Lehigh Valley Center For Sight

Novel antithrombotic pose an equal or lower risk of intraocular hemorrhage than their traditional counterparts, according to this analysis of insurance claims.  Study design This retrospective cohort study analyzed the safety profiles of novel anticoagulants and antiplatelet therapy. Investigators analyzed the incidence of intraocular hemorrhage between months 3 and 12 among new users of antithrombotic drugs. Outcomes A statistical comparison of 146,137 patients taking warfarin and 64,291 patients taking novel anticoagulants dabigatran (Pradaxa) or rivaroxaban (Xarelto) revealed a slightly lower risk of hemorrhage in the latter group at 365 days (HR 0.75; P=0.03). However, a comparison of 103,796 patients taking clopidogrel with 8,386 patients taking novel antiplatelet therapy prasugrel revealed no differences (P=0.53). Limitations The study was unable to determine if patients temporarily stopped their medication at or around the time of eye surgery. Since the rate of intraocula

Investigators report findings from 2 noninferiority trials comparing once-daily netarsudil 0.02% (Rhopressa, Aerie) with twice-daily timolol 0.5% in patients with ocular hypertension or open-angle glaucoma. Netarsudil is new class of glaucoma medication that inhibits Rho kinase and norepinephrine transporters. It lowers IOP by increasing trabecular outflow facility, decreasing production of aqueous humor and decreasing episcleral venous pressure. Study design After a wash-out phase, 1,167 patients in the ROCKET 1 and ROCKET 2 trials were randomized to once-daily netarsudil or twice-daily (BID) timolol. The ROCKET 2 trial had an additional nertasudil BID arm. Patients were followed through 3 months. Outcomes Netarsudil did not meet noninferiority criteria in the ROCKET 1 study (baseline washout IOP between 20 to 27 mm Hg). A post-hoc analysis revealed that netarsudil was noninferior to timolol for patients with a post-washout IOP lower than 25 mm Hg. Each arm of the ROCKET-2 study

FEB 26, 2018 Refractive Mgmt/Intervention This retrospective study compared vector planning to manifest refraction planning in patients undergoing LASIK for myopic astigmatism. Study design The study included 85 treatments based on manifest astigmatism and 79 treatments based on vector planning, which incorporates both manifest refraction and corneal topographic shape. All patients received LASIK with an aberration-neutral profile centered on the visual axis considering 70% of the pupil offset toward the corneal vortex. The treatments used were based 60% emphasis on refractive astigmatism and 40% emphasis on corneal astigmatism. Only patients with a preoperative ocular residual astigmatism (ORA) of greater than 0.75 D were included. The ORA is defined by the vector difference between the manifest and corneal astigmatism. Outcomes Overall, there were no significant differences in postoperative refractive astigmatism, corrected distance visual acuity or uncorrected dista

https://www.aao.org/editors-choice/noninferiority-trials-confirm-iop-benefits-of-once

This assessment by the Ophthalmic Technology Assessment Committee of the Academy’s Cornea and Anterior Segment Disorders Panel reviews the safety and outcomes of Descemet membrane endothelial keratoplasty (DMEK) to treat corneal endothelial dysfunction. Study design The authors reviewed the abstracts of 1,085 articles from the PubMed and Cochrane Library Literature databases, and selected 47 large (>25 DMEK cases), prospective, controlled clinical studies; and observational studies for inclusion in the final assessment. Of the 47 studies, the panel’s methodologist rated 2 as level I evidence, 15 as level II evidence and 30 as level III evidence. Key search terms included Descemet membrane endothelial keratoplasty , Descemet's membrane endothelial keratoplasty , DMEK , posterior lamellar keratoplasty and endothelial keratoplasty. Studies of nonhuman and deep anterior lamellar keratoplasty were excluded. Outcomes By 6 months after DMEK surgery, up to 85% of eyes achieved a

This retrospective review examined recurrence of choroidal neovascularization (CNV) in patients who were weaned off a treat-and-extend anti-VEGF regimen for wet AMD. Study design The cohort comprised 385 eyes (321 patients) who were treated with anti-VEGF injections at 4-week intervals. If the macula remained “dry”, treatment was extended by 1- to 2-week intervals until the injections were 12 weeks apart. Treatment was stopped if there were no signs of disease activity, and reinitiated if there was new or recurrent CNV. Outcomes Approximately 37% of eyes (143 eyes of 120 patients) met criteria for treatment cessation over the average follow-up of 27 months. The overall recurrence rate was 29% (42 eyes of 36 patients) at a median of 14 months after stopping therapy. Mean BCVA was 20/50 at the time of therapy cessation and 20/60 at the time of recurrence. However, most patients recovered their baseline vision after treatment was reinitiated. Limitations This is a retrospective stu

