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The glaucoma treatment paradigm is in evolution. The topical medications-first approach is limited by significant barriers such as high rates of nonadherence and side effects including ocular surface disease. The era of interventional glaucoma has seen the development of selective laser trabeculoplasty (SLT), procedural pharmaceuticals, and minimally invasive glaucoma surgeries (MIGS). New and emerging data support the use of these interventional treatment modalities early in the course of glaucoma rather than reserving them for advanced or treatment-recalcitrant cases. The various treatments available represent multiple mechanisms (e.g., trabecular outflow, uveoscleral outflow, aqueous suppression) and modalities (medications, laser, incisional surgery) by which intraocular pressure (IOP) is reduced. Many patients require more than one treatment to achieve adequate IOP reduction and glaucoma control. Comprehensive IOP control—reduction of both mean IOP and IOP fluctuation—can best be achieved by targeting multiple mechanisms of IOP reduction and taking advantage of the attributes of multiple treatment modalities.

Background: The travoprost intracameral implant and cataract surgery both lower intraocular pressure (IOP). Objectives: We evaluated the safety and IOP-lowering effect at 3 months following administration of travoprost intracameral implant in combination with cataract surgery. Design: Prospective, 12-month, open-label, single-arm trial. Methods: We enrolled patients with age-related cataracts and open-angle glaucoma or ocular hypertension in the same eye. At baseline, patients were required to have an unmedicated mean diurnal IOP (average of 8:00 am, 10:00 am, and 4:00 pm IOPs) of 24 mmHg or greater, and an IOP of 36 mmHg or less at each of these three timepoints. On the day of the combined procedure (day 1), patients who had uncomplicated phacoemulsification cataract surgery received a travoprost intracameral implant. Follow-up evaluations occurred on day 2–3, week 2, week 6, and month 3 visits. Results: Sixty patients had uncomplicated cataract surgery and received a travoprost intracameral implant. There were no serious adverse events. Study eye adverse events were reported in 8.3% of patients. The most frequently reported adverse event was dry eye (6.7%). At month 3, the mean diurnal IOP change from baseline was −10.6 mmHg (95% confidence interval: −11.2, −9.9; p < 0.0001) from an unmedicated baseline mean diurnal IOP of 25.2 mmHg. In addition, at month 3, 97% of eyes had a 20% or greater mean diurnal IOP reduction from baseline, and 91.0% of eyes had a mean diurnal IOP of 18 mmHg or less. Conclusion: Administration of a travoprost intracameral implant combined with routine cataract surgery was safe. The sizable −10.6 mmHg IOP change from baseline at month 3 was both statistically significant and clinically relevant. Trial registration: NCT06061718, Travoprost Intraocular Implant in Conjunction with Cataract Surgery, https://clinicaltrials.gov/study/NCT06061718. Plain language summary Study assessing the safety and the intraocular pressure lowering effect of administering a travoprost intracameral implant in combination with having cataract surgery in patients with open-angle glaucoma or ocular hypertension Why was the study done? The travoprost intracameral implant is a drug delivery system that is placed directly in the eye to continuously release travoprost to lower intraocular pressure in patients with open-angle glaucoma or ocular hypertension. Cataract surgery also is known to lower intraocular pressure in normal eyes and to a greater extent in eyes with glaucoma or ocular hypertension. Placement of the implant in the anterior chamber angle of the eye and cataract surgery are both done through a small corneal incision. What did the researchers do? The researchers studied the safety and the reduction in intraocular pressure after administering a travoprost intracameral implant during the same procedure as removal of the cataractous lens and administration of an intraocular lens. Sixty patients with open-angle glaucoma had the combined procedure and were followed over a 3-month period to check their intraocular pressure and health of their eye. What did the researchers find? There were no serious safety findings after the combined procedure, with less than 10% of patients having any ocular side effect. The most common side effect was dry eye. At month 3, mean intraocular pressure was reduced significantly from the untreated baseline pressure measured before the combined procedure. What do the findings mean? The study showed that it is safe to combine the placement of the travoprost intracameral implant in the eye during the same procedure as routine cataract surgery. The study also showed that there was a substantial lowering of intraocular pressure at 3 months in patients with open-angle glaucoma.

