Publications by authors named "Peter A Netland"

69 Publications

Visible-Light Optical Coherence Tomography Fibergraphy for Quantitative Imaging of Retinal Ganglion Cell Axon Bundles.

Transl Vis Sci Technol 2020 10 9;9(11):11. Epub 2020 Oct 9.

Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA.

Purpose: To develop a practical technique for visualizing and quantifying retinal ganglion cell (RGC) axon bundles .

Methods: We applied visible-light optical coherence tomography (vis-OCT) to image the RGC axon bundles, referred to as vis-OCT fibergraphy, of healthy wild-type C57BL/6 mice. After vis-OCT imaging, retinas were flat-mounted, immunostained with anti-beta-III tubulin (Tuj1) antibody for RGC axons, and imaged with confocal microscopy. We quantitatively compared the RGC axon bundle networks imaged by vis-OCT and confocal microscopy using semi-log Sholl analysis.

Results: Side-by-side comparison of confocal microscopy and vis-OCT confirmed that vis-OCT fibergraphy captures true RGC axon bundle networks. The semi-log Sholl regression coefficients extracted from vis-OCT fibergrams (3.7 ± 0.8 mm) and confocal microscopy (3.6 ± 0.3 mm) images also showed good agreement with each other ( = 6).

Conclusions: We demonstrated the feasibility of using vis-OCT fibergraphy to visualize RGC axon bundles. Further applying Sholl analysis has the potential to identify biomarkers for non-invasively assessing RGC health.

Translational Relevance: Our novel technique for visualizing and quantifying RGC axon bundles provides a potential measurement tool for diagnosing and tracking the progression of optic neuropathies.
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http://dx.doi.org/10.1167/tvst.9.11.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552935PMC
October 2020

Comparison of Silicone- and Porous-Plate Ahmed Glaucoma Valves.

Med Devices (Auckl) 2020 16;13:213-221. Epub 2020 Jul 16.

Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada.

Purpose: Our aim was to evaluate and compare the clinical outcomes after implantation of the silicone-plate (model FP7) and porous polyethylene-plate (model M4) Ahmed Glaucoma Valves.

Patients And Methods: This was a prospective, multicenter, comparative series. A total of 52 eyes (52 patients) were treated with either the silicone or porous plate Ahmed Glaucoma Valve implant. Hypertensive phase was defined as intraocular pressure >21 mmHg during the first 3 months postoperatively. Success was defined as 5 mmHg ≤intraocular pressure ≤21 mmHg (with or without additional glaucoma medications), without loss of light perception and without additional glaucoma procedures. Patients were monitored for 1 year after surgery.

Results: The pre-operative intraocular pressure was 29.9 ± 6.6 mmHg and 33.8 ± 10.5 in the silicone-plate and porous-plate groups, respectively (P = 0.118). At 12 months after surgery, the mean intraocular pressure was 13.6 ± 4.7 mmHg in the silicone-plate group and 17.9 ± 10.9 mmHg in the porous-plate group (P = 0.141). The mean number of glaucoma medications at 12 months was 1.64 ± 1.40 mmHg and 1.89 ± 1.54 mmHg in the silicone- and porous-plate groups, respectively (P = 0.605). Hypertensive phase was not significantly different in the two groups (50.0% of the silicone-plate and 57.7% of the porous-plate groups, P = 0.578). At 12 months after surgery, the percent success for the silicone-plate and porous-plate groups was 88.5% and 53.8%, respectively (P = 0.005). Complications were similar in the two groups.

Conclusion: The porous-plate Ahmed Glaucoma Valve showed similar average intraocular pressure reduction compared with the silicone-plate model. At 12 months after surgery, there was a significantly lower success rate in the porous-plate compared with the silicone-plate group.
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http://dx.doi.org/10.2147/MDER.S258498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371999PMC
July 2020

Effects of Intravitreal Anti-VEGF Therapy on Glaucoma-like Progression in Susceptible Eyes.

J Glaucoma 2019 12;28(12):1035-1040

Department of Ophthalmology, University of Virginia, Charlottesville, VA.

PRéCIS:: Intravitreal anti-vascular endothelial growth factor (VEGF) injections may accelerate glaucomatous change in patients with preexisting glaucoma or ocular hypertension (OHT). The safety of long-term injections in this specific population may be reflected in the need for additional glaucoma interventions.

Purpose: The purpose of this study was to investigate whether repeated anti-VEGF injections accelerate structural and functional glaucomatous change in eyes with preexisting glaucoma or OHT.

Materials And Methods: This is a retrospective, observational study of injected and noninjected fellow eyes. A total of 28 patients with preexisting glaucoma or OHT, who received ≥6 unilateral anti-VEGF injections for concurrent neovascular retinal disease, were selected for chart review. Primary outcome measures were rate of visual field loss in dB/year, rate of change in retinal nerve fiber layer (RNFL) thickness in microns/year, and need for additional glaucoma medications, surgery, or laser.

