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Syril Dorairaj,1 Leticia A Checo,1 Isabella V Wagner,1 Richard D Ten Hulzen,1 Abhimanyu S Ahuja2 1Department of Ophthalmology, Mayo Clinic, Jacksonville, FL, USA; 2Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USACorrespondence: Syril Dorairaj, Department of Ophthalmology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, USA, Tel +1 904-953-2377, Fax +1 904-953-7040, Email dorairaj.syril@mayo.eduPurpose: To describe the safety and efficacy of the Ahmed ClearPath® (ACP) 250 mm2 glaucoma drainage device (GDD) in the treatment of refractory primary open-angle glaucoma (POAG).Patients and methods: This was a retrospective, noncomparative, single-surgeon, interventional case series of adult patients with medically ± surgically refractory POAG undergoing ACP implantation. Intraocular pressure (IOP), the number of glaucoma medications, and complications were recorded over 24 months of follow-up. Primary outcomes included mean reductions in both IOP and medication use through 24 months, and secondary outcomes included the proportion of eyes achieving an IOP between 6 and 19 mmHg, IOP reduction by ≥ 20%, and reduction by ≥ 1 medication at last mean follow-up.Results: Twelve eyes of 11 patients (mean age 71.3 ± 14.1 years) fit inclusion criteria and were enrolled. Most patients were Caucasian (n = 8), female (n = 10), and all had severe POAG (n = 11). The mean last follow-up was 18 months, at which time the mean (standard deviation) baseline IOP of 29.0 (7.6) mmHg was reduced to 12.2 (4.0) mmHg (58% reduction). 91.7% of eyes achieved an IOP between 6 and 19 mmHg, and 100% of eyes met an IOP reduction of ≥ 20%. Mean baseline number of glaucoma medications was 3.0 (0.9) and was reduced to 0.5 (0.7) at last mean follow-up (83.3% reduction), with 91.7% of eyes using ≥ 1 fewer medications. No long-term complications were observed, and short-term complications (mild hyphema, inflammation, and pain) were resolved by month 3.Conclusion: To our knowledge, this is the second long-term study evaluating the efficacy of the Ahmed ClearPath drainage device in adult patients, and the first study with 24-months follow-up. The ACP device is safe and effective at reducing both IOP and medication burdens in patients with severe POAG. Additionally, minimal short-term complications were noted with no long-term adverse effects, increasing comfort for both the surgeon and the patient.Keywords: primary open angle glaucoma, intraocular pressure, IOP-lowering medications, valved drainage devices

Topical anesthetics for control of pain from corneal abrasions can cause drug-related toxicity that delays corneal healing. This report documents three cases where topical anesthetic drops were prescribed in the emergency department for pain control, after which patients developed persistent ocular pain, epithelial toxicity with impaired healing, and significant loss of vision. On consultation with the ophthalmology service, each patient was instructed to discontinue the topical anesthetic drops but to continue topical antibiotics. Soon thereafter, symptoms resolved, and the corneas healed within 72 hours. This report emphasizes the harm that can result from injudicious and/or unmonitored use of topical anesthetics for corneal abrasions. We advise emergency medicine and primary care providers against providing topical anesthetics to patients with corneal abrasions., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Mayo Clinic Institutional Review Board issued approval 24-004713. This retrospective study was performed in accordance with the tenets of the Declaration of Helsinki and was approved by the Mayo Clinic IRB on April 29, 2024. The study was determined to be of low risk to the subjects. There is no personal identifying information within this work. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Miller et al.)

Purpose: To describe the safety and efficacy of the Ahmed ClearPath ® (ACP) 250 mm 2 glaucoma drainage device (GDD) in the treatment of refractory primary open-angle glaucoma (POAG)., Patients and Methods: This was a retrospective, noncomparative, single-surgeon, interventional case series of adult patients with medically ± surgically refractory POAG undergoing ACP implantation. Intraocular pressure (IOP), the number of glaucoma medications, and complications were recorded over 24 months of follow-up. Primary outcomes included mean reductions in both IOP and medication use through 24 months, and secondary outcomes included the proportion of eyes achieving an IOP between 6 and 19 mmHg, IOP reduction by ≥20%, and reduction by ≥1 medication at last mean follow-up., Results: Twelve eyes of 11 patients (mean age 71.3 ± 14.1 years) fit inclusion criteria and were enrolled. Most patients were Caucasian (n = 8), female (n = 10), and all had severe POAG (n = 11). The mean last follow-up was 18 months, at which time the mean (standard deviation) baseline IOP of 29.0 (7.6) mmHg was reduced to 12.2 (4.0) mmHg (58% reduction). 91.7% of eyes achieved an IOP between 6 and 19 mmHg, and 100% of eyes met an IOP reduction of ≥20%. Mean baseline number of glaucoma medications was 3.0 (0.9) and was reduced to 0.5 (0.7) at last mean follow-up (83.3% reduction), with 91.7% of eyes using ≥1 fewer medications. No long-term complications were observed, and short-term complications (mild hyphema, inflammation, and pain) were resolved by month 3., Conclusion: To our knowledge, this is the second long-term study evaluating the efficacy of the Ahmed ClearPath drainage device in adult patients, and the first study with 24-months follow-up. The ACP device is safe and effective at reducing both IOP and medication burdens in patients with severe POAG. Additionally, minimal short-term complications were noted with no long-term adverse effects, increasing comfort for both the surgeon and the patient., Competing Interests: The authors report no conflicts of interest in this work., (© 2022 Dorairaj et al.)