FEB 06, 2018 Glaucoma This pooled analysis assessed the efficacy and safety of latanoprostene bunod compared with timolol for the treatment of open-angle glaucoma. Study design The authors analyzed data from two phase 3, randomized, multicenter, double-masked, parallel-group, noninferiority trials (APOLLO and LUNAR), comprising 840 participants. Adults with open-angle glaucoma or ocular hypertension were randomized 2:1 to receive once-daily latanoprostene bunod (0.024%) or twice-daily timolol (0.5%) for 3 months. Outcomes Patients on latanoprostene bunod achieved a significantly lower mean IOP compared with timolol patients at 9 evaluation time points throughout 3 months of follow-up. The latanoprostene arm also had a greater number of subjects that attained a mean IOP of ≤18 mm Hg and an IOP reduction of ≥25% from baseline. The study detected a 5.9% rate of conjunctival hyperemia in the latanoprostene bunod group. Eye irritation and pain occurred in less than 5% of pa

This retrospective case series compared the accuracy of 7 popular IOL formulas for predicting postoperative refraction in eyes of all ocular dimensions Study design The analysis included 18,501 eyes receiving an Alcon monofocal IOL (SN60WF or SA60AT IOL) over an 18-month period. All eyes had biometry with the Lenstar 900 optical biometer. Investigators analyzed the error in predicted spherical equivalent of each formula (Barrett Universal II, Haigis, Hoffer Q, Holladay 1, Holladay 2, Olsen, and SRK/T), including the Wang-Koch adjustment (Holladay 1, Hoffer Q, Haigis, SRK/T) for eyes with axial length longer than 25 mm. Outcomes For the SN60WF, the Barrett Universal II had the significantly lowest mean absolute error followed by the Olsen, Haigis 1, Holladay 1 Wang-Koch, Holladay 2, Holladay 1, Hoffer Q Wang-Koch, SRK/T, SRK/T Wang-Koch, Hoffer Q, and Haigis Wang-Koch. The results were similar for the SA60AT IOL. For long eyes (>25.5mm), Olsen had the lowest mean error followed

Investigators report findings from 2 noninferiority trials comparing once-daily netarsudil 0.02% (Rhopressa, Aerie) with twice-daily timolol 0.5% in patients with ocular hypertension or open-angle glaucoma. Netarsudil is new class of glaucoma medication that inhibits Rho kinase and norepinephrine transporters. It lowers IOP by increasing trabecular outflow facility, decreasing production of aqueous humor and decreasing episcleral venous pressure. Study design After a wash-out phase, 1,167 patients in the ROCKET 1 and ROCKET 2 trials were randomized to once-daily netarsudil or twice-daily (BID) timolol. The ROCKET 2 trial had an additional nertasudil BID arm. Patients were followed through 3 months. Outcomes Netarsudil did not meet noninferiority criteria in the ROCKET 1 study (baseline washout IOP between 20 to 27 mm Hg). A post-hoc analysis revealed that netarsudil was noninferior to timolol for patients with a post-washout IOP lower than 25 mm Hg. Each arm of the ROCKET-2 study

This retrospective review examined recurrence of choroidal neovascularization (CNV) in patients who were weaned off a treat-and-extend anti-VEGF regimen for wet AMD. Study design The cohort comprised 385 eyes (321 patients) who were treated with anti-VEGF injections at 4-week intervals. If the macula remained “dry”, treatment was extended by 1- to 2-week intervals until the injections were 12 weeks apart. Treatment was stopped if there were no signs of disease activity, and reinitiated if there was new or recurrent CNV. Outcomes Approximately 37% of eyes (143 eyes of 120 patients) met criteria for treatment cessation over the average follow-up of 27 months. The overall recurrence rate was 29% (42 eyes of 36 patients) at a median of 14 months after stopping therapy. Mean BCVA was 20/50 at the time of therapy cessation and 20/60 at the time of recurrence. However, most patients recovered their baseline vision after treatment was reinitiated. Limitations This is a retrospective stu

