Objective: This study compared the peripapillary retinal nerve fiber layer (pRNFL) microangiographic properties [vessel area density (VAD) and blood flux index (BFI)] of unilateral open-angle glaucomatous eyes to contralateral eyes-at-risk, and to eyes of healthy age- and sex-matched subjects. Methods: This was a single-center, case-control study of Filipinos diagnosed with unilateral primary openangle glaucoma (POAG) or normal-tension glaucoma (NTG). Mean overall and quadrantal VAD and BFI of the three groups were measured with optical coherence tomography- angiography (OCT-A). Area under the receiver operating characteristic (AROC) was used to measure diagnostic ability. Results: Twenty-two (22) glaucomatous subjects (15 POAG and 7 NTG eyes), 22 contralateral eyes-at-risk, and 22 normal eyes from age- and sex-matched control subjects completed the study. Eyes with glaucoma showed lower mean overall VAD (40%) and BFI (0.37) compared to eyes-at-risk (44.4% and 0.42, respectively; p <0.001) and control eyes (45.6% and 0.44, respectively; p <0.001). Mean VAD and BFI values of eyes-at-risk and control groups did not significantly differ from each other. Overall pRNFL thickness showed highest diagnostic accuracy for glaucoma (AROC = 0.97), followed by VAD (0.94), and BFI (0.88) (p=0.46). Conclusion VAD and BFI were significantly diminished in unilateral open-angle glaucoma, suggesting that the utility of OCT-A in the detection of glaucoma is comparable to pRNFL thickness.
Microcirculation ; Glaucoma ; Angiography

Introduction: To determine the structure-function correlations of glaucoma in Filipinos using the average peripapillary retinal nerve fiber layer (RNFL) thickness and rim area (RA) of the spectral-domain optical coherence tomography (SD-OCT) and mean defect (MD), pattern standard deviation (PSD), and visual field (VF) clusters of standard automated perimetry (SAP) Methods: Consecutive tests consisting of SD-OCT, SAP, and disc photos were reviewed and selected based on abnormalities in VFs or OCTs or both. Each set of tests was classified as to VF defect type and severity. Mean threshold of VF clusters, MD, and PSD were correlated with average and sectoral RNFL thicknesses and RA. Results: One hundred eighty-six (168) eyes of 121 patients with mean age of 60.2 ± 14.7 years had an average MD, PSD, RNFL thickness, RA of -9.5 ± 8.5 dB, 5.4 ± 3.3 dB, 75.9 ± 15.9 μm, and 0.9 ± 0.4 mm2, respectively. Among VF tests, 23.1% were normal, 16.5% had early, 9.1% moderate, 12.4% advanced, and 8.3% severe glaucoma damage. Most common VF defect types were central islands, combined, and paracentral (16.5%, 14.4%, and 12.2%, respectively). The most commonly affected RNFL segments were inferior, followed by superior, and combined superior and inferior (51.2%, 47.1, and 34%, respectively). Among the OCT parameters, RNFL thickness and RA were strongly correlated (p<0.0001). Between the VF and OCT parameters, the strongest correlation was between the clusters of superior VF defects and the 6-8 o’clock RNFL thinning, followed by the inferior VF defects and the 12-1 o’clock RNFL thinning. Inferior RNFL thinning was strongly correlated with MD and PSD. Conclusion Among Filipino glaucomatous eyes monitored with SD-OCT and SAP, correlation was strongest between the superior VF defects and the infero-temporal RNFL thinning.
Visual Fields ; Tomography, Optical Coherence ; Glaucoma

This document offers guidance to help the ophthalmologist plan for the safe resumption of elective surgical care. There are 4 sections: (I) COVID-19 Awareness, (II) Preparedness, (III) Patient Issues, and (IV) Delivery of Safe and High-Quality Care. Each section contains key issues to be addressed before elective surgery may be safely reinstituted. Understanding the capabilities of health facilities (e.g., testing, operating rooms) as well as the potential limitations in manpower and supplies will remain important, while keeping an eye out on subsequent waves of COVID-19.
COVID-19

With the resumption of elective surgeries during this COVID-19 pandemic, surgeons and facilities should implement infection prevention and control measures to ensure the safety of patients and health care workers. This advisory highlights the key principles, risk stratification considerations, and recommended approach regarding Covid-19 testing prior to elective ophthalmic surgeries.
COVID-19