Results: The number of eyes requiring additional glaucoma surgery or laser was 8 of 28 (28.6%) for the injected group and 2 of 28 (7.1%) for the noninjected group. A significantly greater proportion of injected eyes required invasive glaucoma intervention (P=0.034). Average rate of decline in mean deviation and change in pattern standard deviation were both significantly greater in injected eyes (P=0.029; P=0.019). Estimated mean rate of global retinal nerve fiber layer change was -4.27 µm/y for the injected group and -1.17 µm/y for the noninjected group and was significant only for injected eyes (P=0.014). Only the superior quadrant exhibited thinning that was significantly different between groups (P=0.030).

Conclusions: Intravitreal injections were associated with accelerated functional and structural glaucoma-like change in susceptible eyes. Clinicians should assess the need for glaucoma medications or other interventions over the course of anti-VEGF therapy.
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http://dx.doi.org/10.1097/IJG.0000000000001382DOI Listing
December 2019

Anterior chamber angle in aniridia with and without glaucoma.

Clin Ophthalmol 2019 6;13:1469-1473. Epub 2019 Aug 6.

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA, USA.

Purpose: We performed a retrospective, comparative study to determine if patients with aniridia and glaucoma had open angles on high-resolution anterior segment optical coherence tomography (OCT) and clinical gonioscopy.

Patients And Methods: Forty-three patients (86 eyes) with aniridia had recorded anterior segment OCTs, gonioscopy, or both. Of these patients, 27 (54 eyes) were diagnosed with glaucoma and 16 (32 eyes) had no evidence of glaucoma. All patients had either anterior segment OCT, gonioscopy, or both.

Results: The 43 patients with aniridia had average age of 32±17 years, and 27 (62%) were female. Anterior segment OCT and gonioscopy were recorded in 25 (58%) of the patients and 18 (42%) of the patients had gonioscopy alone. Of the 54 eyes with aniridia and glaucoma, 4 (7%) eyes in 3 patients (11%) had partial or completely closed angles. Of the 32 eyes without glaucoma, all (100%) had open angles. The proportion of open angles in the aniridia with glaucoma eyes was not significantly different compared with the aniridia without glaucoma eyes (=0.32). Of the 4 eyes with closed angles, all had a history of prior surgery for cataract, glaucoma, and/or keratopathy. The proportion of eyes with prior surgery was significantly higher in eyes with open-angle glaucoma and angle-closure glaucoma compared with eyes without glaucoma (<0.001 and =0.002, respectively).

Conclusion: The majority of eyes with aniridia and glaucoma have open anterior chamber angles, similar to patients with aniridia without glaucoma. All eyes with aniridia and glaucoma that had closed angles had a prior history of ocular surgery.
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http://dx.doi.org/10.2147/OPTH.S217930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689658PMC
August 2019

Treatment of Uveitis and Outcomes of Glaucoma Drainage Implant Surgery: A Meta-Analysis.

Ocul Immunol Inflamm 2020 Jul 16;28(5):833-838. Epub 2019 Aug 16.

Department of Ophthalmology, University of Virginia , Charlottesville, VA, USA.

Purpose: We performed a meta-analysis to evaluate the effect of uveitis treatment on glaucoma drainage implant surgical outcomes.

Methods: We included 16 articles in the meta-analysis. Two groups were defined based on medical therapy of uveitis: Group 1: poorly controlled uveitis, and Group 2: well-controlled uveitis including use of immunomodulatory medications.

Results: The two groups were similar in comparisons of follow-up time, age, gender, and etiology of uveitis. Meta-analysis demonstrated significantly greater success in Group 2 (95.1%) compared to Group 1 (81.6%) at 1 year after glaucoma drainage implant surgery ( = .001). The final success was significantly greater ( 0.014) in group 2 compared with group 1 (86.1% and 74.3%, respectively).

Conclusion: Surgical success was significantly higher in uveitic glaucoma patients treated with more intensive immunosuppressive therapy before and after glaucoma drainage implant surgery. The level of control of uveitis perioperatively appears to influence glaucoma drainage implant surgery outcomes.
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http://dx.doi.org/10.1080/09273948.2019.1629602DOI Listing
July 2020

Comparison of Outcomes of Glaucoma Screening in Primary Care and Community Settings.

Ophthalmic Epidemiol 2019 10 17;26(5):355-359. Epub 2019 Jun 17.

Department of Ophthalmology, University of Virginia School of Medicine , Charlottesville , VA , USA.

