose of 50.5 Gy. One patient with a peripheral lesion experienced Grade 2 pain at the internal chest wall or visceral pleura after receiving 54 Gy/8 Fr. No adverse respiratory reaction was noted in the symptoms or respiratory function tests. The 3-year local control rate was 80.4% ± 7.1% (a standard error) with a median follow-up period of 17 months for survivors. Because of the Grade 5 toxicity, we have halted this Phase I/II study and are planning to rearrange the protocol setting accordingly. The 3-year local control rate was 69.6 ± 10.6% for patients who received 48 Gy and 100% for patients who received 60 Gy (p = 0.0442).: ConclusionSmall-volume IGRT using 60 Gy in eight fractions is highly effective for the local control of lung tumors, but MTD has not been determined in this study. The organs at risk are extrapleural organs such as the esophagus and internal chest wall/visceral pleura rather than the pulmonary parenchyma in the present protocol setting. Consideration of the uncertainty in the contouring of normal structures is critically important, as is uncertainty in setup of patients and internal organ in the high-dose hypofractionated IGRT. [Copyright &y& Elsevier]

Background: The rise of large language models (LLM) promises to widely impact healthcare providers and patients alike. As these tools reflect the biases of currently available data on the internet, there is a risk that increasing LLM use will proliferate these biases and affect information quality. This study aims to characterize the effects of different race, ethnicity, and gender modifiers in question prompts presented to three large language models (LLM) on the length and readability of patient education materials about myopia., Methods: ChatGPT, Gemini, and Copilot were provided a standardized prompt incorporating demographic modifiers to inquire about myopia. The races and ethnicities evaluated were Asian, Black, Hispanic, Native American, and White. Gender was limited to male or female. The prompt was inserted five times into new chat windows. Responses were analyzed for readability by word count, Simple Measure of Gobbledygook (SMOG) index, Flesch-Kincaid Grade Level, and Flesch Reading Ease score. Significant differences were analyzed using two-way ANOVA on SPSS., Results: A total of 150 responses were analyzed. There were no differences in SMOG index, Flesch-Kincaid Grade Level, or Flesch Reading Ease scores between responses generated with prompts containing different gender, race, or ethnicity modifiers using ChatGPT or Copilot. Gemini-generated responses differed significantly in their SMOG Index, Flesch-Kincaid Grade Level, and Flesch Reading Ease based on the race mentioned in the prompt (p<0.05)., Conclusion: Patient demographic information impacts the reading level of educational material generated by Gemini but not by ChatGPT or Copilot. As patients use LLMs to understand ophthalmologic diagnoses like myopia, clinicians and users should be aware of demographic influences on readability. Patient gender, race, and ethnicity may be overlooked variables affecting the readability of LLM-generated education materials, which can impact patient care. Future research could focus on the accuracy of generated information to identify potential risks of misinformation., Competing Interests: The author reports no conflicts of interest in this work. This paper/the abstract of this paper was presented at the Association for Research in Vision and Ophthalmology 2024 Conference as a poster presentation with interim findings. The poster’s abstract was published in “ARVO Annual Meeting Abstracts” in Investigative Ophthalmology & Visual Science June 2024, Vol.65, 352: Hyperlink (https://iovs.arvojournals.org/article.aspx?articleid=2796258)., (© 2024 Lee et al.)