A major problem with advanced Macular Degeneration is the growth of blood vessels in the eye. These unwanted blood vessels develop in the late stages of Age-Related Macular Degeneration (ARMD), also known as “wet” ARMD. Dr. Marc Grossman at Natural Eye Care has developed a package of supplements aimed at strengthening the retina and reducing the risk of new blood vessel growth. New blood vessels obscure vision. Wet ARMD patients have few options. Doctors can sometimes zap the eye with lasers in an attempt to reduce the rate of future blood vessel growth. Oral drugs such as ranibizumab can help stop new blood vessels from developing. Injectable drugs are also aimed at stopping the extra blood vessel growth. All these options carry potential side effects and damage. In consultation with their eye doctors, some wet AMD patients have tried research-based targeted nutrition. Certain vitamins, nutrients, homeopathics, and Traditional Chinese Medicine remedies are aimed at supporting the e

This Current Insight outlines current evidence supporting surgical management strategies for trachomatous trichiasis. PLTR and BLTR: Two tried and tested techniques Published in the August 2017 issue of Ophthalmology , the study Predictors of Trachomatous Trichiasis Surgery Outcome compares 2 tarsal rotation surgeries: posterior lamellar tarsal rotation (PLTR) and bilamellar tarsal rotation (BLTR). Clinical trials have shown that PLTR and BLTR are more effective than alternative surgical procedures for the management of trachomatous trichiasis (TT) in trachoma-endemic settings. These tarsal rotation procedures are therefore recommended by the World Health Organization (WHO).  In particular, two trials examined the relative effectiveness of BLTR, tarsal advance and rotation, eversion splinting, tarsal advance (lid split), tarsal advance and grafting, and tarsal grooving. Both trials found the BLTR procedure to be superior than other strategies for the management of TT. 1,2 Further

FEB 06, 2018 Glaucoma This pooled analysis assessed the efficacy and safety of latanoprostene bunod compared with timolol for the treatment of open-angle glaucoma. Study design The authors analyzed data from two phase 3, randomized, multicenter, double-masked, parallel-group, noninferiority trials (APOLLO and LUNAR), comprising 840 participants. Adults with open-angle glaucoma or ocular hypertension were randomized 2:1 to receive once-daily latanoprostene bunod (0.024%) or twice-daily timolol (0.5%) for 3 months. Outcomes Patients on latanoprostene bunod achieved a significantly lower mean IOP compared with timolol patients at 9 evaluation time points throughout 3 months of follow-up. The latanoprostene arm also had a greater number of subjects that attained a mean IOP of ≤18 mm Hg and an IOP reduction of ≥25% from baseline. The study detected a 5.9% rate of conjunctival hyperemia in the latanoprostene bunod group. Eye irritation and pain occurred in less than 5% of pa

Investigators report findings from 2 noninferiority trials comparing once-daily netarsudil 0.02% (Rhopressa, Aerie) with twice-daily timolol 0.5% in patients with ocular hypertension or open-angle glaucoma. Netarsudil is new class of glaucoma medication that inhibits Rho kinase and norepinephrine transporters. It lowers IOP by increasing trabecular outflow facility, decreasing production of aqueous humor and decreasing episcleral venous pressure. Study design After a wash-out phase, 1,167 patients in the ROCKET 1 and ROCKET 2 trials were randomized to once-daily netarsudil or twice-daily (BID) timolol. The ROCKET 2 trial had an additional nertasudil BID arm. Patients were followed through 3 months. Outcomes Netarsudil did not meet noninferiority criteria in the ROCKET 1 study (baseline washout IOP between 20 to 27 mm Hg). A post-hoc analysis revealed that netarsudil was noninferior to timolol for patients with a post-washout IOP lower than 25 mm Hg. Each arm of the ROCKET-2 study