Vitrectomy is an effective treatment for visually disabling vitreous opacities (floaters) but carries significant surgical risk. Nd:YAG laser vitreolysis using newer technology has been shown safe and effective in treating symptomatic Weiss ring vitreous floaters. These Weiss rings, as well as amorphous opacities in the mid- to posterior vitreous, can be impossible to visualize or treat using conventional YAG lasers. In the cases presented here, undetected symptomatic amorphous type posterior vitreous floaters were confirmed with assistance of a novel optical coherence tomography application and successfully treated using a YAG laser optimized for vitreolysis. These cases suggest that with proper technology and technique, laser vitreolysis may be safer and more effective than previously recognized. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:806–811.]

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset thunderclap headache and focal neurologic deficits. Once thought to be a rare syndrome, more advanced non-invasive imaging has led to an increase in RCVS diagnosis. Unilateral vertebral artery dissection has been described in fewer than 40% of cases of RCVS. Bilateral vertebral artery dissection has rarely been reported. We describe the case of a patient with RCVS and bilateral vertebral artery dissection presenting with an intramedullary infarct treated successfully with medical management and careful close follow-up. This rare coexistence should be recognized as the treatment differs.

BackgroundAccurate assessment of the prevalence of large vessel occlusion (LVO) in patients presenting with acute ischemic stroke (AIS) is critical for optimal resource allocation in neurovascular intervention.ObjectiveTo perform a systematic review of the literature in order to identify the proportion of patients with AIS presenting with LVO on image analysis.MethodsA systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in order to identify studies reporting LVO rates for patients presenting with AIS. Studies that included patients younger than 18 years, were non-clinical, or did not report LVO rates in the context of a consecutive AIS series were excluded. Characteristics regarding presentation, diagnosis, and LVO classification were recorded for each paper.ResultsSixteen studies, spanning a total of 11 763 patients assessed for stroke, were included in the qualitative synthesis. The majority (10/16) of articles reported LVO rates exceeding 30% in patients presenting with AIS. There was substantial variability in the LVO definitions used, with nine unique classification schemes among the 16 studies. The mean prevalence of LVO was 31.1% across all studies, and 29.3% when weighted by the number of patients included in each study.ConclusionsDespite the wide variability in LVO classification, the majority of studies in the last 10 years report a high prevalence of LVO in patients presenting with AIS. These rates of LVO may have implications for the volume of patients with AIS who may benefit from endovascular therapy.

Topical glaucoma medications have favorable safety and efficacy, but their use is limited by factors such as side effects, nonadherence, costs, ocular surface disease, intraocular pressure fluctuations, diminished quality of life, and the inherent difficulty of penetrating the corneal surface. Although traditionally these limitations have been accepted as an inevitable part of glaucoma treatment, a rapidly-evolving arena of minimally invasive surgical and laser interventions has initiated the beginnings of a reevaluation of the glaucoma treatment paradigm. This reevaluation encompasses an overall shift away from the reactive, topical-medication-first default and a shift toward earlier intervention with laser or surgical therapies such as selective laser trabeculoplasty, sustained-release drug delivery, and micro-invasive glaucoma surgery. Aside from favorable safety, these interventions may have clinically important attributes such as consistent IOP control, cost-effectiveness, independence from patient adherence, prevention of disease progression, and improved quality of life.

Achieving a target intraocular pressure (IOP) in patients with ocular hypertension and open-angle glaucoma has many barriers, some treatment specific and others patient specific. Nonadherence to IOP-lowering eyedrops is one of the major barriers to effective glaucoma treatment. There is a wide range of patients who may benefit from non-topical treatment modalities such as selective laser trabeculoplasty and sustained-release drug delivery, including those who face challenges with topical eyedrops, and those who find benefit in independence from daily medication administration. Sustained-release drug delivery options for lowering IOP include the bimatoprost intracameral implant 10 µg (Bim-I), a relatively new treatment option. This article provides expert opinion on the use of the implant based on available literature, supplementary analysis of clinical trial data, and the experience of the authors who have performed thousands of Bim-I administrations. A single administration of Bim-I has demonstrated the potential to reduce IOP and the need for topical IOP-lowering medication for up to 2 years. Evidence suggests that the safety profile of the implant is most favorable in patients with wide-open (Shaffer grade 4) angles. Recommendations regarding the administration procedure and patient follow-up are provided. The objective of this expert opinion is to help optimize patient selection for Bim-I administration, the implantation procedure, follow-up management, and clinical outcomes while minimizing and addressing potential complications.