Purpose: To investigate treatment patterns of childhood glaucoma in the United States., Design: Retrospective clinical cohort study SUBJECTS: Patients under 18 years of age with a diagnosis code for glaucoma between January 1, 2013, and December 31, 2020, in the IRIS® Registry (Intelligent Research in Sight)., Methods: Patient demographic information and clinical characteristics were extracted. A Cox regression model was used to determine predictors of undergoing incisional glaucoma surgery., Main Outcome Measures: The primary outcomes were the percentage of childhood glaucoma eyes that underwent glaucoma-related procedures and those receiving intraocular pressure (IOP)-lowering medications. Our secondary outcomes were hazard ratios (HRs) of demographic and clinical factors for undergoing incisional surgeries., Results: A total of 5017 eyes of 3069 patients were included in this study. Based on billing codes, 208 eyes (4.1%) had primary congenital glaucoma (PCG), 1911 eyes (38.1%) had juvenile open-angle glaucoma (JOAG), 999 eyes (19.9%) had glaucoma following cataract surgery (GFCS), and 1646 (32.8%) had secondary glaucoma other than GFCS. Out of 5017 eyes with childhood glaucoma, 808 eyes (16.1%) underwent glaucoma-related procedures, and 4698 eyes (93.6%) received antiglaucoma medications. Angle surgery was the most common first-recorded procedure for PCG, and tube shunt surgery for GFCS and secondary glaucoma. Laser trabeculoplasty was mainly performed for JOAG by non-glaucoma subspecialists. Factors associated with higher likelihood of incisional surgeries were PCG (vs. JOAG, HR 5.40, 95% confidence interval [CI] 1.55-18.84, p = 0.008), increase in IOP (HR 1.06 per mmHg, CI 1.05-1.08, p<0.001), and index date at age < one year (vs. ages 11-15 years, HR 6.08, CI 1.51 - 24.44, p = 0.011). Being cared for by a non-glaucoma subspecialist was associated with a lower likelihood of undergoing incisional surgery (HR: 0.32 (95%CI: 0.23 - 0.44, p<0.001)., Conclusions: We found that 1 in 6 childhood glaucoma eyes underwent glaucoma-related procedures, and nearly all received antiglaucoma medications. The choice of first-recorded procedure differed across age and diagnosis. Type of glaucoma, baseline IOP, age, and type of treating subspecialist were predictors for undergoing incisional glaucoma surgery., Competing Interests: Declaration of interests The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Tobias Elze reports financial support was provided by NIH R01 EY030575. Tobias Elze reports financial support was provided by NIH P30 EY003790. Asahi Fujita reports financial support was provided by Takeda Science Foundation. Asahi Fujita reports financial support was provided by JSPS Overseas Challenge Program for Young Researchers. Asahi Fujita reports financial support was provided by JSPS Research Fellowships for Young Scientists. Asahi Fujita reports financial support was provided by The Japan Foundation for Pediatric Research. Asahi Fujita reports financial support was provided by Watanabe Foundation. Asahi Fujita reports financial support was provided by Nakatomi Foundation. Asahi Fujita reports financial support was provided by Mochida Memorial Foundation for Medical and Pharmaceutical Research. Ta Chen Chang reports financial support was provided by 2024 American Glaucoma Society Mid-Career Physician Scientist Award Grant. Nazlee Zebardast reports a relationship with Character Biosciences that includes: consulting or advisory. David S. Friedman reports a relationship with Life Biosciences that includes: consulting or advisory. David S. Friedman reports a relationship with Thea Pharmaceuticals that includes: consulting or advisory. David S. Friedman reports a relationship with Abbvie that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

We conducted a retrospective review of patients (< 18 years) between 2013 and 2021 to determine risk factors of pediatric patients receiving a glaucoma drainage device (GDD) needing a scleral buckle (SB) and vice versa. The first population underwent an SB placement with no prior GDD. The second underwent a GDD implantation with no prior SB. We analyzed 133 eyes in the SB-first group. The common indications were retinal detachment associated with a syndrome/disease (41.2%), blunt trauma (21%), and non-syndromic pathologic myopia (11%). Twelve eyes (9%) required subsequent GDD implantation with a mean time to reoperation of 19.73 months (median 2.3 months). Eyes with trauma had a 5-fold risk (hazard ratio [HR] 4.81, p = 0.0069) of requiring a subsequent GDD. Each additional glaucoma medication before initial SB surgery increased the risk by 1.81 (p = 0.0096). 135 eyes were in the GDD-first group. Four eyes (3%) required a subsequent SB. The mean time to reoperation was 17 months (median 9.2 months). There was a statistically significant association with trauma (HR 12.3, p = 0.0341) only. Pediatric eyes with a history of trauma and/or multiple glaucoma medications before intervention have a high risk of requiring both an SB and GDD., (© 2024. The Author(s).)