: To compare outcomes of glaucoma screening in primary care and community settings, including the follow-up rates of subjects with positive screening results. : This was a comparative, prospective, non-randomized study. Subjects were recruited by medical students in community-based and primary care settings and screened for glaucoma using the same screening strategy. : Two hundred and fifteen total patients were screened, 117 in community settings and 98 in primary care settings. Positive screenings were seen in 34% of patients in the community setting group (n = 40) and 40% of patients in the primary care setting group (n = 39). Of the patients who screened positive, 74% completed their initial follow-up appointment in the primary care setting group compared with 47.5% in the community-based setting group ( = .015). In the primary care setting, 18% were lost to follow up compared with 42.5% in the community-setting ( = .018). African-Americans were more likely to follow-up ( = .025) and less likely to be lost to follow-up ( = .033) in the primary care setting compared with the community-based setting. : Patients with a positive glaucoma screening result in a primary care setting are more likely to follow up than those in a community-based setting.
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http://dx.doi.org/10.1080/09286586.2019.1626444DOI Listing
October 2019

Dexamethasone implantation in birdshot chorioretinopathy - long-term outcome.

Int Med Case Rep J 2018 30;11:349-358. Epub 2018 Nov 30.

Department of Ophthalmology, University of Virginia, Charlottesville, VA, USA,

Purpose: To evaluate the long-term efficacy of the 0.70 mg dexamethasone (DEX) intravitreal implant in patients with birdshot chorioretinopathy (BSCR).

Methods: Retrospective descriptive case series of BSCR patients treated with DEX implant (DEX implant 0.70 mg, DEX). Patients receiving treatment between September 2013 and November 2016 with a minimum follow-up (FU) of 12 months were included. The outcomes of primary interest were vision-related functioning, Snellen visual acuity, ocular inflammation status, presence or absence of vasculitis, change in central macular thickness, and development of glaucoma and/or cataract. Change in vision-related functioning was evaluated by comparing the National Eye Institute Visual Function Questionnaire-25. The outcomes were assessed at baseline, after DEX implant, at time of relapse, and at last FU.

Results: Three patients (six eyes) were included in the study and were followed for 1-3 years. They received 1-4 DEX implants OU. All patients demonstrated improvement in National Eye Institute Visual Function Questionnaire-25 scores. Mean Snellen visual acuity better than or equal to 20/40 was seen in three eyes at baseline and five eyes at last FU. At induction, all of the patients (six eyes) had active vitritis and two (four eyes) had retinal vasculitis. All three patients (six eyes) were quiet at last FU. One patient (two eyes) developed bilateral ocular hypertension requiring topical therapy and discontinuation of DEX implants. Two patients (three eyes) developed posterior subcapsular cataract during therapy. Two patients (four eyes) showed progression of disease while on DEX therapy. All patients were eventually transitioned to systemic immunosuppressive drug therapy.

Conclusion: BSCR patients receiving DEX implant experienced clinically meaningful improvements in patient-reported visual function as well as ocular inflammation. However, patients in this study required repeat implantation and were unable to be maintained on DEX implant long term due to development of adverse effects or progression of disease. Eventually, it was necessary to transition to systemic immunosuppressive therapy in all patients.
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http://dx.doi.org/10.2147/IMCRJ.S164206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280912PMC
November 2018

The Evolution of Glaucoma Drainage Implants.

J Ophthalmic Vis Res 2018 Oct-Dec;13(4):498-500

Department of Ophthalmology, University of Virginia, School of Medicine, Charlottesville, Virginia, USA.

The modern glaucoma drainage implant era was initiated with implantation of a plate posterior to the limbus connected to the anterior chamber by a long silicone tube. Non-restrictive (Molteno and Baerveldt implants) and flow-restrictive (Ahmed Glaucoma Valve) implants were developed. With increased clinical experience, variables influencing success and failure of glaucoma drainage implant surgery were better understood. In an iterative process, complications were reduced and indications for drainage implant surgery were broadened. Growth of utilization of glaucoma drainage implants has dramatically increased in recent years. Glaucoma drainage implants have improved the prognosis for surgical success for refractory glaucoma, and have a well-established role in the surgical treatment of glaucoma.
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http://dx.doi.org/10.4103/jovr.jovr_26_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6210865PMC
November 2018

Decompression Retinopathy After Goniotomy in a Child: A Case Report.

J Glaucoma 2017 Aug;26(8):747-748

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA.

Purpose: To report a case of ocular decompression retinopathy that developed in a child after undergoing goniotomy for uncontrolled pediatric uveitic glaucoma.

Patient And Methods: We describe an 11-year-old Hispanic boy with a history of idiopathic uveitis and elevated intraocular pressure (IOP) in both eyes. He developed marked elevation of the IOP in the right eye (44 mm Hg) despite glaucoma medical therapy.

Results: The patient's right eye was treated with goniotomy, with reduction of vision to 20/70 and IOP to between 4 and 7 mm Hg during the first week postoperatively. The retina developed diffuse hemorrhages, both deep and superficial. Many of these hemorrhages had white centers. The findings were consistent with decompression retinopathy. The retinal hemorrhages began to improve 2 weeks and had cleared by 6 weeks after surgery. The IOP measurements ranged between 14 and 16 mm Hg from 2 to 6 weeks after goniotomy and the vision returned to preoperative baseline of 20/20-2 in the right eye. Six weeks after the initial surgery, the left eye was treated with goniotomy with no complications.

