The STARflo™ glaucoma implant: a single-centre experience at 24 months Abstract Purpose To evaluate the 24-month outcomes following STARflo™ implantation in patients with moderate or advanced open-angle glaucoma. Methods We enrolled 32 patients (40 eyes) with high intraocular pressure (IOP) resistant to topical and systemic medical therapy. After baseline assessments, patients were implanted with STARflo™ implants with the goal of IOP reduction and long-term maintenance. Patients were followed for 24 months. Complete success of implantation was defined as a restoration of normal IOP without topical glaucoma medications, while qualified success was defined as a restoration of normal IOP with implantation and topical glaucoma medications. Results STARflo™ did not satisfactorily reduce IOP at 24 months. Twenty-eight eyes (70%) had elevated IOP at least once during the 24 months post-implantation period. Five eyes (12.5%) developed corneal decompensation. The average IOP 24 months after the surgery was 13.42 ± 6.03 mmHg and was not significantly different than IOP at 12 months (13.2 ± 5.59 mmHg). Moreover, 45% of treated eyes needed additional glaucoma procedures after 1 year and 2 years to achieve these IOPs. STARflo™ did reduce the average number of topical glaucoma medications from 2.7 pre-implantation to 1.17 at 24 months postoperatively in the rest 55% of the eyes. Conclusions The STARflo™ implantation did not meet success criteria and so appears to be an ineffective alternative to filtering surgical procedures for patients with treatment-refractory open-angle glaucoma.

Answer to the Letter to the Editor relating: Lytvynchuk LM, Falkner-Radler CI, Krepler K, Glittenberg CG, Ahmed D et al. “Dynamic intraoperative optical coherence tomography for inverted internal limiting membrane flap technique in large macular hole surgery” Graefe’s Arch Clin Exp Ophthalmol 2019 May 29; https://doi.org/10.1007/s00417-019-04364-5 written by Michalewska Z. and Nawrocki J.

Acute and chronic optic nerve head biomechanics and intraocular pressure changes in patients receiving multiple intravitreal injections of anti-VEGF Abstract Purpose To evaluate acute and chronic changes in optic nerve head (ONH) structures and intraocular pressure (IOP) in patients receiving intravitreal injections (IVIs) of anti-VEGF. Methods Twenty-nine eyes receiving IVIs for the first time were studied. IOP, retinal nerve fiber layer (RNFL) thickness, and ONH structures were evaluated by Spectralis optical coherence tomography with enhanced depth imaging technology. Structures were measured before and 5 min after each one of the three monthly injections of a loading dose treatment. In 13 eyes (44.8%) with more than six IVIs, another evaluation pre and immediately postinjection was performed after 1 year. Results A significant acute and transient IOP increase (all p ≤ 0.001), Bruch’s membrane opening (BMO) enlargement (p ≤ 0.001), cup widening (p < 0.05) and deepening (p ≤ 0.001), and prelaminar tissue thinning (p ≤ 0.001) were observed 5 min after each injection. Compared with baseline values, a significant BMO expansion (p = 0.001) and RNFL thinning (p < 0.001) were observed in the third month. In eyes with more than six IVIs, similar immediate postinjection changes, including IOP increase (p = 0.001), prelaminar tissue thinning (p = 0.007), and cup deepening (p = 0.012) were observed at 1 year, while BMO expansion was not significant (p = 0.556). Compared with baseline preinjection values, a significant BMO expansion (p = 0.003), prelaminar tissue thinning (p = 0.011), and cup deepening (p = 0.006) in the inferior region of the ONH occurred. No change in IOP was observed at the end of follow-up. Conclusions Repeated IVIs could lead to irreversible changes in ONH structures. Large-scale, prospective studies are required to determine the long-term effects of anti-VEGF treatments in ONH tissues.