FEB 23, 2018 By Anni Griswold Comprehensive Ophthalmology, Cornea/External Disease, Pediatric Ophth/Strabismus A weekly roundup of ophthalmic news from around the web. An artificial eye surface built from human cells could help scientists test treatments for dry eye, corneal ulcers and other conditions. The surface is lubricated with each blink of a faux eyelid, crafted from a thin hydrogel film . Engineers from the University of Pennsylvania unveiled the model last week, during the annual meeting of the American Association for the Advancement of Science. Science News   *Image courtesy of Dan Huh Laboratory/University of Pennsylvania Physician burnout is starting to spill over into patient care , according to a recent report in JAMA Internal Medicine . More than 1 in 3 physicians show signs of emotional exhaustion and depersonalization , and are at risk of abandoning their practice and receiving ombudsman complaints.  Healio Smart traffic signals may soon he

Using data from the Gutenberg Health Study, researchers examined the effect of systemic anti-hypertensive medications on IOP. Study design This population-based, prospective cohort study included 13,527 patients who were on a wide range of cardiovascular medications: peripheral vasodilators, diuretics, β-blockers (overall, selective and non-selective), calcium channel blockers, renin–angiotensin blockers (overall, ACE inhibitors and angiotensin-receptor blockers), nitrates, other antihypertensive medications, aspirin and statins. IOP was measured using a non-contact tonometer. Any patient on topical IOP-lowering medications or with a history of any ocular surgery was excluded. Outcomes A multivariate analysis found no statistically significant association between the use of oral anti-hypertensive medications and IOP in non-glaucomatous patients. Specifically, in contrast to prior studies, the authors found no association between β-blockers and lower IOP, though there was a slight

This Current Insight outlines current evidence supporting surgical management strategies for trachomatous trichiasis. PLTR and BLTR: Two tried and tested techniques Published in the August 2017 issue of Ophthalmology , the study Predictors of Trachomatous Trichiasis Surgery Outcome compares 2 tarsal rotation surgeries: posterior lamellar tarsal rotation (PLTR) and bilamellar tarsal rotation (BLTR). Clinical trials have shown that PLTR and BLTR are more effective than alternative surgical procedures for the management of trachomatous trichiasis (TT) in trachoma-endemic settings. These tarsal rotation procedures are therefore recommended by the World Health Organization (WHO).  In particular, two trials examined the relative effectiveness of BLTR, tarsal advance and rotation, eversion splinting, tarsal advance (lid split), tarsal advance and grafting, and tarsal grooving. Both trials found the BLTR procedure to be superior than other strategies for the management of TT. 1,2 Further

FEB 06, 2018 Glaucoma This pooled analysis assessed the efficacy and safety of latanoprostene bunod compared with timolol for the treatment of open-angle glaucoma. Study design The authors analyzed data from two phase 3, randomized, multicenter, double-masked, parallel-group, noninferiority trials (APOLLO and LUNAR), comprising 840 participants. Adults with open-angle glaucoma or ocular hypertension were randomized 2:1 to receive once-daily latanoprostene bunod (0.024%) or twice-daily timolol (0.5%) for 3 months. Outcomes Patients on latanoprostene bunod achieved a significantly lower mean IOP compared with timolol patients at 9 evaluation time points throughout 3 months of follow-up. The latanoprostene arm also had a greater number of subjects that attained a mean IOP of ≤18 mm Hg and an IOP reduction of ≥25% from baseline. The study detected a 5.9% rate of conjunctival hyperemia in the latanoprostene bunod group. Eye irritation and pain occurred in less than 5% of pa

This retrospective case series compared the accuracy of 7 popular IOL formulas for predicting postoperative refraction in eyes of all ocular dimensions Study design The analysis included 18,501 eyes receiving an Alcon monofocal IOL (SN60WF or SA60AT IOL) over an 18-month period. All eyes had biometry with the Lenstar 900 optical biometer. Investigators analyzed the error in predicted spherical equivalent of each formula (Barrett Universal II, Haigis, Hoffer Q, Holladay 1, Holladay 2, Olsen, and SRK/T), including the Wang-Koch adjustment (Holladay 1, Hoffer Q, Haigis, SRK/T) for eyes with axial length longer than 25 mm. Outcomes For the SN60WF, the Barrett Universal II had the significantly lowest mean absolute error followed by the Olsen, Haigis 1, Holladay 1 Wang-Koch, Holladay 2, Holladay 1, Hoffer Q Wang-Koch, SRK/T, SRK/T Wang-Koch, Hoffer Q, and Haigis Wang-Koch. The results were similar for the SA60AT IOL. For long eyes (>25.5mm), Olsen had the lowest mean error followed