A 62-year-old woman with stable unilateral glaucoma in the left eye presented for a cataract consultation. In 2010, laser peripheral iridotomies (LPI) were performed on both eyes by a different provider. Her postoperative course was complicated by a recalcitrant steroid response with a highest intraocular pressure (IOP) of 65 mm Hg in the left eye. A trabeculectomy with a glaucoma minishunt (EX-PRESS, Alcon) was then performed by that provider (Supplemental Figure 1, http://links.lww.com/JRS/A603). Thereafter, IOP control of the left eye was normalized and maintained without topical antiglaucoma medications. Historically, her right eye has been always her better eye. Recently, she noticed metamorphopsia in her left eye. Her ocular history was also notable for high refractive errors requiring continuous spectacles wear, possible mild refractive amblyopia of the left eye, history of submacular choroidal nevus with drusen in the right eye, and an epiretinal membrane (ERM) with macular pucker in the left eye. Her husband is an optician. Both inquire about refractive cataract surgery options to correct astigmatism and presbyopia; both have reservations regarding cost and visual quality associated with diffractive optic intraocular lenses (IOLs). Her deteriorating visual acuity in both eyes affects her ability to work. Her corrected distance visual acuity was 20/40 in both eyes (pinhole, no help) while wearing spectacles according to a prescription of -8.50 diopters (D) +1.50 D × 106 for the right eye and -13.00 D +3.25 D × 057 for the left eye. Her corrected near visual acuity was 14/14 in both eyes with the abovementioned prescription and a +3.00 D add. Central corneal thickness was 618 µm in the right eye and 631 µm in the left eye. IOP was 20 mm Hg in the right eye and 10 mm Hg in the left eye on no antiglaucoma medications. Pertinent findings on slitlamp examination included bilateral dermatochalasis, a shallow diffuse thick bleb superiorly in the left eye only, patent LPI superiorly in both eyes, nuclear sclerotic and cortical cataracts in both eyes (with prominent focal spoke superiorly left eye only) (Figure 1, A-C). Fundus photos show posterior vitreous detachment in both eyes, ERM with macular pucker in the left eye, and submacular choroidal nevus (2.5 × 3.0 disc diameter size) with overlying drusen in the right eye (Supplemental Figure 2, A, http://links.lww.com/JRS/A604). Gonioscopy revealed open angles in both eyes, albeit with focal narrowing without synechiae superiorly in the left eye only (Figure 1, D-FJOURNAL/jcrs/04.03/02158034-202207000-00020/figure1/v/2022-06-24T130746Z/r/image-tiff). Most importantly, however, the distal tip of the minishunt was not positioned as expected in the anterior chamber; rather, it was noted to pierce the peripheral iris near the iris root superiorly. Most of the minishunt shaft and spur were positioned in the posterior chamber with the distal tip penetrating into the superior aspect of the capsular bag and cataract in the left eye-like a deadbolt. Visual field testing showed a full field in the right eye and an inferior nasal step in the left eye (Supplemental Figure 2, B, http://links.lww.com/JRS/A604). In addition to slitlamp, gonioscopic, and fundus photos, we also obtained optical coherence tomography of the macula and nerve (Supplemental Figure 2, C, http://links.lww.com/JRS/A604), optical biometry, ultrasound biomicroscopy, endothelial cell counts, and corneal topography (Supplemental Figure 3, http://links.lww.com/JRS/A605). How would you counsel this patient regarding her glaucoma condition, the misplanted minishunt, and her cataract surgery and IOL options? How would you manage the misplanted minishunt? What surgical approaches or specific techniques would you consider for cataract removal and visual rehabilitation?, (Copyright © 2022 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To determine the probability of converting from pigment dispersion syndrome to pigmentary glaucoma., Design: Retrospective community-based study of all newly diagnosed cases of pigment dispersion syndrome or pigmentary glaucoma., Method: Subjects were patients newly diagnosed with pigment dispersion syndrome or pigmentary glaucoma from 1976 to 1999 in Olmsted County, Minnesota. Criteria for pigment dispersion syndrome were two of three signs: midperipheral, radial iris transillumination defects; Krukenberg spindle; heavy trabecular meshwork pigmentation. Criteria for pigmentary glaucoma were pigment dispersion syndrome and two of three findings: intraocular pressure (IOP) greater than 21 mm, optic nerve damage, or visual field loss. Kaplan-Meier survival curves were used to determine the probability of conversion to pigmentary glaucoma., Results: A total of 113 patients were newly diagnosed with pigment dispersion syndrome over the 24-year period. Of these, 9 persons developed pigmentary glaucoma or elevated IOP requiring therapy. The probability of converting to pigmentary glaucoma was 10% at 5 years and 15% at 15 years. An additional 23 patients were found to have pigmentary glaucoma at their initial examination. The mean age at diagnosis of pigmentary glaucoma was 42 +/- 12 years; 78% of patients were male, whereas 58% of patients with pigmentary dispersion syndrome glaucoma were male. The most significant risk factor for conversion to pigmentary glaucoma was an IOP greater than 21 mm Hg at initial examination, whereas age, refractive error, and family history of glaucoma were not correlated with conversion., Conclusions: The risk of developing pigmentary glaucoma from pigment dispersion syndrome was 10% at 5 years and 15% at 15 years. Young, myopic men were most likely to have pigmentary glaucoma. An IOP greater than 21 mm Hg at initial examination was associated with an increased risk of conversion.