Purpose: To determine the morphology and postoperative outcomes of pediatric cataracts with thin (leptophakic) lenses., Design: Retrospective comparative clinical cohort study., Methods: We identified the records of pediatric patients who had undergone cataract surgery between 2018 and 2023 and lens thickness less than 2 standard deviations of age-stratified normal eyes in the general population. Matching controls were identified based on sex, age at surgery, and intraocular lens implant status. Data abstracted include axial length, anterior chamber depth, lens thickness, visual acuity, intraocular pressure, and surgical details., Results: A total of 13 eyes from 7 patients were identified to be leptophakic, 8 of which had matching controls. Compared with the control eyes, leptophakic eyes had thinner lenses (2.74 ± 0.39 mm vs 4.82 ± 1.01 mm, P < .01) with comparable anterior chamber depth (3.28 ± 0.76 mm vs 2.98 ± 1.28 mm, P = .13) and axial lengths (19.17 ± 2.61 mm vs 20.76 ± 1.76 mm, P = .20). Following cataract surgery, visual acuity improved for both the leptophakic and control cohorts within 2.5 months postoperatively (-0.68 ± 0.37 logMAR vs -0.06 ± 0.42 logMAR, P = .03) and at 1-2 years postoperatively (-1.58 ± 1.03 logMAR vs -0.60 ± 0.49 logMAR, P = .22) without any glaucoma-related adverse events. Of note, 5 of 13 leptophakic eyes (38%) were found to have posterior capsular ruptures intraoperatively., Conclusions: Leptophakic eyes demonstrated similar intraoperative and short-term postoperative outcomes when compared to control eyes, although vigilance for posterior capsular defects and ruptures may be necessary., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This retrospective cohort study describes the real-world incidence and maintenance of clinically meaningful intraocular pressure (IOP) reduction ("response") following stand-alone phacoemulsification for 667,987 eyes with suspected or confirmed glaucoma in the IRIS Registry (Intelligent Research in Sight) from 1/1/2013-9/30/2019. Intraocular pressure responders had ≥ 20% IOP reduction in daily mean IOP from baseline on two consecutive postoperative visits. We declared failure if a responder no longer maintained ≥ 20% IOP reduction. The estimated IOP responder rate was 41.3% by Kaplan-Meier analysis. Multivariate analysis demonstrated relationships between IOP response and baseline IOP (hazard ratio (HR) (95% confidence interval)) 1.48 (1.48-1.49), per 3 mmHg, P < 0.0001), age (HR 1.14 (1.13-1.14), per 10 years, P < 0.0001), male sex (HR 1.13 (1.12-1.15), P < 0.0001), prostaglandin analogue (HR 0.88 (0.87-0.90), P < 0.0001), and Rho-kinase inhibitor use (HR 1.50 (1.32-1.70), P = 0.01). Fifty percent of IOP responders failed at a median time of 14.3 months. Multivariate analysis demonstrated relationships between failure and baseline IOP (HR 0.75 (0.75-0.76), per 3 mmHg, P < 0.0001), nitric oxide donating prostaglandin (HR 1.78 (1.46-2.18), P < 0.0001) and Rho-kinase inhibitor use (HR 1.73 (1.43-2.09), P < 0.0001). Clinicians may counsel glaucoma patients with risk factors on whether to anticipate an IOP response and its expected duration after stand-alone phacoemulsification., (© 2024. The Author(s).)

Purpose: To evaluate risk factors for intraocular pressure (IOP) spike after cataract surgery using the IRIS® Registry (Intelligent Research in Sight)., Design: Retrospective clinical cohort study., Participants: Adults with IRIS Registry data who underwent stand-alone phacoemulsification from January 1, 2013, through September 30, 2019., Methods: Intraocular pressure spike was defined as postoperative IOP of > 30 mmHg and > 10 mmHg from the baseline within the first postoperative week. Odds ratios (ORs) for demographic and clinical characteristics were calculated with univariable and multivariable logistic regression analyses., Main Outcome Measures: Incidence and OR of IOP spike., Results: We analyzed data from 1 191 034 