Influence of holding weights of different magnitudes on intraocular pressure and anterior eye biometrics Abstract Purpose This study is aimed at determining the impact of holding weight corresponding to the 10% and 20% of participants’ body weight during 5-min on intraocular pressure (IOP) and anterior eye biometrics. Methods Eighteen healthy young adults grabbed two jugs with comfort-grip handles, which were filled with water in order to achieve the desirable load (10% and 20% of participants’ body weight). A rebound tonometer and Oculus Pentacam were used to assess IOP and anterior segment biometrics, respectively, at baseline, after 0.5, 2, 3.5, and 5 min of holding weights, as well as after 0.5 and 2 min of recovery in each experimental condition (control, 10%, and 20%). Results There was a significant effect of the load used on IOP (p = 0.016, ƞp2 = 0.215) and anterior chamber angle (p = 0.018, ƞp2 = 0.211), with the load corresponding to 20% of participants’ body weight promoting a significant IOP rise (corrected p value = 0.035, d = 0.67), and anterior chamber angle reduction (corrected p value = 0.029, d = 0.69) in comparison with the control condition. No effects of holding weight were observed for anterior chamber depth and central corneal thickness (p > 0.348). Conclusions Our data evidence that holding weight during 5 min increases IOP and narrows the anterior chamber angle, being these effects significant when using a load corresponding to 20% of body weight. Based on the current outcomes, lifting or carrying heavy loads may be discouraged for glaucoma patients or individuals at high risk for glaucoma onset, although future studies should explore the clinical relevance of our findings.

Effect of topical steroids on recently developed incomplete nasolacrimal duct obstruction: optical coherence tomography study Abstract Purpose To evaluate the effect of a topical steroid instillation on recently developed incomplete nasolacrimal duct obstruction (NLDO) evaluated by using anterior segment optical coherence tomography (ASOCT). Methods Forty-nine eyes of 31 patients with incomplete NLDO who developed epiphora within 3 months were recruited and treated with a topical steroid for 3 months. Tear meniscus height (TMH) and area (TMA) were measured by ASOCT. The treatment was considered to be effective when there was improvement of subjective epiphora, normal tear meniscus on slit lamp examination, a fluorescein dye disappearance test with grade 0 or 1, and TMH < 250 μm on ASOCT. The treatment effectiveness and associated factors were analyzed. Results Treatment was effective in 24 eyes (49.0%) after 6 months of follow-up. TMH and TMA at 3 months were significantly decreased in the effective group on ASOCT (TMH: from 385 to 268 μm, p = 0.002, TMA: from 0.0564 to 0.0266 mm2, p = 0.001, Wilcoxon test). In the effective group, the eyes with normal tear meniscus at 1 month were significantly more frequent than those in the ineffective group (p < 0.001, Fisher’s exact test). No patient in the effective group required further invasive management during 3 years of follow-up. Conclusions Topical steroid instillation has a significant therapeutic effect on recently developed incomplete NLDO. Additional invasive procedures were avoided in half of the subjects.

Breakdown of the blood-eye barrier in choroidal melanoma after proton beam radiotherapy Abstract Purpose Irradiation of choroidal melanoma is a safe and globe preserving procedure. Chronic inflammatory processes and ischemia are the main reasons for secondary enucleation in the long run. The aim of this study was to determine whether intraocular inflammation and especially inflammatory response after proton beam therapy (PBT) is related to primary tumor characteristics such as height, tumor volume, and initial flare values. Methods Twenty-six patients treated for uveal melanoma using PBT were included. All patients were examined for signs of inflammation using laser flare photometry (LFP). Each examination included assessment of the melanoma and fellow eye (which acted as the control) and imaging of the melanoma. Results Significant differences of flare values between melanoma eyes and control group were found both at baseline (median 17.65 ph/ms (min 4, max 37.10), 7.45 ph/ms (min 0.80, max 16.40), respectively) and during follow-up (median 21.45 ph/ms (min 4.5, max 70.90); 6.05 ph/ms (min 2.40, max 16.40), respectively) (p < 0.001, Wilcoxon test). Flare values in melanoma eyes increased significantly after PBT (p = 0.005, Wilcoxon test) and after a follow-up of 94 days (median, 7–420 days). Flare values of the control group did not change (p = 0.946, Wilcoxon test). The increase of flare values correlated significantly with maximum tumor height and volume (Spearman-Rho 0.633, p = 0.001 and 0.519, p = 0.007, respectively). Conclusion LFP has proven to show significantly higher flare values in melanoma eyes as compared with the control group and provides data on the course of the inflammatory response after treatment. It may ease treatment planning both at baseline and during follow-up.