How We Get Them & How We Get Rid Of Them Do you have something that looks like a pimple on the outside or inside your eyelid? I s it terribly uncomfortable and unsightly?   You either have a stye or a chalazion on your eye.   C halazion is a no n-infected swelling of the lid caused by a blocked lipid  gland. Lipid fr o m the  blocked gl and leaks into the eye lid tissue causing an inflammation which eventually clears t h e irritating l ipid. This  can take 2 to 4 weeks or mo re. Sty es are caused by bacteria from your skin that gets into a nd irritates the oil  glands in  the eyelids. These bacteria, which normally exist harmlessly on the skin of the eye, can  sometimes g e t trapped along with dead skin cells on the edge of the eyelid. The result is a swollen, red, and painful bump  that can develop over the course o f a few days. While most styes or chalazions are harmless and will heal on their own in about a week or two, they can still be thoroughly unpleasant. Fortunately

Using data from the Gutenberg Health Study, researchers examined the effect of systemic anti-hypertensive medications on IOP. Study design This population-based, prospective cohort study included 13,527 patients who were on a wide range of cardiovascular medications: peripheral vasodilators, diuretics, β-blockers (overall, selective and non-selective), calcium channel blockers, renin–angiotensin blockers (overall, ACE inhibitors and angiotensin-receptor blockers), nitrates, other antihypertensive medications, aspirin and statins. IOP was measured using a non-contact tonometer. Any patient on topical IOP-lowering medications or with a history of any ocular surgery was excluded. Outcomes A multivariate analysis found no statistically significant association between the use of oral anti-hypertensive medications and IOP in non-glaucomatous patients. Specifically, in contrast to prior studies, the authors found no association between β-blockers and lower IOP, though there was a slight

This Current Insight outlines current evidence supporting surgical management strategies for trachomatous trichiasis. PLTR and BLTR: Two tried and tested techniques Published in the August 2017 issue of Ophthalmology , the study Predictors of Trachomatous Trichiasis Surgery Outcome compares 2 tarsal rotation surgeries: posterior lamellar tarsal rotation (PLTR) and bilamellar tarsal rotation (BLTR). Clinical trials have shown that PLTR and BLTR are more effective than alternative surgical procedures for the management of trachomatous trichiasis (TT) in trachoma-endemic settings. These tarsal rotation procedures are therefore recommended by the World Health Organization (WHO).  In particular, two trials examined the relative effectiveness of BLTR, tarsal advance and rotation, eversion splinting, tarsal advance (lid split), tarsal advance and grafting, and tarsal grooving. Both trials found the BLTR procedure to be superior than other strategies for the management of TT. 1,2 Further

FEB 12, 2018 Oculoplastics/Orbit This retrospective study examined demographic risk factors for developing eyelid squamous cell carcinoma (SCC). Study design Using data from the National Cancer Registration and Analysis Service, investigators identified all cases of eyelid SCC in England between 2000 and 2014. Outcomes Over the 15-year study period, there were 4,022 patients with newly diagnosed SCC affecting the eyelid. The age-standardized number of reported cases of eyelid SCC rose approximately 2% per year over the study period. The risk for developing an eyelid SCC approximately doubled each decade after age 60. Men were at 1.9-times greater relative risk compared with women. The authors did not find any association between income quintile and risk of SCC. Limitations The cause for the increasing incidence of eyelid SCC was not studied. While age may represent one factor, others such as an increasing rate of patients receiving immunosuppression therapies may als

A major problem with advanced Macular Degeneration is the growth of blood vessels in the eye. These unwanted blood vessels develop in the late stages of Age-Related Macular Degeneration (ARMD), also known as “wet” ARMD. Dr. Marc Grossman at Natural Eye Care has developed a package of supplements aimed at strengthening the retina and reducing the risk of new blood vessel growth. New blood vessels obscure vision. Wet ARMD patients have few options. Doctors can sometimes zap the eye with lasers in an attempt to reduce the rate of future blood vessel growth. Oral drugs such as ranibizumab can help stop new blood vessels from developing. Injectable drugs are also aimed at stopping the extra blood vessel growth. All these options carry potential side effects and damage. In consultation with their eye doctors, some wet AMD patients have tried research-based targeted nutrition. Certain vitamins, nutrients, homeopathics, and Traditional Chinese Medicine remedies are aimed at supporting the e