eyes (patient mean age, 71.3 years; 61.2% female sex; and 24.8% with glaucoma). An IOP spike occurred in 3.7% of all eyes, 5.2% of eyes with glaucoma, and 3.2% of eyes without glaucoma (P < 0.0001). Multivariable analyses of all eyes indicated a greater risk of IOP spike with higher baseline IOP (OR, 1.57 per 3 mmHg), male sex (OR, 1.79), glaucoma (OR, 1.20), Black race (OR, 1.39 vs. Asian and 1.21 vs. Hispanic), older age (OR, 1.07 per 10 years), and complex surgery coding (OR, 1.22; all P < 0.0001). Diabetes (OR, 0.90) and aphakia after surgery (OR, 0.60) seemed to be protective against IOP spike (both P < 0.0001). Compared with glaucoma suspects, ocular hypertension (OR, 1.55), pigmentary glaucoma (OR, 1.56), and pseudoexfoliative glaucoma (OR, 1.52) showed a greater risk of IOP spike and normal-tension glaucoma (OR, 0.55), suspected primary angle closure (PAC; OR, 0.67), and PAC glaucoma (OR, 0.81) showed less risk (all P < 0.0001). Using more baseline glaucoma medications was associated with IOP spike (OR, 1.18 per medication), whereas topical β-blocker use (OR, 0.68) was protective (both P < 0.0001)., Conclusions: Higher baseline IOP, male sex, glaucoma, Black race, older age, and complex cataract coding were associated with early postoperative IOP spike, whereas diabetes and postoperative aphakia were protective against a spike after stand-alone phacoemulsification. Glaucomatous eyes demonstrated different risk profiles dependent on glaucoma subtype. The findings may help surgeons to stratify and mitigate the risk of IOP spike after cataract surgery., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To synthesize the outcome measures used by randomized controlled trials (RCTs) for childhood glaucoma., Methods: MEDLINE, EMBASE, and Scopus were searched from inception to February 17, 2023. Randomized controlled trials and observational studies related to childhood glaucoma were included. Primary and secondary outcomes were extracted and the data was used to generate a literature review., Results: This review identified 42 unique reports pertaining to childhood glaucomas. Most of the studies originated from Egypt, India, and the USA. Intraocular pressure (IOP) outcomes were the most frequent outcomes studied, followed by clinical outcomes and safety outcomes. Clinical outcomes were the most common secondary outcomes studied, followed by IOP outcomes and safety outcomes., Conclusions: This systematic review found heterogenous outcomes with IOP outcomes as the most studied primary outcome. As the remaining outcomes were not consistently utilized, this review highlights the need for a consensus on studies of pediatric glaucoma., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Visual impairment (VI) negatively affects a child's quality of life. The prevalence of VI in the Caribbean is nearly three times higher than in the United States, but the causes remain uncertain. This study leverages Barbados' unique eye care system to survey the eye diseases and VI prevalence in Barbadian children. Medical records of all patients aged <19 years who received ophthalmic care in Barbados' two public eye care centers between January and December 2019 were reviewed, capturing the entirety of public pediatric eye care within the study period. Age at the first visit to the clinic and at the final visit in 2019, sex, best-corrected visual acuity (BCVA), past medical history, and clinical diagnoses were extracted and analyzed. VI was defined as a BCVA of 6/12 or worse in the better-seeing eye. There were 3278 patient records with a mean age at the first visit of 7.8 ± 3.9 years. There were 80 (2.4%) children with VI, 62.5% of which were attributed to amblyopia. A total of 94% of VI was preventable or treatable. The most common diagnoses were refractive error (87.5%), strabismus (27.5%), and allergic eye disease (20.0%). Amblyopia is the major cause of pediatric VI in Barbados and is largely avoidable.