Short-term effects of anti-vascular endothelial growth factor on peripapillary choroid and choriocapillaris in eyes with neovascular age-related macular degeneration Abstract Purpose To investigate the effects of anti-vascular endothelial growth factor (anti-VEGF) on the peripapillary choroid and choriocapillaris in eyes with neovascular age-related macular degeneration (nAMD). Methods We included consecutive patients who underwent three monthly intravitreal injections of aflibercept or ranibizumab for nAMD, followed by swept-source optical-coherence tomography angiography (SS-OCTA). Peripapillary choroidal thickness (CT) and vascular density (VD) of the peripapillary choriocapillaris were measured in SS-OCT and OCTA images at baseline and at 1 month after three monthly injections of anti-VEGF. Results In 68 eyes of 68 patients with nAMD, peripapillary CT decreased from 124.5 ± 69.9 μm to 116.5 ± 68.2 μm (P = 0.003) after three monthly intravitreal injections of anti-VEGF. The mean vascular density (VD) of the peripapillary choriocapillaris also decreased from 73.99 ± 6.33 to 71.82 ± 6.51 (P < 0.001). The change in the peripapillary choriocapillaris VD was significantly affected by baseline peripapillary choriocapillaris VD, baseline peripapillary CT, and type of nAMD (P = 0.004, P = 0.028, P = 0.015, respectively). The baseline VD of the choriocapillaris was lower in non-responders (median, 70.63; 25–75%, 68.12–71.27) than in responders (median, 75.32; 25–75%, 70.09–79.96) (P = 0.032). Conclusion These results suggest that anti-VEGF injection influences the peripapillary choriocapillaris flow out of exudative lesions, and that its effects depend on the baseline status of the choroid and choriocapillaris.

Vitreo-macular interface disorders in retinitis pigmentosa Abstract Purpose To investigate the prevalence and progression of vitreo-macular interface disorders (VMID) phenotypes and their natural history in retinitis pigmentosa (RP). Methods A total of 257 eyes of 145 RP patients with VMID were retrospectively evaluated. Patients were divided according to the VMID subtypes into epiretinal membranes (ERMs), vitreo-macular traction (VMT) group, and macular hole (MH). Serial eye-tracked spectral-domain optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA) changes were analyzed for a mean follow-up of 36.95 months. The status of posterior vitreous cortex was also considered. A control group of 65 eyes belonging to 65 RP patients with no macular changes was also recruited. Results VMID and control groups had the same baseline BCVA (0.50 vs 0.44 LogMAR) and did not differ in terms of phakic status. Different VMID groups had similar BCVA at baseline (p = 0.98). ERM represented the most prevalent disorder (207/257 eyes, 80.5%), followed by 35/257 (13.6%) VMT, and 15/257 Lamellar MH (LMH) eyes (5.8%). There were no cases of full thickness MH. Throughout the 36.9 months of follow-up, BCVA decreased an average 0.09 LogMAR from 0.31 to 0.4 in VMID patients and 0.01 in controls. VMID subgroup analysis showed a significant BCVA decrease in ERM patients (− 20.29%, p < 0.001), while VMT and LMH did not change significantly. Foveal thickness also remained stable over time. Complete PVD was present in 11 eyes in ERM, VMT, and LMH. Conclusions Our study confirms the high prevalence of VMID in RP patients; however, only ERMs determined a significant loss of vision over 24 months. The high prevalence of VMID in RP patients suggests that macular alteration other than edema represents part of disease spectrum.

