Making a Correct Diagnosis of Glaucoma: Data From the EMGT Précis: A correct diagnosis of glaucoma established at initial visits. Purpose: It has been suggested that a diagnosis of glaucoma cannot be certain until progression has been demonstrated. Our aim was to evaluate the correctness of a glaucoma diagnosis established after 2 initial visits. Patients and Methods: Patients included in the Early Manifest Glaucoma Trial (EMGT) who had continued follow-up for at least 15 years were included in this analysis. The patients had been recruited primarily through a population screening and were diagnosed with glaucoma if the Glaucoma Hemifield Test was outside normal limits in the same sector at two consecutive visits. A Glaucoma Hemifield Test classification of borderline was also diagnostic if corresponding optic disc findings were present. At least one of the following criteria had to be fulfilled during follow-up to confirm the initial diagnosis: (1) visual field progression in at least one eye according to the EMGT criterion; (2) development of manifest glaucoma in an initially ineligible fellow eye; (3) optic disc progression in at least one eye; (4) optic disc hemorrhages in at least 1 eye. Results: Of the 255 patients included in the EMGT, 117 were followed for at least 15 years, representing 147 eyes eligible for our study. During follow-up, 134 eyes (91%) showed visual field progression, and, of the remaining 13 eyes, only 4 (3%) did not fulfill any of the criteria to confirm the diagnosis. Conclusions: A diagnosis made applying strict criteria to 2 initial visual field tests, supported by optic disc findings if visual field findings were borderline, was almost always correct.

Long-term Clinical Outcomes of Ahmed and Baerveldt Drainage Device Surgery for Pediatric Glaucoma Following Cataract Surgery Precis: In this retrospective case series, both Baerveldt and Ahmed glaucoma drainage devices resulted in good long-term outcomes in eyes with pediatric glaucoma following cataract surgery (GFCS). Background: The aim of this study was to describe the long-term safety and efficacy of primary glaucoma drainage device surgery in patients with pediatric GFCS. Methods: We retrospectively identified 28 eyes of 28 patients with GFCS that underwent tube shunt surgery with the Ahmed Glaucoma Valve or Baerveldt Glaucoma Implant. The primary outcome measure was a surgical failure, defined as intraocular pressure (IOP) >21 mm Hg or not reduced by 20% below baseline on 2 consecutive follow-up visits after 3 months, IOP <5 mm Hg on 2 consecutive follow-up visits after 3 months, and reoperation for glaucoma. Results: The mean duration between cataract removal and the diagnosis of glaucoma was 3.6±1.5 years. Kaplan-Meier survival curves indicated a mean time to failure of 41.9±2.1 months after drainage device surgery. The cumulative probability of failure at 1, 2, 3, and 4 years was 3.6%, 19%, 28%, and 28%. IOP was significantly decreased from 29.3±4.1 mm Hg preoperatively to 17.6±1.6 mm Hg at the final follow-up visit (P<0.001). The number of glaucoma medications at baseline was 3.1±0.6, which decreased to 2.1±0.7 at the final visit (P=0.001). Conclusions: Glaucoma drainage device surgery results in good long-term outcomes in patients with GFCS.

Role of Pattern Electroretinogram in Ocular Hypertension and Early Glaucoma Purpose: To test whether pattern electroretinogram (PERG) can early detect retinal ganglion cells dysfunction in ocular hypertension. Design: Cross-sectional observational study. Participants: The study included 3 groups: control, primary open-angle glaucoma (POAG) and ocular hypertension (OHT) groups with 30 eyes in each group. Materials and Methods: Visual fields were examined using automated perimetry with central 24-2 program. Optical coherent tomography (OCT) was done to assess the neuroretinal rim area, vertical cup/disc ratio, and average superior and inferior retinal nerve fiber layer thickness. PERG was recorded using skin electrodes. Amplitude and latency of P50 and N95 were documented. Results: PERG data: the mean P50 and N95 latency were significantly higher in the POAG group and the OHT group compared with the control group (P<0.001, <0.001, respectively). Also, the mean P50 and N95 amplitude were significantly lower in the POAG group and the OHT group compared with the control group (P<0.001,<0.001, respectively). In the POAG group, there was a significant negative correlation between PSD on one hand and P50 amplitude (r=−0.620, P=0.001) and N95 amplitude (r=−0.61, P<0.001) on the other hand. Also, the mean deviation was positively correlated with P50 amplitude (r=0.51, P=0.007) and N95 amplitudes (r=0.50, P=0.002). However, there was no significant correlation between PERG parameters and OCT parameters. In the OHT group, PERG parameters did not correlate with visual field and OCT parameters. Conclusions: PERG can detect the dysfunctional, but still live retinal ganglion cells earlier than OCT in OHT cases, allowing the early start of treatment that can restore the ganglion cell function before irreversible damage occurs.