Conclusions: Ocular decompression retinopathy, an uncommon complication of glaucoma surgery, can occur after goniotomy.
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http://dx.doi.org/10.1097/IJG.0000000000000681DOI Listing
August 2017

Risk factors for tube exposure as a late complication of glaucoma drainage implant surgery.

Clin Ophthalmol 2016 30;10:547-53. Epub 2016 Mar 30.

Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, OH, USA.

Purpose: The purpose of this study was to evaluate the risk factors for tube exposure after glaucoma drainage implant surgery.

Patients And Methods: This was a retrospective case-controlled observational study of 64 eyes from 64 patients. Thirty-two eyes of 32 patients with tube erosion requiring surgical revision were compared with 32 matched control eyes of 32 patients. Univariate and multivariate risk factor analyses were performed.

Results: Mean age was significantly younger in the tube exposure group compared with the control group (48.2±28.1 years versus 67.3±18.0 years, respectively; P=0.003). The proportion of diabetic patients (12.5%) in the tube exposure group was significantly less (P=0.041) compared with the control group (37.5%). Comparisons of the type and position of the drainage implant were not significantly different between the two groups. The average time to tube exposure was 17.2±18.0 months after implantation of the drainage device. In both univariate and multivariate analyses, younger age (P=0.005 and P=0.027) and inflammation prior to tube exposure (P≤0.001 and P=0.004) were significant risk factors. Diabetes was a significant risk factor only in the univariate analysis (P=0.027).

Conclusion: Younger age and inflammation were significant risk factors for tube exposure after drainage implant surgery.
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http://dx.doi.org/10.2147/OPTH.S104029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820194PMC
April 2016

Clinical Management of Malignant Glaucoma.

J Ophthalmol 2015 24;2015:283707. Epub 2015 Dec 24.

Medical College of Wisconsin, 925 N 87th Street, Milwaukee, WI 53226, USA.

Malignant glaucoma remains one of the most challenging complications of ocular surgery. Although it has been reported to occur spontaneously or after any ophthalmic procedure, it is most commonly encountered after glaucoma surgery in eyes with prior chronic angle closure. The clinical diagnosis is made in the setting of a patent peripheral iridotomy and axial flattening of the anterior chamber. Intraocular pressure is usually elevated, but it may be normal in some cases. Although the exact etiology of this condition is not fully understood, several mechanisms have been proposed and it is thought to result from posterior misdirection of aqueous humor into or behind the vitreous. This review discusses pathophysiology, differential diagnosis, imaging modalities, and current treatment strategies for this rare form of secondary glaucoma.
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http://dx.doi.org/10.1155/2015/283707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4706935PMC
January 2016

EX-PRESS Glaucoma Filtration Device: efficacy, safety, and predictability.

Med Devices (Auckl) 2015 2;8:381-8. Epub 2015 Sep 2.

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA, USA.

Trabeculectomy has been the traditional primary surgical therapy for open-angle glaucoma. While trabeculectomy is effective in lowering intraocular pressure, complications associated with the procedure have motivated the development of alternative techniques and devices, including the EX-PRESS Glaucoma Filtration Device. This review describes the efficacy, safety, complication rates, and potential advantages and disadvantages of the EX-PRESS Glaucoma Filtration Device. EX-PRESS implantation is technically simpler compared with that of trabeculectomy, with fewer surgical steps. Vision recovery has been more rapid after EX-PRESS implantation compared with trabeculectomy. Intraocular pressure variation is lower during the early postoperative period, indicating a more predictable procedure. While efficacy of the EX-PRESS implant has been comparable to trabeculectomy, postoperative complications appear less common after EX-PRESS implantation compared with trabeculectomy. The EX-PRESS Glaucoma Filtration Device appears to be safe and effective in the surgical management of open-angle glaucoma.
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http://dx.doi.org/10.2147/MDER.S63350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562650PMC
September 2015

Lead time for appointment and the no-show rate in an ophthalmology clinic.

Clin Ophthalmol 2015 18;9:513-6. Epub 2015 Mar 18.

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA, USA.

Purpose: The purpose of this study was to determine if there is a correlation between the time in advance an appointment is scheduled and the no-show rate.

Methods: This was a cross-sectional study conducted in an outpatient ophthalmology clinic. Appointment data were analyzed for 51,529 ophthalmology appointments in the computerized scheduling database during a 12-month period.

Results: The average no-show rate was 21.7% and 6.6% for resident- and faculty-clinic, respectively (P<0.001). The no-show rate increased, and the likelihood an appointment would be kept decreased as the time in advance an appointment was scheduled increased. With a lead time for appointment of 0-2 weeks, the average no-show rate was 9.1% and 2.4% for the resident- and faculty-clinic, respectively. With a lead time for appointment of 6 months, the average no-show rate increased to 38.3% (P<0.001) and 6.9% (P<0.001) for the resident-and faculty-clinic, respectively. A predicted no-show rate model showed approximately 2% reduction of the no-show rate for 10% increase of the proportion of patients scheduled within 2 weeks, potentially reducing the no-show rate by nearly 60% with all appointments scheduled 0-2 weeks in advance.