Objective: To report the clinical profile and treatment outcomes of neovascular glaucoma (NVG). Methods: A retrospective cohort study was done in a single tertiary hospital. Medical records of patients diagnosed with NVG from January 2000 to August 2018 were reviewed and pertinent data were collected. Study outcomes included visual acuity (VA) and intraocular pressure (IOP) and were analyzed for eyes that received any of the following: intravitreal bevacizumab (IVBe), pan-retinal photocoagulation (PRP), trabeculectomy with mitomycin (trab-MMC), or diode laser cyclophotocoagulation (DLCP) with at least 1 month of follow-up. Results: There were 162 patients (181 eyes) diagnosed with NVG. Mean age at the time of diagnosis was 55.6 ± 14 years. Diabetic retinopathy (DR) was observed in 81 (45%) eyes and central retinal vein occlusion (CRVO) in 48 (27%) eyes. Baseline VA was hand movement in 67 (37%) eyes and no light perception (NLP) in 49 (27%) eyes. Only 60 (33%) eyes had ≥1 month of follow up (mean of 73 ± 119.1 weeks) after procedures were done. IVBe was done in 22 (37%) eyes, trab-MMC in 20 (33%), PRP in 22 (37%), and DLCP in 24 (40%) eyes. IOP decreased from 45 to 20 mmHg (p<0.001) but VA decreased from LogMAR 1.7 to 2.1 (p<0.01). There was significant VA decrease in eyes that underwent a single procedure (p<0.02) but none in eyes that underwent 2 or 3 procedures. Nonetheless, there was significant IOP decrease (p<0.05) when one procedure was done. Of the 49 eyes that had baseline sight, 19 (41%) converted to NLP (p<0.01). Conclusion Most patients presenting with advanced NVG had DR and CRVO. Procedures led to better IOP but not VA and some lost vision. Aggressive screening for NVG among high-risk groups is warranted to institute treatment early.
Bevacizumab ; Retinal Vein Occlusion ; Diabetic Retinopathy ; Glaucoma, Neovascular ; Trabeculectomy

OBJECTIVE: To identify the glaucoma clinical practice patterns among the members of the Philippine Glaucoma Society (PGS) from 2015 to 2016 using an online survey. METHODS: An online link was sent to each consenting PGS member which directed them to two poll sites. These sites asked questions about demographics and their preferred clinical practice patterns. Frequency and percent distributions were used to analyze the data. RESULTS: There was a high response rate from PGS members at 97% (42 out of 43 members). More than half of respondents (51%, n=22) defined glaucoma as glaucomatous optic neuropathy with an evident visual field loss. IOP was routinely measured by 90% (n=38) of the respondents with majority preferring to use the Goldmann applanation tonometer (GAT) (98%, n=41). Gonioscopy was done on all new patients by all PGS members but only 62% did regular gonioscopy on follow-up consultations. Most of the respondents relied on the 90D lens (88%) to assess the optic nerve. Visual field examination (VFE) was routinely requested by all respondents. Pachymetry and anterior segment optical coherence tomography (AS-OCT) were used sparingly at only 43% and 12% respectively. Appositional angle closure was addressed by performing laser iridotomy with majority of the respondents preferring a site that is covered by the upper eyelid (57%). Prostaglandin analogues were the top choice as first-line monotherapy for eyes with open-angle glaucoma. Majority of the respondents (55%) opted to do laser trabeculoplasty (LTP) as an adjunct to medical therapy. Mitomycin-C was the preferred intraoperative antimetabolite for trabeculectomy by 98% (n=41). Ahmed (71%, n=30) was the more favored glaucoma drainage device (GDD) by our respondents over Baerveldt (19%, n=8). CONCLUSION: This survey showed majority of the glaucoma practices of PGS members appear to adhere to the current clinical practice guidelines.
Philippines ; Glaucoma ; Tetrahymenina ; Surveys and Questionnaires

OBJECTIVE: To describe the demographic and clinical characteristics of patients with glaucoma managed at private and government institutions in the Philippines between 2009 and 2014.

METHODS: A research team from two private and two government institutions in the Philippines reviewed the case records of 1246 patients seen who met the following criteria: intraocular pressure of >21 mmHg, optic nerve and nerve fiber layer abnormalities, and visual field defects. For bilateral cases, we selected the eye with worse glaucoma parameters.

RESULTS: There were 600 and 646 patients in the private and government groups (mean age at presentation, 60.51 and 55.88 years), respectively, with the majority being Filipino (91%). Patients with visual acuity (VA) of 20/20 to 20/40 were more frequently observed in private centers (58.7% vs. 41.3%), while a VA worse than counting fingers was more frequently observed in government centers (66.1% vs. 33.9%). Within-group analysis showed that primary angle-closure glaucoma was the most frequent glaucoma subtype in both private (27.3%) and government institutions (37.8%). In between-group analysis showed the following to be more common in private than government centers: primary open-angle glaucoma (61.3% vs. 38.7%), normal-tension glaucoma (63.9% vs. 36.1%), ocular hypertension (92.3% vs. 7.7%), and glaucoma suspects (80.4% vs. 19.6%) while government institutions registered a larger number of primary angle-closure glaucoma (59.8% vs. 40.2%) and secondary glaucoma (70.3% vs. 29.7%) cases. Medical treatment using a single drug and multiple drugs was employed for 245 (23%) and 825 (77%) patients, respectively. Within-group analysis showed that laser iridotomy and trabeculectomy were the most commonly performed laser and surgical procedures in both institution types.