To report 12-month efficacy outcomes of 360° canaloplasty and 180° trabeculotomy using the OMNI surgical system in combination with phacoemulsification in patients with mild-moderate open-angle glaucoma (OAG) and visually significant cataract. Fifteen multi-subspecialty ophthalmology practices and surgery centers located in 14 US states. Prospective, multicenter, IRB approved study of patients treated with canaloplasty (360°) and trabeculotomy (180°). Eligible patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤33 mmHg on 1 to 4 hypotensive medications. Unmedicated post-washout mean diurnal IOP (DIOP) ≥21 and ≤36 mmHg. Medication washout preoperatively and prior to month 12 DIOP. Effectiveness outcomes were IOP and IOP lowering medication use. Safety outcomes included adverse events and secondary surgical interventions (SSIs). Evaluations at 1, 3, 6, and 12 months. A total of 149 subjects underwent surgery and 120 were included in the final effectiveness analysis. Mean (standard deviation) unmedicated diurnal IOP was reduced from 23.8 (3.1) mmHg at baseline to 15.6 (4.0) at month 12 (-35%) and medications (before washout) were reduced from 1.8 (0.9) at baseline to 0.4 (0.9) at month 12 (-80%). At month 12, 84.2% of eyes achieved IOP reductions >20% from baseline, 80% of eyes were medication-free, and 76% of eyes achieved IOP between 6-18 mmHg inclusive. Adverse events were uncommon. Most were mild and self-limited including transient hyphema (9 of 149; 6%) and transient IOP elevations (3 of 149; 2.0%). No eyes required SSIs or experienced loss of VA that was attributable to the device or procedure. Canaloplasty and trabeculotomy performed with the OMNI surgical system at the time of phacoemulsification significantly reduces unmedicated mean diurnal IOP and medication use 12 months postoperatively, with an excellent safety profile. This procedure should be considered for eyes with mild-moderate OAG to reduce IOP, medication burden, or both.

Abstract Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. We review the literature and discuss the pathophysiology, symptomatology, management, and treatment of bilateral carotid cavernous fistulas. Within our own cases, treatment of the patients was varied. The patient in case 1 was successfully treated with endovascular therapy after a failed trial of anticoagulation. The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.

To report interim 6-month safety and efficacy outcomes of 360° canaloplasty and 180° trabeculotomy using the OMNI Surgical System concomitantly with phacoemulsification in patients with open-angle glaucoma (OAG). Fifteen multi-subspecialty ophthalmology practices and surgery centers located in 14 states (Alabama, Arizona, Arkansas, Florida, Georgia, Iowa, Kansas, Montana, Nebraska, North Dakota, Oklahoma, Pennsylvania, Texas, and Wisconsin). Prospective, multicenter, IRB approved study of patients treated with canaloplasty (360°) and trabeculotomy (180°). Eligible patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤33 mmHg on 1 to 4 hypotensive medications. Medication washout prior to baseline diurnal IOP (Goldmann). Effectiveness outcomes included mean IOP and medications. Safety outcomes included adverse events (AE), best corrected visual acuity (BCVA) and secondary surgical interventions (SSI). Analysis includes descriptive statistics and t-tests evaluating change from baseline. A total of 137 patients were enrolled and treated. Mean diurnal IOP after washout was 23.8 ± 3.1 mmHg at baseline. At month 6, 78% (104/134) were medication free with IOP of 14.2 mmHg, a mean reduction of 9.0 mmHg (38%). 100% (104/104) had a ≥ 20% reduction in IOP and 86% (89/104) had IOP ≥6 and ≤18 mmHg. The mean number of medications at screening was 1.8 ± 0.9 and 0.6 ± 1.0 at month 6. AE included transient hyphema (4.6%) and IOP elevation ≥10 mmHg (2%). There were no AE for loss of BCVA or recurring hyphema. There were no SSI. Canaloplasty followed with trabeculotomy and performed concomitantly with phacoemulsification has favorable intra and perioperative safety, significantly reduces IOP and anti-glaucoma medications through 6 months in eyes with mild-moderate OAG.