FEB 12, 2018 Oculoplastics/Orbit This retrospective study examined demographic risk factors for developing eyelid squamous cell carcinoma (SCC). Study design Using data from the National Cancer Registration and Analysis Service, investigators identified all cases of eyelid SCC in England between 2000 and 2014. Outcomes Over the 15-year study period, there were 4,022 patients with newly diagnosed SCC affecting the eyelid. The age-standardized number of reported cases of eyelid SCC rose approximately 2% per year over the study period. The risk for developing an eyelid SCC approximately doubled each decade after age 60. Men were at 1.9-times greater relative risk compared with women. The authors did not find any association between income quintile and risk of SCC. Limitations The cause for the increasing incidence of eyelid SCC was not studied. While age may represent one factor, others such as an increasing rate of patients receiving immunosuppression therapies may als

A major problem with advanced Macular Degeneration is the growth of blood vessels in the eye. These unwanted blood vessels develop in the late stages of Age-Related Macular Degeneration (ARMD), also known as “wet” ARMD. Dr. Marc Grossman at Natural Eye Care has developed a package of supplements aimed at strengthening the retina and reducing the risk of new blood vessel growth. New blood vessels obscure vision. Wet ARMD patients have few options. Doctors can sometimes zap the eye with lasers in an attempt to reduce the rate of future blood vessel growth. Oral drugs such as ranibizumab can help stop new blood vessels from developing. Injectable drugs are also aimed at stopping the extra blood vessel growth. All these options carry potential side effects and damage. In consultation with their eye doctors, some wet AMD patients have tried research-based targeted nutrition. Certain vitamins, nutrients, homeopathics, and Traditional Chinese Medicine remedies are aimed at supporting the e

FEB 12, 2018 Oculoplastics/Orbit This retrospective study examined demographic risk factors for developing eyelid squamous cell carcinoma (SCC). Study design Using data from the National Cancer Registration and Analysis Service, investigators identified all cases of eyelid SCC in England between 2000 and 2014. Outcomes Over the 15-year study period, there were 4,022 patients with newly diagnosed SCC affecting the eyelid. The age-standardized number of reported cases of eyelid SCC rose approximately 2% per year over the study period. The risk for developing an eyelid SCC approximately doubled each decade after age 60. Men were at 1.9-times greater relative risk compared with women. The authors did not find any association between income quintile and risk of SCC. Limitations The cause for the increasing incidence of eyelid SCC was not studied. While age may represent one factor, others such as an increasing rate of patients receiving immunosuppression therapies may als

Investigators evaluated the potential of machine learning to predict vision outcomes from baseline assessments of patients receiving ranibizumab for neovascular AMD. Study design This post hoc analysis of prospective trial data included 614 patients receiving monthly or PRN ranibizumab for wet AMD. Monthly OCT volume scans were processed by a fully automated computational image analysis capable of detecting intraretinal cystoid fluid (IRF), subretinal fluid (SRF) and pigment epithelial detachment (PED). Investigators assessed the reliability of quantitative OCT biomarkers and BCVA measurements at baseline and months 1, 2, and 3 to predict BCVA at 12 months. Outcomes At baseline, OCT features and BCVA were significantly correlated (R 2 =0.21). The most relevant OCT biomarker for baseline BCVA was the horizontal extension of IRF in the foveal region. SRF and PED, however, were unrelated to baseline vision. When predicting visual outcomes at 12 months, the model's accuracy impro

FEB 16, 2018 By Anni Griswold Cataract/Anterior Segment, Comprehensive Ophthalmology, Retina/Vitreous A weekly roundup of ophthalmic news from around the web. An Oregon woman who pulled 14 live worms from her eye over the course of 20 days is the first reported human to be infected with Thelazia gulosa , a parasite previously found only in cows. “I’ll never forget when the doctor and the intern saw it wiggle across my eye,” she told National Geographic . “He freaked out and jumped back, and was like, Oh my god, I saw it! I just saw it!” Remarkably, her vision returned to normal and she made a full recovery once all the worms were removed. National Geographic Researchers at the NIH were “astounded” to find bright spots dotting the eyes of stroke patients . They traced the spots to an unlikely source: the MRI contrast agent gadolinium, which traverses the blood-ocular barrier after a stroke and bubbles first into the aqueous chamber, then appears hours later in the