Aqueous humor outflow (AHO) pathways are the main site of resistance causing elevated intraocular pressure in glaucoma, especially primary open-angle glaucoma patients. With the recently introduced technique of aqueous angiography (AA); functional, real time assessment of AHO from proximal (trabecuar meshwork) to distal pathways under physiological conditions has been made possible. AHO pathways are segmental, and AA can identify high-flow region (increased angiographic signals) and low flow region (decreased angiographic signals) in an individual. With the introduction of canal-based minimally invasive glaucoma surgeries (MIGS), the assessment of AHO can help guide the placement of stents/incisions during MIGS procedures. This can allow individualized and targeted MIGS procedures in glaucoma patients for better results. Based on the density of AHO pathways visualized on AA, surgeons can decide whether to perform MIGS or conventional glaucoma surgery for improved outcomes for the patient. Immediate intraoperative assessment for functionality of the MIGS procedure performed is possible with AA, allowing for surgical adjustments of MIGS procedure in the same sitting, if needed. This review provides a summary of the studies performed with AA to date, with a special focus on Indian patients. It covers the basics and clinical applications of AA for improving surgical outcomes in glaucoma patients.
The purpose of this review is to outline the risk factors, clinical features, diagnosis, and management of acute corneal hydrops in corneal ectatic disorders.The advent of newer investigative modalities aids in diagnosis and planning of treatment in cases of acute hydrops. Although visual outcome does not differ with intervention such as intracameral air/gas injection the duration of symptoms and the risk of complications decrease in comparison with medical therapy alone.The intent of this article is to highlight the various risk factors and the newer diagnostic modalities such as ultra biomicroscopy, anterior segment optical coherence tomography and confocal microscopy in cases of acute corneal hydrops. Further, the conventional as well as the newer treatment modalities are also described. Although newer diagnostic and treatment modalities are found to be useful, the available information in literature is limited. This article will encourage future prospective studies and randomized controlled trials, which may help in finding novel diagnostic and effective therapeutic techniques.
Abortion of ovule leading to lowering of seed set or seedlessness. A number of mechanisms have been suggested to occur side by side, creating a sort of “genetic sieve” which leads to development of certain embryo genotypes preferentially. These include lack of pollination, Parent-offspring conflict and sibling rivalry as internal. Several species invariably practicing obligate ovule abortion. Hyptis suaveolens (L.) Poit. (family-Lamiaceae) falls in this category. It is known by several vernacular names (American Mint, Ganga Tulsi, Vilaiyti Tulsi, Bustrena and Kallu Thumbai); an important invader of the tropical and sub-tropical regions of the world. The species behaves as a self-pollinated plant in the tropical climes of study area i.e., Jammu province of UT of J&K, India. Present work is done to explore the details of the process of ovule abortion and its implications for the invasiveness of this species.
Purpose: To evaluate the efficacy and safety of intracameral amphotericin B (ICAMB) in the management of fungal keratitis.Methods: In total, 45 eyes with smear-confirmed fungal keratitis with hypopyon were randomized into three treatment groups: Group I (topical antifungal treatment + oral antifungal); Group II (topical antifungal treatment + ICAMB + oral antifungal); and Group III (topical antifungal treatment + drainage of hypopyon + ICAMB + oral antifungal). The main outcome measures were treatment success rate, time to heal, visual acuity gain, and presence of complications.Results: There were no differences in the treatment success rates (p = 0.66), time to healing (p = 0.18), or mean final visual acuity (logMAR) (p = 0.8) between the three groups. The major complication observed was increased incidence of cataract in group III (40%), though it was statistically insignificant.Conclusions: ICAMB does not offer any benefit over topical antifungal therapy when performed alone or associated with drainage of hypopyon.
To compare the safety and efficacy of trypan blue 0.1%, gentian violet 0.001%, indocyanine green 0.5% (ICG), fluorescein 2%, and the patient's autologous blood for anterior capsule staining in cases of white cataract.Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.Fifty eyes of 50 patients with age-related white cataract had anterior capsule staining with trypan blue, ICG, or gentian violet under an air bubble or subcapsularly with fluorescein or autologous blood followed by phacoemulsification with foldable intraocular lens implantation. Each stain was used in 10 eyes. The ease of creating a continuous curvilinear capsulorhexis (CCC) and the complications during the surgery were noted. Postoperative examinations at 6 hours, 1 day, 1 week, and 1 month included slitlamp microscopy, uncorrected visual acuity, and best corrected visual acuity (BCVA). The staining patterns on the anterior capsule, side port, corneal tunnel, and anterior cortex were assessed intraoperatively and within 6 hours and at 1 day. The intraocular pressure (IOP) was assessed at 1 day; pachymetry, at 1 day and 1 month; and the endothelial cell count, at 1 month.The surgeon had best visualization during the anterior capsulorhexis with trypan blue, ICG, and gentian violet, and a complete CCC was achieved in all eyes in the 3 groups. Two eyes each in the fluorescein and autologous blood groups had extension of the CCC so that the capsulorhexis was complete but not curvilinear. Anterior capsule fibrosis was detected with trypan blue (1 eye) and ICG (2 eyes). The anterior vitreous was stained with fluorescein in 2 eyes. All eyes achieved a BCVA of 20/30 or better from 1 week postoperatively to the last follow-up. The side port and corneal tunnel were stained most intensely with gentian violet followed by trypan blue and ICG and less intensely with fluorescein and autologous blood. The IOP, pachymetry, and endothelial cell loss were comparable between the stains.Although trypan blue, ICG, gentian violet, fluorescein, and autologous blood were safely used to stain the anterior capsule for phacoemulsification in eyes with white cataract, trypan blue, ICG, and gentian violet were more effective in staining the capsule.