Childhood Glaucoma: Long-Term Outcomes of Glaucoma Drainage Device Implantation Within the First 2 Years of Life Précis: Glaucoma drainage device (GDD) implantation within the first 2 years of life yields an overall success rate of 59.0% at 5 years. It is safe and requires a relatively low number of postoperative interventions. Purpose: The purpose of this study was to evaluate the long-term outcomes of the treatment of childhood glaucoma with GDDs within the first 2 years of life. Methods: A total of 43 children (60 eyes) having undergone GDD implantation within the first 2 years of life at Moorfields Eye Hospital between July 2005 and November 2014 were included in this retrospective case series. Kaplan-Meier survival curves were created for the evaluation of surgical success. Log-rank analysis was performed for the detection of risk factors for failure. Main outcome measures: Overall success rates at 1, 5, and 7 years after surgery. Surgical success: intraocular pressure ≥5/≤21 mm Hg, no further glaucoma surgery required, nonoccurrence of loss of perception of light or devastating complications. Results: The results are listed as follows: Median duration of follow-up was 48.0 months. Median age at surgery was 11.5 months. Seventy-three percentage of children were white. Most common types of glaucoma were primary congenital glaucoma [(PCG); 67%], glaucoma following cataract surgery (18%), and anterior segment dysgenesis (10%). Overall success rates were 93%, 59%, and 59%, respectively. There were no differences in the survival rates as a function of PCG/non-PCG, sex, and removal of intraluminal stent suture. Mean number of general anesthesia administrations during the first postoperative year was 1.8. Conclusions: GDD implantation within the first 2 years of life is effective and safe. The low number of general anesthesia administrations required during the first postoperative year could help to reduce the burden placed on children and carers. Further research is required to directly compare the efficiency of GDD implantation with other surgical options.

Surgical Outcomes of Prolene Gonioscopy-assisted Transluminal Trabeculotomy in Patients With Moderate to Advanced Open-Angle Glaucoma Précis: The present study demonstrates that surgical success rate of gonioscopy-assisted transluminal trabeculotomy (GATT) is 83.7% according to target intraocular pressure (IOP) ≤21 mm Hg and ≥20% reduction from baseline in patients with moderate to advanced glaucoma, with an average follow-up of 19.4 months. Purpose: The aim of the study was to assess the outcomes of GATT in eyes with moderate to advanced open-angle glaucoma. Patients and Methods: A retrospective study included 104 eyes of 104 patients, with a mean age of 58.9±18.5 (15 to 87) years, who underwent GATT using the 6/0 prolene suture to treat open-angle glaucoma. The GATT procedure was carried out alone or in combination with phacoemulsification. IOP at baseline, third, sixth, ninth, 12th, and 18th months of follow-up; need of antiglaucoma medication; need of further glaucoma surgery; cup/disc ratio; and best-corrected visual acuity (BCVA) were recorded. Patients with prior incisional glaucoma surgery were excluded. Surgical success was determined for both IOP <21 and <18 mm Hg and also ≥20% reduction from baseline without further glaucoma surgery. Results: A total of 65 patients with primary open-angle glaucoma (POAG) and 39 patients with secondary open-angle glaucoma (SOAG), including pseudoexfoliative, pigmentary, uveitic, and steroid-induced glaucoma underwent GATT. Preoperative mean IOP was 25.0±7.3 mm Hg. Preoperative average number of antiglaucoma medications was 3.4±0.6. The average follow-up time was 19.4±8.1 (6 to 37) months. Preoperative average BCVA was 0.51±0.24, and cup/disc ratio was 0.85±0.14. Surgical success was achieved in 87 of 104 (83.7%). Seven patients had medically uncontrolled glaucoma after GATT surgery, and they underwent further surgery. Patients with POAG had a higher percentage of IOP reduction than patients with SOAG at 18th month of follow-up (40.1% vs. 27.6%). Need for medication at final visit was similar between POAG and SOAG. Conclusion: GATT procedure is a safe and successful option for the treatment of moderate to advanced open-angle glaucoma. Surgical success could be maintained up to ∼18 months.