Conclusion: Clinic no-show rate increased as appointment lead time increased. Predictive models suggest that the implementation of a short-term appointment scheduling strategy may reduce the overall clinic no-show rate, particularly in clinic populations with a high no-show rate.
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http://dx.doi.org/10.2147/OPTH.S82151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4370946PMC
April 2015

Xenopus pax6 mutants affect eye development and other organ systems, and have phenotypic similarities to human aniridia patients.

Dev Biol 2015 Dec 25;408(2):328-44. Epub 2015 Feb 25.

Department of Biology, University of Virginia, Charlottesville, VA 22904, USA; Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA 22908, USA. Electronic address:

Mutations in the Pax6 gene cause ocular defects in both vertebrate and invertebrate animal species, and the disease aniridia in humans. Despite extensive experimentation on this gene in multiple species, including humans, we still do not understand the earliest effects on development mediated by this gene. This prompted us to develop pax6 mutant lines in Xenopus tropicalis taking advantage of the utility of the Xenopus system for examining early development and in addition to establish a model for studying the human disease aniridia in an accessible lower vertebrate. We have generated mutants in pax6 by using Transcription Activator-Like Effector Nuclease (TALEN) constructs for gene editing in X. tropicalis. Embryos with putative null mutations show severe eye abnormalities and changes in brain development, as assessed by changes in morphology and gene expression. One gene that we found is downregulated very early in development in these pax6 mutants is myc, a gene involved in pluripotency and progenitor cell maintenance and likely a mediator of some key pax6 functions in the embryo. Changes in gene expression in the developing brain and pancreas reflect other important functions of pax6 during development. In mutations with partial loss of pax6 function eye development is initially relatively normal but froglets show an underdeveloped iris, similar to the classic phenotype (aniridia) seen in human patients with PAX6 mutations. Other eye abnormalities observed in these froglets, including cataracts and corneal defects, are also common in human aniridia. The frog model thus allows us to examine the earliest deficits in eye formation as a result of pax6 lesions, and provides a useful model for understanding the developmental basis for the aniridia phenotype seen in humans.
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http://dx.doi.org/10.1016/j.ydbio.2015.02.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549229PMC
December 2015

Keratopathy, cataract, and dry eye in a survey of aniridia subjects.

Clin Ophthalmol 2015 10;9:291-5. Epub 2015 Feb 10.

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA, USA.

Purpose: To determine the prevalence of keratopathy, cataract, and dry eye in a group of individuals with aniridia.

Methods: We reviewed survey data from the Aniridia Foundation International (AFI) registry, which included 99 subjects who self-reported on corneal disease, cataract, and dry eye disease.

Results: The average age of respondents was 25.3±18.6 years, with a range of 0 to 67. Of 99 subjects, 46% stated they have corneal disease, 32% stated they did not, and 22% were unsure. The average age of diagnosis of keratopathy was 20.0±12.2 years. Keratolimbal allograft was reported in 20% and penetrating keratoplasty in 9%. Cataract was reported in 65%, with an average age of 9.4±14.0 years at time of diagnosis, and cataract surgery was reported in 32%. The average age of subjects at the time of cataract and corneal surgery was 28.4±13.7 and 33.5±11.4 years, respectively. Symptomatic dry eye was reported in 56% of subjects, with an average age at diagnosis of 23.8±13.3 years.

Conclusion: There is a high prevalence of corneal disease in aniridia, with diagnosis in late childhood or early adulthood in nearly one-half of subjects, often requiring corneal surgery. Cataract and dry eye are commonly associated with aniridia. Although aniridia subjects may have been aware of the diagnosis of cataract at an early age, they usually were treated for cataract and keratopathy as adults.
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http://dx.doi.org/10.2147/OPTH.S74648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334340PMC
February 2015

Cataract surgery in glaucoma patients: how much benefit?

Authors:
Peter A Netland

Am J Ophthalmol 2014 Jan;157(1):1-3

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, Virginia. Electronic address:

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http://dx.doi.org/10.1016/j.ajo.2013.09.021DOI Listing
January 2014

Randomized, prospective, comparative trial of EX-PRESS glaucoma filtration device versus trabeculectomy (XVT study).

Am J Ophthalmol 2014 Feb 7;157(2):433-440.e3. Epub 2013 Nov 7.

Washington University, St. Louis, Missouri.

Purpose: To compare the clinical outcomes of the EX-PRESS glaucoma filtration device placed under a partial-thickness scleral flap with trabeculectomy.

Design: Randomized, prospective, multicenter trial.

Methods: A total of 120 eyes in 120 subjects were analyzed, including 59 eyes treated with EX-PRESS and 61 eyes treated with trabeculectomy. Both the EX-PRESS and the trabeculectomy groups were treated intraoperatively with mitomycin C and followed postoperatively for 2 years. Surgical success was defined as 5 mm Hg ≤ intraocular pressure ≤ 18 mm Hg, with or without medications, without further glaucoma surgery.