Purpose: To determine the acoustic spectra of currently used phacoemulsification units and to contrast phacoemulsification-generated acoustic spectra with representative audiograms of common types of sensorineural hearing loss., Setting: Mayo Clinic, Rochester, Minnesota, USA., Methods: The acoustic spectra of 3 phacoemulsification systems (Alcon Series 20,000 Legacy, Storz Millennium, and AMO Diplomax) were recorded in an acoustically soundproofed room using a Roland VS-880 Digital Studio Workstation and analyzed with a Hewlett-Packard 35660A Dynamic Signal Analyzer., Results: Phacoemulsification handpiece-generated harmonic overtones produced during ultrasound mode (6.0, 12.0, and 18.8 kHz for the 20,000 Legacy and Diplomax; 7.0 and 14.2 kHz for the Millennium) were outside the range of minimal decibel loss in individuals with hearing loss. Supplemental, low-frequency, console-generated tones produced during ultrasound mode (0.4 to 2.0 kHz for the Diplomax; 0. 1 to 1.5 kHz for the Millennium) were within the range of minimal decibel loss in individuals with hearing loss., Conclusion: Phacoemulsification systems with console-generated, low-frequency tones were audible to ophthalmologists with common types of sensorineural hearing loss.

Purpose: A quantitative study was performed to compare the effect of two commonly used fixation pressures, 0 mm Hg (immersion) and 10 mm Hg (perfusion), on the porosity of the juxtacanalicular tissue and the size of Schlemm's canal., Methods: Twelve pairs of human eyes were studied by fixing one eye with perfusion fixation and the fellow eye with immersion fixation. Morphometric analysis of the juxtacanalicular tissue and Schlemm's canal was performed. Outflow resistance was calculated from these measurements and compared with the measured outflow resistance obtained in six eyes., Results: Schlemm's canal was narrowed in perfusion-fixed eyes, with a 47% smaller cross-sectional area than in immersion-fixed eyes (P = 0.04). Juxtacanalicular tissue of perfusion-fixed eyes had a 13.4% increase in the relative amount of empty space when compared with immersion-fixed fellow eyes (P = 0.04). Solid tissue components were almost equally divided among amorphous basement membrane, tendon and sheath material, and cytoplasm. No obvious washout of extracellular material was noted in perfused tissue. Measured outflow resistance was 100 times larger than outflow resistance of the juxtacanalicular tissue calculated from histologic measurements., Conclusions: Perfusion fixation at physiologic intraocular pressure caused a 47% decrease in the area of Schlemm's canal and a mean increase of 13.4% in the relative amount of empty space in the juxtacanalicular tissue compared with immersion-fixed fellow eyes. Perfusion of fixative did not appear to cause washout of extracellular material. Perfusion-fixed tissue appears preferable for studies of Schlemm's canal and for ultrastructural studies of the aqueous outflow pathways within the juxtacanalicular tissue.