Postoperative pain following Descemet membrane endothelial keratoplasty (DMEK): a prospective study Abstract Purpose To evaluate postoperative pain following Descemet membrane endothelial keratoplasty (DMEK). Methods Seventy-one patients completed perioperatively (day before surgery, day of surgery, 1st, 2nd, and 3rd day after surgery) four different questionnaires (a hospital internal protocol, QUIPS, PainDETECT®, and SF36) regarding their pain and other clinical parameters such as constipation, tiredness, vertigo, sleep disorders, concentration disorders, nausea, and emesis. All standardised questionnaires were evaluated to quantify average pain intensity as well as maximum pain intensity (NRS, 0 [no pain] to 10 [maximal pain], respectively). Analgesic treatment and intraocular pressure (IOP) during the perioperative stay were documented. Results Mean average pain intensity was 0.70 ± 1.64 before surgery, 1.97 ± 2.05 on the day of surgery, 1.39 ± 1.68 on day 1, 0.87 ± 1.36 on day 2, and 0.81 ± 1.24 on day 3 after surgery. Maximum pain intensity was 0.65 ± 1.81 before surgery, 3.35 ± 2.98 on the day of surgery, 2.68 ± 2.99 on day 1, 1.49 ± 2.15 on day 2, and 1.26 ± 2.02 on day 3 after surgery. During the first three postoperative days, over 90% of the patients stated no or well tolerable pain. Eighty-three percent had postoperatively no need for analgesics at all. On the first two postoperative days, maximum IOP correlated significantly with reported increased maximum pain intensity (p = 0.043 and p = 0.029, respectively). All patients had very little problems with constipation, tiredness, vertigo, sleep disorder, concentration disorders, nausea, and emesis. Conclusions DMEK is associated with low postoperative pain intensity. Strong pain increase may indicate IOP elevation and should be further investigated and treated. Clinical trial registration German Clinical Trial Register (DRKS00013995)

Results of lamellar macular hole-associated epiretinal proliferation embedding technique for the treatment of degenerative lamellar macular hole Abstract Purpose To investigate the outcomes of embedding lamellar hole-associated epiretinal proliferation (LHEP) into retinal cleavage for the surgical treatment of degenerative lamellar macular hole (LMH). Methods We retrospectively reviewed the medical records of 34 consecutive eyes of degenerative LMH patients who underwent vitrectomy with LHEP embedding and who were followed up for at least 12 months. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), and macular structure preoperatively and at the final follow-up were compared. Results The mean (±SD) follow-up period was 30.0 ± 17.7 months. Twelve patients (35.3%) were men, and the mean age was 69.6 ± 10.1 years. Twenty-three eyes (67.6%) underwent simultaneous cataract surgery. BCVA was significantly improved at the final visit, from 0.31 ± 0.25 logarithm of the minimum angle of resolution units to 0.10 ± 0.25 (P < 0.01). This improvement in mean BCVA at the final postoperative visit occurred regardless of whether the eyes underwent simultaneous cataract surgery, from 0.30 ± 0.26 preoperatively to 0.04 ± 0.16 (P < 0.01) in the “with cataract surgery” group and from 0.32 ± 0.26 preoperatively to 0.21 ± 0.35 (P < 0.05) in the “without cataract surgery” group. CRT was also significantly improved at the final visit, from 123.2 ± 42.6 μm preoperatively to 191.2 ± 42.6 μm (P < 0.01). External limiting membrane and ellipsoid zone defects were detected in 17 (50.0%) and 15 (44.1%) eyes, respectively, but these were resolved in 10 (58.8%) and 7 (46.7%) eyes, respectively, at the final visit. No intraoperative or postoperative complications were observed. Conclusions Embedding LHEP may be an effective and safe procedure to treat degenerative LMH.