Results: Mean intraocular pressure was significantly reduced compared with baseline in both groups (P < 0.001). Average intraocular pressure and number of medications were similar in both groups during follow-up, with mean intraocular pressure at 2 years after surgery of 14.7 ± 4.6 mm Hg and 14.6 ± 7.1 mm Hg in the EX-PRESS and trabeculectomy groups, respectively (P = 0.927). At 2 years after surgery, the success rate was 83% and 79% in the EX-PRESS and trabeculectomy groups, respectively (P = 0.563). Although visual acuity (logMAR) was significantly decreased on day 1 in both groups, the vision was not significantly different compared with baseline at 1 month after EX-PRESS implant (P = 0.285) and 3 months after trabeculectomy (P = 0.255). The variance of early postoperative intraocular pressure values was similar between groups on the first postoperative day but higher after trabeculectomy compared with EX-PRESS implant on day 7 (P = 0.003). The total number of postoperative complications was higher after trabeculectomy than after EX-PRESS implantation (P = 0.013).

Conclusions: Mean intraocular pressures, medication use, and surgical success were similar at 2 years after treatment with the EX-PRESS device and trabeculectomy. Vision recovery between groups was also similar throughout the study, although return to baseline vision was more rapid in the EX-PRESS group. Intraocular pressure variation was lower during the early postoperative period, and postoperative complications were less common after EX-PRESS implantation compared with trabeculectomy.
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http://dx.doi.org/10.1016/j.ajo.2013.09.014DOI Listing
February 2014

Wait time as a driver of overall patient satisfaction in an ophthalmology clinic.

Clin Ophthalmol 2013 20;7:1655-60. Epub 2013 Aug 20.

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA, USA.

Purpose: The purpose of this study was to determine whether the actual time patients spend waiting is correlated with overall patient satisfaction scores.

Methods: This was a cross-sectional survey study conducted in an outpatient ophthalmology clinic. The actual time each patient waited to be called by the provider was recorded, and a survey was given at the end of the visit.

Results: There was a significant correlation between the time patients spent waiting and overall patient satisfaction scores (P < 0.001). Patients who were not completely satisfied waited twice as long as those who were completely satisfied (P < 0.001), regardless of whether patients received free care. Satisfaction with the amount of time spent waiting was the strongest driver of overall satisfaction score.

Conclusion: Minimizing the time patients spend waiting to see a provider can result in higher overall patient satisfaction scores, regardless of financial status.
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http://dx.doi.org/10.2147/OPTH.S49382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3754818PMC
August 2013

Gamma-irradiated cornea allograft for glaucoma surgery.

J Glaucoma 2013 Jun-Jul;22(5):355-7

Department of Ophthalmology, University of North Carolina, Chapel Hill, NC, USA.

Purpose: To describe the clinical outcomes and surgical applications of γ-irradiated cornea allograft in glaucoma surgery.

Materials And Methods: We reviewed 10 consecutive patients who underwent primary or secondary glaucoma procedures using sterile cornea allograft.

Results: Ten eyes of 10 patients (5 males, mean age 50 y) were treated with sterile, irradiated cornea allograft. Mean follow-up was 24 months (range, 22.4 to 26.8 mo). The allograft was used for coverage of a primary glaucoma tube shunt in 3 patients, coverage of a revised glaucoma tube shunt in 5 patients, tectonic support of a revised trabeculectomy flap in 1 patient, and coverage of subconjunctival prolene sutures following a surgical iridoplasty in 1 patient. The allografts were stable and biocompatibile in all 10 cases during the follow-up period, evidenced by maintained clarity of the corneal tissue, absence of clinical signs of immunologic rejection or ocular inflammation, and integrity of the sterile cornea and the conjunctiva over the graft. Cosmetic results were satisfactory and there were no complications during the follow-up period.

Conclusions: In this small case series, sterile, γ-irradiated cornea allograft appeared to be safe and effective when used in glaucoma and anterior segment surgical procedures. Our results suggest advantages of sterile cornea allograft for coverage of glaucoma drainage implant tubes, including tissue transparency, resilience, and ease of surgical use.
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http://dx.doi.org/10.1097/IJG.0b013e318241b9ffDOI Listing
December 2013

Screening for glaucoma: rationale and strategies.

Curr Opin Ophthalmol 2013 Mar;24(2):144-9

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA 22908-0715, USA.

Purpose Of Review: Late diagnosis of glaucoma is a leading factor in vision loss associated with this disease. Screening programs seek to diagnose glaucoma at an earlier, more treatable stage. Our purpose was to review the influence of screening location and testing strategies in glaucoma screening.

Recent Findings: Screening high-risk groups appears effective, although general population-based screening programs have not been cost effective. Community-based screening programs have achieved limited success due to lack of follow-up of screened patients. High-risk patients often do not present for office-based screening programs. Screening strategies that employ a single test or few tests are generally more effective compared with strategies using multiple tests, due to avoidance of false positives. Compared with currently available screening tests, frequency-doubling technology (FDT) perimetry has shown higher sensitivity and specificity. Recent evidence suggests that automated assessment of the optic nerve and retinal nerve fiber layer may be superior to FDT perimetry, but the techniques remain unproven in screening settings.