Purpose: We compared next generation sequencing multigene panels (NGS-MGP) from 5 commercial laboratories to inform ophthalmologists' decision making in diagnostic genetic testing for congenital anterior segment anomalies (CASAs)., Design: Comparison of commercial genetic testing panels., Methods: This observational study gathered publicly available information on NGS-MGP from 5 commercial laboratories for the following: cataracts, glaucoma, anterior segment dysgenesis (ASD), microphthalmia-anophthalmia-coloboma (MAC), corneal dystrophies, and Axenfeld-Rieger syndrome (ARS). We compared gene panel composition, consensus rate (genes covered by all the panels per condition, "concurrent"), dissensus rate (genes covered by only 1 panel per condition, "standalone"), and intronic variant coverage. For individual genes, we compared publication history and association with systemic conditions., Results: Altogether, cataract, glaucoma, corneal dystrophies, MAC, ASD, and ARS panels tested 239, 60, 36, 292, and 10 discrete genes, respectively. The consensus rate varied between 16% and 50%, and the dissensus rate varied between 14% and 74%. After pooling concurrent genes from all conditions, 20% of these genes were concurrent in 2 or more conditions. For both cataract and glaucoma, concurrent genes had significantly stronger correlation with the condition than standalone genes., Conclusions: The genetic testing of CASAs using NGS-MGPs is complicated, owing to their number, variety, and phenotypic and genetic overlap. Although the inclusion of additional genes, such as the standalone ones, might increase diagnostic yield, these genes are also less well studied, indicating uncertainty over their role in CASA pathogenesis. Rigorous prospective diagnostic yield studies of NGS-MGPs will aid in making decisions of panel selection for the diagnosis of CASAs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To describe real-world intraocular pressure (IOP) changes following stand-alone cataract surgery by comparing postoperative IOP to phakic fellow eyes., Design: Retrospective clinical cohort study., Methods: A total of 1,334,868 patients (336,060 with glaucoma and 998,808 without glaucoma) in the IRIS® Registry (Intelligent Research in Sight) underwent stand-alone phacoemulsification from 1 January 2013 to 30 September 2019 with a fellow eye that had subsequent cataract surgery. Postoperative daily mean IOP was compared between surgical and control eyes from postoperative day 1 to 90. A generalized linear model determined when the postoperative daily mean IOP stabilized to calculate a final mean IOP, which was then compared to baseline IOP., Results: Postoperative daily mean IOP was initially greater for surgical than for control eyes because of an early postoperative IOP spike. By postoperative day 13, postoperative daily mean IOP was significantly lower for surgical than for control eyes every day through postoperative day 90 (P < .001). There was a mean (SD) decrease from baseline to final mean IOP of 1.55 (3.52) mm Hg or 7.79% for all surgical eyes, 1.91 (3.93) mm Hg or 8.89% for surgical eyes with glaucoma, and 1.37 (3.28) mm Hg or 7.24% for surgical eyes without glaucoma, respectively. There was a statistically significant decrease from baseline to the final mean IOP for all surgical eyes, surgical eyes without glaucoma, and all categories of pre-glaucoma and glaucoma (P < .0001 for all, excluding uveitic glaucoma [P = .0016])., Conclusions: Eyes both with and without glaucoma that underwent stand-alone phacoemulsification had a significant decrease in IOP through the 90-day postoperative period compared to baseline and phakic fellow eyes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To identify the factors associated with the complications and failure of gonioscopy-assisted transluminal trabeculotomy (GATT) in children., Design: Retrospective case series., Methods: This study was conducted in an institutional setting in a pediatric population (aged <18 years) who had undergone GATT. Records were reviewed, and pre- and postoperative intraocular pressures (IOP), extent of angle treated, medications, complications, and failure were recorded. Failure was defined as IOP >21 mm Hg or <5 mm Hg, absence of at least 20% IOP reduction, performance of additional IOP-lowering surgery, or loss of light perception vision., Results: A total of 74 eyes of 57 patients were included (mean age, 7.1 years). Over a median follow-up period of 28.5 months, 36 eyes (48.6%) failed. IOP spikes occurred in 25 eyes (33.8%) and were a significant risk factor for failure (hazard ratio [HR] = 2.17; P = .0207). Postoperative hyphema was a significant risk factor for IOP spike (HR = 4.13, P = .003) but not for failure (HR = 0.7, P = .2977). The risk of IOP spike was lowest in eyes treated with nonsteroidal anti-inflammatory drugs (NSAIDs; HR = 0.27, P = .0016). The risk of failure increased significantly in eyes that received topical corticosteroids (compared to NSAIDs; HR = 5.72, P = .0005), in eyes with <360 ○ incisions (HR = 4.69, P < .0001), and in younger children., Conclusions: GATT is a reasonably effective procedure in childhood glaucoma. Postoperatively, the use of topical NSAIDs (without corticosteroid) may decrease the risk of failure. Eyes with IOP spikes without hyphema are at the highest risk for failure., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To assess the safety and effectiveness of augmented MicroPulse (MP-TSCPC) with limited Continuous Wave Transscleral Cyclophotocoagulation (CW-TSCPC) in patients with refractory glaucoma., Methods: Thirty-eight eyes of 38 patients underwent combined MP-TSCPC and CW-TSCPC at Massachusetts Eye and Ear. Kaplan-Meier survival curves and Wilcoxon paired sign rank tests were performed to evaluate intraocular pressure (IOP), glaucoma medication burden, best corrected visual acuity (BCVA), and adverse events., Results: With success defined as IOP reduction ≥ 30% and IOP between 5 and 18 mmHg, the cumulative probability of success at 1 year and 1.5 years were 0.81 (95% confidence interval (CI), 0.68-0.96) and 0.65 (95% CI, 0.50-0.86), respectively. With success defined as IOP reduction ≥ 50% and IOP between 5 and 18 mmHg, the success probability at 1 year and 1.5 years were 0.72 (95% CI, 0.57-0.89) and 0.56 (95% CI, 0.40-0.78), respectively. IOP and medication burden reductions were significant at all follow-up visits compared to baseline. Average IOP decreased from 27.9 mmHg at baseline to 11.4 mmHg at 1 year (p < 0.001) and 10.0 mmHg at 1.5 years (p < 0.001). Average medication burden decreased from 3.8 to 1.7 at 1.5 years (p = 0.001). No significant differences in visual acuity were observed at any time point. No long-term sight-threatening complications due to the combined procedure were observed, and most of the complications observed were mild and transient., Conclusion: In patients with refractory glaucoma, the combination of augmented MP-TSCPC with limited CW-TSCPC provides a significant IOP-lowering effect and decrease in medication burden without increased risk of postoperative complications., (© 2021. The Author(s).)