Longitudinal Analysis of Bruch Membrane Opening Morphometry in Myopic Glaucoma Précis: The Bruch membrane opening (BMO) was posteriorly bowed and the degree of nonplanarity increased in stable and progressive glaucoma subjects. BMO became more posterior relative to the Bruch membrane (BM) in control and both stable and progressive glaucoma subjects. Purpose: To investigate longitudinal changes in morphologic characteristics of the BMO in control and glaucomatous subjects. Materials and Methods: A total of 53 myopic eyes (17 control, 6 suspect, 20 stable glaucoma, and 10 progressing glaucoma) were followed for an average of 4.2±1.4 years and imaged at the baseline and 2 follow-up appointments using a 1060 nm swept-source optical coherence tomography system. BM and BMO were segmented, and 4 morphometric BMO parameters (area, ellipse ratio, nonplanarity, and depth) were measured. Results: There were no significant changes in BMO area or ellipse ratio for all groups. BMO nonplanarity was shown to increase in the glaucoma groups. BMO depth relative to BM increased in all groups except the suspects (control: 8.1 µm/y, P=0.0001; stable glaucoma: 3.5 µm/y, P=0.0001; progressing glaucoma: 14.0 µm/y, P=0.0026). In linear mixed-model analysis, axial length was positively associated with BMO area in all groups except for progressing glaucoma, and with BMO nonplanarity in stable glaucoma. It was not a significant factor to the slopes of the BMO parameters in the ANCOVA analysis of slopes. Conclusions: Longitudinally, BMO increased in nonplanarity in the glaucoma eyes, and its axial position relative to BM became more posterior in both control and glaucoma eyes.

Older Drivers and Glaucoma in India: Driving Habits and Crash Risks Précis: In India, older drivers with glaucoma show greater driving difficulty but are not involved in higher number of on-road accidents. To achieve balance between safety aspects and independence for drivers with glaucoma is important. Purpose: The purpose of this study was to analyze driving habits of patients with glaucoma and to compare their driving behavior, driving difficulties, and accident rates with nonglaucoma controls. Patients: Patients with glaucoma aged older than 40 years were recruited. Subjects with best-corrected visual acuity ≤6/24 in the better-seeing eye and those having primary eye disorder other than glaucoma were excluded. Age-matched nonglaucoma controls were recruited. Subjects with clinically significant cataract and/or with best-corrected visual acuity ≤6/24 in both eyes were excluded. All cases and controls were legally licensed to drive. Materials and Methods: In this study, Driving Habits Questionnaire was used. Collected data were statistically analyzed using SAS, version 9.2 (GLM procedure), and IBM SPSS, version 22. P-values <0.05 were considered statistically significant. Results: All controls and 84% (n=84/100) of cases were current drivers. Among them, 16% (n=16/100) cases had stopped driving, of which 31.25% (n=5/16) had stopped because of self-reported ocular causes. Cases drove lesser number of days per week (P=0.001) and had more driving dependence on other drivers (44%, n=37/84) compared with controls. Glaucoma was significantly associated with driving difficulty in the rain, in rush-hour traffic, and at night. Comparing driving difficulty scores and visual field index within glaucoma group showed statistical significance [F(1,82)=22.12, P<0.001]. Composite scores of driving difficulty (P<0.001) and driving space (P=0.003) between the 2 groups showed strong statistical significance. Controls had higher number of self-reported accidents (P<0.001). Conclusions: Patients with glaucoma show greater driving difficulty, self-regulate their driving behavior, and restrict their driving. Older patients with glaucoma in India are not involved in higher rates of on-road crash risks compared with nonglaucoma drivers.

Outcomes of Micropulse Transscleral Cyclophotocoagulation in Eyes With Good Central Vision Precis: This study is the first to report micropulse transscleral cyclophotocoagulation (MP-TSCPC) use in only good vision patients. MP-TSCPC significantly reduced intraocular pressure (IOP) and glaucoma medication use without any significant reduction in visual acuity at every postoperative follow-up point. Purpose: To evaluate outcomes of MP-TSCPC in eyes with baseline best-corrected visual acuity (BCVA) of ≥20/60. Methods: A retrospective review of patients who underwent MP-TSCPC at Mayo Clinic and Ross Eye Institute from July 2016 to August 2017 with BCVA of ≥20/60, and a minimum of 3 months follow-up. Results: A total of 61 eyes of 46 patients (68.80±17.12 y) underwent MP-TSCPC with a mean follow-up of 10.2±3.1 months. Mean IOP and mean number of glaucoma medications used were significantly reduced from baseline at every follow-up time point (P<0.0001). At month 12, mean IOP was reduced 40.2% from baseline with 85.4% of the patients having an IOP reduction of ≥20%, and mean glaucoma medication use reduced by 0.82±0.53 with 79.6% of the patients having a reduction of ≥1 medication. There was no significant reduction in BCVA from baseline at any follow-up point (P>0.05), except for 10 eyes with a vision loss of ≥2 lines and 5 out of 10 eyes had cataract progression. The probability of complete success (IOP range, 6 to 21 mm Hg or ≥20% IOP reduction; BCVA loss ≤2 lines, no reoperation for glaucoma) was 74.14%, 83.61%, 84.21%, and 75.0% at months 1, 3, 6, 12, respectively. The probability of qualified success (above criteria for IOP, no reoperation and BCVA loss >2 lines) was 81.03%, 91.80%, 94.74%, and 93.75% at months 1, 3, 6, 12, respectively. Conclusions: MP-TSCPC should be considered earlier in the management of glaucoma and can possibly be offered as an alternative to incisional glaucoma surgeries.