Summary: Community-based screening of high-risk groups with functional testing using FDT perimetry can be effective, but newer automated structural measurements of the optic nerve and retinal nerve fiber layer may allow improved glaucoma screening sensitivity and specificity in the future.
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http://dx.doi.org/10.1097/ICU.0b013e32835cf078DOI Listing
March 2013

Ocular injuries in trauma patients: an analysis of 28,340 trauma admissions in the 2003-2007 National Trauma Data Bank National Sample Program.

J Trauma Acute Care Surg 2012 Nov;73(5):1308-12

Department of Emergency Medicine, University of Virginia, Charlottesville 22908, USA.

Background: Trauma-induced eye injuries are the leading cause of monocular blindness in the United States. Few studies to date have focused on ocular injuries in the trauma population. Our intent was to determine the annual percentage of ocular injury, types of injuries, and percentage with ocular injury-related procedures performed during the same hospitalization.

Methods: This study was a retrospective analysis of 28,340 patient records included in the National Trauma Data Bank National Sample Program from 2003 to 2007. Patients with ocular injuries and related procedures were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes and were subsequently grouped into categories of ocular injury using the criteria of the Barell body region injury diagnosis matrix. Weighted national estimates for the proportion of patients with ocular trauma were calculated based on the relative weights for patients in each facility within the sample universe. Weighted frequencies were expressed as a percentage of the total population of trauma admissions, with 95% confidence intervals calculated for precision.

Results: During the time frame examined, 1.97% to 6.00% of annual trauma patient admissions included ocular injuries. The most common injuries were contusions or superficial injuries and then closed orbit fractures accounting for 0.95% to 2.48% and 0.58% to 2.37% of all injuries, respectively. Between 0.56% and 1.52% of annual trauma admission had both ocular trauma and related procedures during their hospitalization. Popular treatments were therapeutic procedures on eyelids, conjunctiva, and/or cornea occurring in 0.15% to 0.84% of all trauma patients. Facial fracture-related procedures were reported for between 0.16% and 0.65% of all trauma patient admissions.

Conclusion: The National Trauma Data Bank National Sample Program can be used to create useful estimates of ocular injury characteristics among patients seen in the population seen in trauma centers, including types of ocular injury and related procedures performed during the same admission.

Level Of Evidence: Epidemiologic study, level V.
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http://dx.doi.org/10.1097/TA.0b013e31825c78d9DOI Listing
November 2012

Trabeculectomy versus combined trabeculotomy-trabeculectomy in pediatric glaucoma.

J Pediatr Ophthalmol Strabismus 2012 Nov-Dec;49(6):359-65. Epub 2012 Jul 17.

Purpose: To compare outcomes between trabeculectomy and combined trabeculotomy-trabeculectomy in children with glaucoma.

Methods: This was a retrospective, comparative study of 40 eyes in 33 patients with pediatric glaucoma: 17 eyes treated with trabeculectomy and 23 eyes treated with combined trabeculotomy-trabeculectomy. Both groups were treated with intraoperative mitomycin C. Success was defined as intraocular pressure (IOP) of 21 mm Hg or less and greater than 5 mm Hg with no additional glaucoma surgery.

Results: Mean follow-up was 38.3 months. There was no significant difference in mean IOP lowering between groups during the follow-up period. Log-rank survival analysis showed a significantly higher success rate after combined surgery compared with trabeculectomy (P = .027). Treatment failures occurred in 5 patients with trabeculectomy and in 2 patients undergoing combined trabeculotomy-trabeculectomy. Failures resulted from increased IOP (n = 3) or hypotony (n = 4). There were no significant differences in complications observed after surgery in both groups.

Conclusion: Trabeculectomy and combined trabeculotomy-trabeculectomy with mitomycin C were equally effective at lowering average IOP in children. Combined trabeculotomy-trabeculectomy was associated with greater long-term success.
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http://dx.doi.org/10.3928/01913913-20120710-06DOI Listing
May 2014

Citing first publication.

Authors:
Peter A Netland

Clin Ophthalmol 2012 20;6:605. Epub 2012 Apr 20.

Department of Ophthalmology, University of Virginia, Charlottesville, Virginia, VA, USA.

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http://dx.doi.org/10.2147/OPTH.S31043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3346192PMC
October 2012

Ocular and systemic findings in a survey of aniridia subjects.

J AAPOS 2011 Dec;15(6):562-6

Department of Ophthalmology, University of Virginia School of Medicine, Charlottesville , Virginia 22908-0715, USA.

Purpose: To determine the prevalence of ocular and systemic abnormalities in a group of subjects with aniridia.

Methods: Survey forms developed by Aniridia Foundation International were sent to all members prior to the 2010 AFI member conference. An additional form was provided for completion by physicians caring for patients. Forms were then collected from all members who attended the meeting.