Background: Digital optic disc photographs are integral to remote telehealth ophthalmology, yet no quality control standards exist for the brightness setting of the images. This study evaluated the relationship between brightness setting and cup/disc ratio (c/d) grading among glaucoma specialists., Methods: Optic disc photographs obtained during routine examinations under anesthesia were collected to construct an image library. For each optic disc, photographs were obtained at 3 light intensity settings: dark, medium, and bright. From the image library, photograph triads (dark, medium and bright) of 50 eyes (50 patients) were used to construct the study set. Nine glaucoma specialists evaluated the c/d of the study set photographs in randomized order. The relationships between the brightness levels and the c/d grading as well as graders' years in practice and variability were evaluated., Results: The c/d were graded as significantly larger in bright photographs when compared to photographs taken at the medium light intensity (0.53 vs 0.48, P < 0.001) as well as those taken at the dark setting (0.47, P < 0.001). In addition, no relationship was found between ophthalmologists' years in practice and the variability of their c/d grading (P = 0.76)., Conclusion: Image brightness affects c/d grading of nonstereoscopic disc photographs. The brighter intensity is associated with larger c/d grading. Photograph brightness may be an important factor to consider when evaluating digital disc photographs., (© 2021. The Author(s).)

Purpose: This study evaluated whether the rate of retinal nerve fiber layer (RNFL) thinning is faster in eyes receiving intravitreal injections than in fellow uninjected eyes among patients suspected of having or confirmed to have glaucoma and exudative age-related macular degeneration (AMD)., Design: Retrospective comparative cohort study., Methods: Patients with a diagnosis of unilateral exudative AMD and confirmed to have or suspected of having glaucoma in both eyes receiving unilateral intravitreal injections were identified. Those with ≥3 RNFL optical coherence tomography scans and ≥6 injections were included in the study. Rates of RNFL thinning in the injected eye versus the uninjected eye were estimated using linear mixed models. The main outcome measurement was the differences in rates of RNFL thinning in the injected versus the fellow uninjected eye. The effects of postinjection elevation of intraocular pressure (IOP), injection frequency, and number of injections were also evaluated., Results: A total of 53 patients met the inclusion criteria, receiving 26.4 ± 15.9 intravitreal injections. The average rate of RNFL thinning in uninjected eyes was -0.620 μm/year (P = .029). Injected eyes had an additional incremental loss of -0.385 μm/year, but this value was not statistically significant (95% confidence interval [CI]: -1.147 to 0.379 μm/year; P = .324). Subgroup analysis with only glaucoma patients (n = 33) also demonstrated a nonsignificant effect of injections (-0.568 μm/year; 95% CI: -1.454 to 0.319 μm/year; P = .212). Postinjection IOP elevation, injection frequency, and total number of injections were not associated with faster RNFL loss., Conclusions: Among exudative AMD patients with glaucoma or suspected of having glaucoma, the rate of RNFL thinning in eyes receiving intravitreal injections did not significantly differ from that of fellow uninjected eyes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To assess the number of infants at risk of delayed primary congenital glaucoma (PCG) evaluation due to long travel times to specialists., Design: Cross-sectional geospatial service coverage analysis., Methods: All American Glaucoma Society (AGS) and American Association for Pediatric Ophthalmology and Strabismus (AAPOS) provider locations were geocoded using each organization's member directory. Sixty-minute drive time regions to providers were generated using ArcGIS Pro (Esri). The geographic intersection of AGS and AAPOS service areas was computed because patients typically require visits to both types of specialists. American Community Survey data were then overlaid to estimate the number of infants within and beyond the AGS/AAPOS service areas., Results: One thousand twenty-nine AGS and 1,040 AAPOS provider locations were geocoded. The analysis yielded 944,047 infants age 0-1 year (23.6%) who live beyond the AGS/AAPOS service areas. Therefore, approximately 14-94 new PCG cases/year may be at risk of delayed diagnosis as a result of living in a potential service desert. Compared with children living within the AGS/AAPOS service areas, children aged <6 years in these potential service deserts were more likely to live in households earning below the US federal poverty level, lack health insurance, and live in a single-parent home. These communities are disproportionately likely to experience other rural health disparities and are more prevalent across the Great Plains., Conclusion: Service coverage analysis is a useful tool for identifying underserved regions for PCG referrals and evaluation. These data may assist in targeting screening programs in low access areas for pediatric glaucoma care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to report the safety and efficacy of pars plana glaucoma drainage devices with pars plana vitrectomy using one of the vitrectomy sclerotomy sites for tube placement in patients with refractory glaucoma., Methods: Retrospective case series of 28 eyes of 28 patients who underwent combined pars plana glaucoma drainage device and pars plana vitrectomy between November 2016 and September 2019 at Massachusetts Eye and Ear. Main outcome measures were intraocular pressure (IOP), glaucoma medication burden, best corrected visual acuity, and complications. Statistical tests were performed with R and included Kaplan-Meier analyses, Wilcoxon paired signed-rank tests, and Fisher tests., Results: Mean IOP decreased from 22.8 mmHg to 11.8 mmHg at 1.5 years (p = 0.002), and mean medication burden decreased from 4.3 to 2.1 at 1.5 years (p = 0.004). Both IOP and medication burden were significantly lower at all follow-up time points. The probability of achieving 5 < IOP ≤ 18 mmHg with at least 20% IOP reduction from preoperative levels was 86.4% at 1 year and 59.8% at 1.5 years. At their last visit, three eyes (10.7%) achieved complete success with IOP reduction as above without medications, and 14 eyes (50.0%) achieved qualified success with medications. Hypotony was observed in 1 eye (3.6%) prior to 3 months postoperatively and 0 eyes after 3 months. Visual acuity was unchanged or improved in 23 eyes (82.1%) at their last follow-up. Two patients had a visual acuity decrease of > 2 lines. Two eyes required subsequent pars plana vitrectomies for tube obstruction, and one eye had transient hypotony., Conclusions: The results of pars plana glaucoma drainage device and pars plana vitrectomy using one of the vitrectomy sclerotomy sites for tube placement are promising, resulting in significant IOP and medication-burden reductions through postoperative year 1.5 without additional risk of postoperative complications. Inserting glaucoma drainage devices into an existing vitrectomy sclerotomy site may potentially save surgical time by obviating the need to create another sclerotomy for tube placement and suture one of the vitrectomy ports.