Glaucoma Drainage Devices and Reasons For Keratoplasty Précis: Over 10 years in a tertiary care setting, glaucoma drainage devices (GDDs) have not increased as a reason for keratoplasty. Purpose: The purpose of this study was to determine whether the reasons for keratoplasty have changed between 10 years in a tertiary care setting, with special attention to the rate of GDDs as a reason for keratoplasty. Methods: Patients aged 18 years or above who underwent keratoplasty at Mayo Clinic, Rochester, MN from 2005 to 2006 and 2015 to 2016 were studied. All reasons for keratoplasty performed in the study time period are assessed, including patients who previously had a GDD implanted in the same eye. After analyzing the reasons for keratoplasty, we assess whether the reasons for keratoplasty have changed between 2005 to 2006 and 2015 to 2016 in association with the increasing placement of GDDs. Results: The number of keratoplasty procedures performed in the 2 time periods increased by 62% from 163 (2005 to 2006) to 264 (2015 to 2016), whereas GDD placement increased by 164% from 80 GDD (2005 to 2006) to 211 GDD (2015 to 2016). Although the performance of keratoplasty increased between the 2 points in time, the frequency of each cause for keratoplasty did not change significantly. The majority of keratoplasties were performed due to corneal disease, and GDDs made up a small portion of reasons for keratoplasty (2005 to 2006, 4.29%; 2015 to 2016, 5.68%). Conclusions: The frequency of GDDs as a reason for keratoplasty has not changed significantly between 10 years in this tertiary care setting. Patients with GDDs who later required keratoplasty had associated features including multiple surgical procedures and comorbid infection, pseudophakic bullous keratopathy, Fuchs dystrophy, pseudoexfoliation, uveitis, and congenital glaucoma.

Mitomycin C-augmented Phacotrabeculectomy Versus Phacoemulsification in Primary Angle-closure Glaucoma: A Randomized Controlled Study Precis: Phacotrabeculectomy yielded similar results to phacoemulsification in primary angle-closure glaucoma (PACG) in terms of intraocular pressure (IOP) lowering, glaucoma medications and success rates. Although releasable sutures may have reduced the risk of hypotony; complications and interventions were more common with phacotrabeculectomy. Purpose: To compare the efficacy and safety of phacotrabeculectomy using releasable sutures and adjunctive mitomycin C versus phacoemulsification alone in the management of PACG. Patients and Methods: In total, 63 eyes of 63 PACG patients were randomized to undergo either mitomycin C-augmented phacotrabeculectomy with tight scleral flap closure using releasable sutures aiming at no flow or phacoemulsification alone. The primary outcomes were success rates and complications. Secondary outcomes were IOP and glaucoma medications. Results: The IOP and glaucoma medications were significantly reduced at 1, 3, 6, and 12 months postoperatively in both groups (P<0.001). There was no statistically significant difference in IOP, IOP reduction, success rates, or survival times between both groups. Glaucoma medications were only significantly lower in the phacotrabeculectomy group at 1 and 3 months. The rates of postoperative interventions and complications were higher in the phacotrabeculectomy group. Complete success, defined as an IOP of 6 to 21 mm Hg on no medications and with no signs of glaucoma progression, was achieved in 58% in the phacotrabeculectomy group, compared with 62% in the phacoemulsification group (P=0.9). Only 2 eyes (6%) in the phacoemulsification group required a subsequent trabeculectomy. Conclusions: Trabeculectomy did not seem to add an advantage when combined with phacoemulsification in PACG patients and was associated with more postoperative interventions. Despite the use of releasable sutures to allow titration of the IOP postoperatively, the rate of hypotony and other complications was higher in the phacotrabeculectomy group.