Results: A total of 155 surveys were distributed, of which 83 (53%) were completed. The mean age was 25.4 ± 18.4 years, with 65% sporadic and 35% familial cases, and 2.4% with WAGR (Wilms' tumor, aniridia, genitourinary anomalies, and mental retardation) syndrome. Ocular abnormalities included nystagmus (83%), cataract (71%), dry eye (53%), glaucoma (46%), keratopathy (45%), foveal hypoplasia (41%), strabismus (31%), and retinal disease (5%). The mean age at diagnosis of aniridia was 22.1 months (median, 1.5 months) and glaucoma was 13.6 years (median, 8.5 years). Of 38 subjects with aniridia and glaucoma, 76% were treated medically, and 58% had been treated surgically. In subjects with glaucoma, the mean number (± SD) of glaucoma medications was 1.8 ± 1.3, and number of surgical procedures was 1.7 ± 2.0. Developmental delay was reported in 17%. The mean body mass index and the prevalence of obesity in subjects with aniridia was significantly greater (P = 0.003) than in siblings without aniridia.

Conclusions: In this study, aniridia was associated with nystagmus and other motility problems, cataract, glaucoma, and keratopathy. Systemic abnormalities included increased average body mass index and obesity, which appeared to occur not only in WAGR syndrome but more broadly in aniridia.
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http://dx.doi.org/10.1016/j.jaapos.2011.07.009DOI Listing
December 2011

Trabeculectomy versus Ahmed Glaucoma Valve implantation in neovascular glaucoma.

Clin Ophthalmol 2011 1;5:281-6. Epub 2011 Mar 1.

Glaucoma Consultants Northwest, Seattle, WA, USA;

Purpose: To compare surgical outcomes in neovascular glaucoma patients who underwent trabeculectomy with mitomycin C versus Ahmed Glaucoma Valve implantation.

Patients And Methods: This was a retrospective comparative case series. We reviewed 40 eyes of 39 patients with underlying diagnosis of neovascular glaucoma, divided into two groups: Ahmed Glaucoma Valve (N = 20) and trabeculectomy with mitomycin C (N = 20). Surgical success was defined as 6 mm Hg ≤ intraocular pressure ≤21 mm Hg, with or without the use of glaucoma medications, with no further glaucoma surgery, and light perception or better vision. Early postoperative hypotony was defined as intraocular pressure <5 mm Hg during the first postoperative week.

Results: The average follow-up was 31 months (range 6-87 months) for the Ahmed Glaucoma Valve group and 25 months (6-77 months) for the trabeculectomy group. Although the mean number of postoperative intraocular pressure-lowering medications was significantly higher in the trabeculectomy group compared with the Ahmed Glaucoma Valve group at 3 and 6 month time points, there was no statistically significant difference at any other time point. There was no statistically significant difference between both groups in postoperative visual acuity and intraocular pressure. Success was 70% and 65% at 1 year and 60% and 55% at 2 years after Ahmed Glaucoma Valve and trabeculectomy, respectively. Kaplan-Meier survival curve analysis showed no significant difference in success between the two groups (P = 0.815). Hyphema was the most common complication in both groups.

Conclusion: We found similar results after trabeculectomy with mitomycin C and Ahmed Glaucoma Valve implantation in eyes with neovascular glaucoma.
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http://dx.doi.org/10.2147/OPTH.S16976DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065568PMC
July 2011

CNS targets support and sustain differentiation of cultured neuronal and retinal progenitor cells.

Neurochem Res 2011 Apr 20;36(4):619-26. Epub 2010 Oct 20.

Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN 38105, USA.

Superior colliculus (SC) is the target of retinal neurons, allowing them to form connections. Cultured stem cells/progenitors can potentially be used as donor tissue to reconstruct degenerated retina including perhaps replacing lost ganglion cells in glaucoma. In which case, it will be essential for these cells to integrate with the central nervous system targets. Here, we have investigated if the mid-brain region containing superior colliculus (SC) provides a permissive environment for the survival and differentiation of neural progenitors, including retinal progenitor cells propagated in cultures. Neural (NPCs) and retinal progenitor cells (RPCs) from green fluorescent protein (GFP) transgenic mice were cultured. Passage two through four neural and retinal progenitor cells were subsequently cocultured with the SC organotypic slices and maintained in culture for 17 and eight days respectively. Differentiation of the neurons was studied by immunocytochemistry for retinotypic neuronal markers. Retinal progenitor cells cocultured with SC slices were able to differentiate into various neuronal morphologies. Some cocultured progenitor cells differentiated into neurons as suggested by class III β tubulin immunoreactivity. In addition, specific retinotypic neuronal differentiation of RPC was detected by immunoreactivity for calbindin and PKC. SC provides a permissive environment that supports survival and differentiation of the progenitor cells.
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http://dx.doi.org/10.1007/s11064-010-0279-zDOI Listing
April 2011