Purpose: To determine the risk factors for failures and complications of gonioscopy-assisted transluminal trabeculotomy (GATT) in a young cohort., Design: Retrospective case series., Participants: Eyes that underwent GATT at Bascom Palmer Eye Institute., Methods: Preoperative and postoperative intraocular pressure (IOP), extent of angle treated, postoperative IOP spike, postoperative drop regimen, and postoperative failure were recorded. Failure was defined as (1) IOP of more than 21 mmHg or less than 5 mmHg after postoperative month 3, (2) absence of at least 20% reduction from the preoperative IOP baseline after postoperative month 3, or (3) performance of additional IOP-lowering surgery before postoperative month 3. Intraocular pressure spike complication was defined as an increase in IOP in the operated eye at any postoperative visit to higher than preoperative IOP within the first 3 months. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to assess the time to events (failure and IOP spike)., Main Outcome Measures: Risk of failure associated with any of the preoperative, intraoperative, or postoperative variables., Results: A total of 102 eyes of 88 patients were included. The median follow-up time was 7.4 months, with an interquartile range of 3.3 to 13.1 months (standard deviation, 8.7 months). Patients who used corticosteroids after surgery were more likely to experience IOP spikes than those using nonsteroidal anti-inflammatory drugs (NSAIDs) alone (hazard ratio, 3.34; P = 0.042), and patients who underwent noncircumferential trabeculotomy were 2.56 times more likely to experience treatment failure (P = 0.002) compared with those who underwent circumferential surgery., Conclusions: Eyes that received postoperative corticosteroids were more likely to experience an IOP spike complication than those that received postoperative NSAIDs alone, which may suggest corticosteroid-mediated outflow obstruction distal to the trabecular meshwork. Achieving a circumferential trabeculotomy and using only NSAIDs may be more likely to result in surgical success when compared with noncircumferential trabeculotomy or using postoperative corticosteroids., (Published by Elsevier Inc.)

Purpose: To examine the short-term efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in a series of patients who developed glaucoma following vitreoretinal surgery., Patients and Methods: Retrospective case series of consecutive patients aged above 18 years with secondary open-angle glaucoma following vitreoretinal surgery who had undergone GATT between January 2015 and June 2019. Eyes were excluded if there is<1 month of follow-up or glaucoma before vitreoretinal surgery., Results: Eight eyes of 8 patients were included, with age range 18 to 72 years (median 43.5 y). Mean pretreatment intraocular pressure (IOP) was 32.7±5.1 mm Hg with a mean of 4.8±0.9 medications. Following GATT, mean IOP improved to 13.6±1.8 mm Hg (P<0.001) with a reduction to 1.6±1.4 medications after a mean follow-up of 8.6 months (range 1 to 25 mo). Five of the 8 eye (62.5%) had silicone oil in the vitreous cavity during GATT, none of which had concurrent oil removal., Conclusions: GATT is a safe and effective procedure for eyes with secondary open-angle glaucoma following vitreoretinal surgery. Further studies are needed to elucidate long-term benefits of angle surgery on eyes with high pressure following vitreoretinal surgery.

Purpose: To discuss the value and limitations of interpreting small case series for the purpose of understanding the pathophysiology of conditions affecting the visual system and how they may influence patient care decision making., Design: Selective review of English-language ophthalmic articles published in peer-reviewed journals since 1950., Methods: Author-initiated PubMed Central query of small case series in glaucoma, pediatric neuro-ophthalmology, and diabetic retinopathy., Results: A review of well-known ophthalmic case studies by Gass, Irvine, Brockhurst, and others shows that small samples can provide suggestions to the skilled clinician for adding steps to the examination process when uncovering rare or previously unknown associated complications, as is the case for this perspective's initiating studies by Groth and Brodsky. However, as shown by the now-retracted small case series in Lancet connecting measles-mumps-rubella vaccinations with autism, small case series do not replace the value of clinical trials, with rare exception, when considering impacts to widespread, common clinical practice., Conclusion: Small case series may contribute to an improved understanding of pathophysiology of rare ophthalmic conditions, but alone are insufficient to provide evidence for changing clinical practice of common eye diseases., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The circumpapillary retinal nerve fiber layer (RNFL) thickness was assessed by spectral domain optical coherent tomography (SD-OCT) before and after surgical reduction of intraocular pressure in an eye with primary infantile glaucoma. In this case, a postoperative reduction of cupping and a subsequent increase in neuroretinal rim area is associated with a paradoxical thinning of the RNFL. This is the first-known characterization of cupping reversal using SD-OCT.