CONCLUSION: There is a contrasting profile of glaucoma between clinical institutions in the Philippines with openangle glaucoma being more predominant in private centers while closed-angle glaucoma and secondary glaucoma being more frequent in government centers. Our findings may provide important preliminary information that can aid future health studies or training programs.

OBJECTIVE: Since cataract and glaucoma often coexist, and there is no agreement as to their optimal management, a review of the surgical strategies for coexisting I cataract and glaucoma is necessary. The latest evidence-based findings from various studies are presented. METHODS: A literature search of the latest full articles (up to September 2006) was conducted on the surgical management of coexisting cataract and glaucoma. The results of the 2001 Johns Hopkins milestone study were also included for analysis and comparison. RESULTS: Evidence is strong that trabeculectomy is associated with increased risk of postoperative cataract. Though cataract surgery alone may be appropriate for some glaucoma patients, combined cataract and glaucoma surgery lower long-term intraocular pressure (IOP) more than cataract extraction alone. Use of intraoperative mitomycin-C is beneficial in combined surgery. Limbu and fornix-based conjunctival flaps are equally effective for lowering IOP combined surgery. Trabeculectomy alone lowers long-term IOP more tha combined extracapsular cataract extraction (ECCE) and trabeculectomy. Evidence is weak that combined surgery with phacoemulsification rather than ECCE results in lower long-term IOP, as does two-site compared to single-site combined surgery. CONCLUSION: The literature does not point to an optimal strategy for controlling in patients with coexisting cataract and glaucoma needing surgery. There is a continued need for high-quality studies of longer duration and more information on the optic nerve and visual field.
GLAUCOMA ; CATARACT ; INTRAOCULAR PRESSURE ; OCULAR HYPERTENSION ; OCULAR HYPOTENSION ; SURGERY ; PHACOEMULSIFICATION ; TRABECULECTOMY

OBJECTIVE: Glaucomatous optic neuropathy (GON), defined as definitive damage to the optic-nerve head (ONH) and retinal-nerve-fiber layer (RNFL), involves structural changes in the ONH and RNFL and functional losses in the central visual field. Due to the unique anatomic distribution of the nerve fibers as they enter the ONH, there are specific changes in the ONH correlated with specific findings in the visual-field characteristic of GON. The evaluation of these changes is discussed. METHODS: There are qualitative and quantitative methods in the structural examination of the ONH and RNFL, and quantitative techniques in the functional assessment of the central visual field. They are correlated to one another their strengths and limitations are discussed. RESULTS: Clinical evaluation of the ONH and RNFL consists of five basic rules: (1) identify the limits of the optic disc and determine its size, (2) identify the s of the neuroretinal rim, (3) examine the RNFL, (4) examine the region for parapapillary atrophy, and (5) look for retinal and optic-disc hemorrhages. These steps are simple to use and comprise a portion of the comprehensive eye evaluation. Without proper documentation of the changes in glaucoma progression may be missed. Computer-based digital-imaging technology exemplified by the HRT II, GDx, OCT, provides fast, reproducible, objective measurements of the ONH and RNFL, allowing for more precise diagnosis and monitoring of glaucoma. These changes have good correlation to functional assessments exemplified by the standard automated perimetry (SAP) and the selective perimetry (FDT, SWAP). Typical glaucomatous visu field defects include nasal step, paracentral scotoma, and arcuate defects which follow the RNFL pattern. Progression of these defects is monitored over time and needs to be differentiated from long-term fluctuation. CONCLUSION: The clinician should perform both structural and functional assessments to diagnose and monitor glaucoma. Both examinations provide complimentary information and each has its own place in the clinical care of glaucoma patients. The newer imaging devices and selective perimetry augment the diagnostic armamentarium of the clinician and should, therefore, be used appropriately.
GLAUCOMA ; OPTIC NERVE ; VISUAL FIELDS ; VISUAL FIELD TESTS ; OPTIC DISK

Human ; Adult ; GLAUCOMA-OPEN-ANGLE ; GLAUCOMA,SIMPLEX ; GLAUCOMA, COMPENSATED ; IRIDOCORNEAL ENDOTHELIAL SYNDROME ; FILTERING SURGERY ; GLAUCOMA ; SCLEROSTOMY ; TRABECULECTOMY