Inheritance and Family HistoryGlaucoma is a polygenic disease with an estimated heritability of 70%. 6First-degree relatives of glaucoma patients have a 22% lifetime risk of glaucoma as compared to 2.3% among those with no family history.About 10% of siblings of glaucoma patients have glaucoma compared to 0.7% of siblings of those without glaucoma. 7The novel loci for adult-onset glaucoma include the following: POAG, [ABCA1, AFAP1, GMDS, PMM2, TGFBR3, FNDC3B, ARHGEF12, growth arrest-specific protein 7 (GAS7), FOXC1, ATXN2, TXNRD2]; PACG, (EPDR1, CHAT, GLIS3, FERMT2, DPM2-FAM102); and exfoliation syndrome (XFS) glaucoma (calcium voltage-gated channel subunit α1 A). 8 Sixteen genomic regions have been associated with POAG, eight with PACG and two with XFS.Molecular and cellular events caused by mutations in myocilin, organ procurement and transplantation network, and TANK-binding kinase 1 have been suggested to have a role in early onset glaucoma. 8Transmembrane and coiled-coil domains 1 and GAS7 mutations can effect neuron regeneration along with IOP elevation.p38 mitogen-activated protein kinases are common pathways involved in neurodegenerative IntroductIonThough IOP remains to be the best established and most modifiable risk factor, glaucoma is best considered a progressive optic neuropathy representing the final outcome of a number of disorders.As per the current knowledge, the etiopathogenesis of glaucoma may involve either one or a combination of the following major mechanisms:• Mechanical damage/barotrauma (IOP-related).• Vascular (decreased blood supply to optic nerve head).• Biochemical (decreased levels of neurotrophic factors/increase in levels of neurotoxins/mitochondrial dysfunction).There is increasing evidence that factors not limited and related to the IOP have a significant role in the etiopathogenesis as well as the progression of glaucoma. 1We need to approach glaucoma as a systemic disease and look at each system of the human body and its impact on glaucoma.This article aims to agglomerate all the risk modifiers/stressors associated with primary open and angle closure glaucoma, which together constitute a cumulative biological risk of causation/progression of glaucomatous damage. EpIdEmIologIcal Factors AgeAge is a significant modifier of the relationship between IOP and retinal nerve fiber layer (RNFL) loss over time and older patients are more likely to have glaucoma progression than younger patients at similar IOP. 2 This may be related to mitochondrial dysfunction, inability to handle oxidative damage, vascular alterations, and changes in the biomechanics of the optic nerve head with advancing age. 3 RaceHigher prevalence, earlier presentation, and faster progression of primary open-angle glaucoma (POAG) in African and Hispanic populations can be due to thinner corneas, larger optic nerve heads, and a higher prevalence of vascular diseases such as diabetes and hypertension. 4Asians are more susceptible to primary angle closure glaucoma (PACG) due to the risk of having narrow angles.
Purpose: Topical glaucoma medication is the first line of management to reduce intraocular pressure (IOP) in patients with glaucoma. In this study, we intended to compare the ultrastructural findings of the cornea in patients with glaucoma before and after the reduction of the IOP through confocal microscopy. Methods: Ten patients (19 eyes) with newly diagnosed glaucoma were recruited from the glaucoma services of our tertiary care center. Demographic parameters were noted, and basic ocular examination, specular microscopy (Topcon SP3000P, Tokyo, Japan), and ultrasonic pachymetry (300 AP, Sonomed Escalon, Stoneham, MA, USA) were performed. In vivo confocal microscopy of corneal sections was performed using the z-ring Confoscan 4.0 (Nidek, Inc., Freemont, CA) at baseline and after 3 months of starting glaucoma medications. Results: The mean age of the patients was 53.53 ± 9.34 years. There was a statistically significant reduction ( P < 0.0001) of IOP from 30.21 ± 7.42 mmHg (baseline) to 16.42 ± 4.14 mmHg (3 months). The mean central corneal thickness at baseline was 533.42 ± 3.96 µm, and it further decreased to 521.94 ± 42.45 µm at the end of 3 months ( P = 0.006). No significant change was noted in the mean epithelial cell density, mean keratocyte density in anterior and posterior stroma, and the mean endothelial cell density and cell area ( P >0.5). There was no significant percentage change in these parameters before and after the lowering of the IOP. Conclusion: A short-term (3 months) decrease in IOP using topical glaucoma medications caused a significant reduction in corneal thickness but did not have any significant ultrastructural changes in cornea measured using confocal microscopy.
Descemet membrane endothelial keratoplasty (DMEK) is a partial-thickness corneal transplantation procedure that involves selective transplantation of Descemet membrane and endothelium. DMEK offers significant advantages over other keratoplasty techniques such as faster visual rehabilitation, better final visual acuity due to minimal optical interface effects, lower risk of allograft rejection and less long-term dependence on topical steroids. Despite all its advantages, DMEK has been found to be challenging than other corneal transplantation techniques, and its steep learning curve appears to be an obstacle to its widespread use and adoption by corneal surgeons worldwide. DMEK surgical training laboratories (wet labs) provide a window of opportunity for surgeons to learn, prepare, manipulate, and deliver these grafts in a risk-free environment. Wet labs are a significant learning tool especially for those institutions that have limited tissue availability in their local centers. We provide a step-by-step guide for preparing DMEK grafts using different techniques on human and non-human models with instructional videos. The article would eventually help the trainees and the educators understand the requirements for performing DMEK and conducting a DMEK wet lab and develop their skills and interests from a wide variety of available techniques.
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