Among various altered fractionation regimens, hyperfractionated radiotherapy (HFRT) has been considered effective to raise survival rate(SR)as well as local control rate(LCR)in head and neck cancers. We reviewed our results of HFRT (117 cases) treated between 1995 and 2004 and compared with those of conventionally fractionated radiotherapy (CFRT; 80 cases) treated during the same period. By disease site, naso-/oro-/hypopharynx/larynx were 5/23/44/45 vs. 10/6/10/54. There were more advanced-stage cases in HFRT group (stage I/II/III/IV = 19/36/23/35 vs. 42/16/8/ 14). Median RT dose were 72 Gy vs. 66 Gy. In 71 cases, chemotherapy was added (HF/CF = 54/17). In stage III and IV cases, there was a borderline significant difference in LCR (at 5 years; 44.3% for HFRT group vs. 24.5% for CFRT group; p = 0.0502), and a tendency in SR(at 5 years; 50.7% for HFRT group vs. 16.7% for CFRT group; p = 0.1210). By disease site, LCR of HFRT group was higher in hypopharynx(p = 0.0005)and oropharynx(p = 0.0003), and SR of HFRT group was higher in hypopharynx(p = 0.0023). Acute toxicity was heavy but in most cases it was tolerable and there were no severe late toxicities. From our data, it was suggested that HFRT might be effective in certain kinds of head and neck cancers.

Radiation therapy (RT) for prostate cancer has been developing dramatically during the past 10 years in Japan as well as in USA. There are several ways to treat prostate cancer by RT. As for external-beam RT (EBRT), a more sophisticated technique beyond 3-dimensional conformal RT called intensity modulated RT was developed and has been in use in many Japanese RT centers. It can raise the total radiation dose and is expected to increase the biochemical control rate. As for brachytherapy, a low-dose-rate seed implant using iodine-125 was initiated in 2003 and has become widespread throughout Japan in only a few years. High-dose-rate brachytherapy using iridium-19 2 has also been used in more advanced cases combined with EBRT. Brachytherapy offers an ideal RT dose concentration and can avoid rectal complications. As for particle therapy, we have carbon and proton in several institutions in Japan. Particles have the merit of good dose distributions and for carbons, relative biological effectiveness. Furthermore, some centers are considering the stereotactic hypofractionated RT due to the relatively low alfa-beta ratio of prostate cancer. Recent reports showed that after a certain period of followup, the biochemical control rate was similar either with external beam high-quality RT, brachytherapy, heavy ion RT and surgery. Therefore, the choice of treatment should depend on the adverse effects, quality of life, medical costs, and the lifestyle of the patient. The merits and demerits of each treatment modality were discussed. Longer follow-up is still necessary and informed consent is mandatory when choosing a treatment modality.

Aim: To evaluate the conservativeness of low dose rate interstitial irradiation (LII) for cancer of the mobile tongue., Patients and Methods: Between 1975 and 2002, 100 consecutive patients (71 men, 29 women) underwent LII as curative treatment. Stages were I/IIIII/IV = 16/63/16/4. Seventy-one cases were treated with LII alone and 29 cases treated combined with external irradiation. Median total dose of LH was 70 Gy/7 days., Results: Overall, 5- and 10-year local control and LII-treated patients' survival rates were 93% and 91%, 64% and 57%, respectively. Delayed neck metastases were observed in 21% of initially N0 cases, 56% of which could be salvaged by operation. Early stage and well-differentiated tumors carried better prognoses., Conclusion: LII of cancers of the mobile tongue results in good local control and survival. With careful monitoring of patients to ensure early detection of delayed metastases, LII should allow organ conservation and yield favourable therapeutic results compared with those of surgery.

Purpose: Accurate diagnosis of tumor extent is important in three-dimensional conformal radiotherapy. This study reports the use of image fusion between (18)F-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG-PET) and magnetic resonance imaging/computed tomography (MRI/CT) for better targets delineation in radiotherapy planning of head-and-neck cancers., Methods and Materials: The subjects consisted of 12 patients with oropharyngeal carcinoma and 9 patients with nasopharyngeal carcinoma (NPC) who were treated with radical radiotherapy between July 1999 and February 2001. Image fusion between 18FDG-PET and MRI/CT was performed using an automatic multimodality image registration algorithm, which used the brain as an internal reference for registration. Gross tumor volume (GTV) was determined based on clinical examination and 18FDG uptake on the fusion images. Clinical target volume (CTV) was determined following the usual pattern of lymph node spread for each disease entity along with the clinical presentation of each patient., Results: Except for 3 cases with superficial tumors, all the other primary tumors were detected by 18FDG-PET. The GTV volumes for primary tumors were not changed by image fusion in 19 cases (89%), increased by 49% in one NPC, and decreased by 45% in another NPC. Normal tissue sparing was more easily performed based on clearer GTV and CTV determination on the fusion images. In particular, parotid sparing became possible in 15 patients (71%) whose upper neck areas near the parotid glands were tumor-free by 18FDG-PET. Within a mean follow-up period of 18 months, no recurrence occurred in the areas defined as CTV, which was treated prophylactically, except for 1 patient who experienced nodal recurrence in the CTV and simultaneous primary site recurrence., Conclusion: This preliminary study showed that image fusion between 18FDG-PET and MRI/CT was useful in GTV and CTV determination in conformal RT, thus sparing normal tissues.