The use of Molteno implant and anterior chamber tube shunt to encircling band for the treatment of glaucoma in keratoplasty patients

This retrospective study reviews the results of 35 keratoplasty patients with complex corneal and glaucoma disease, who received Molteno-type (n = 25) or anterior chamber tube shunt to encircling band (ACTSEB)-type (n = 10) implant for the treatment of difficult glaucomas. The implant was placed before the keratoplasty in 14 eyes, during the keratoplasty procedure in 6 eyes, and subsequent to the corneal surgery in 15 eyes. Mean follow-up for the keratoplasty was 25.46 months (range, 6-58 months) and 24.74 months (range, 7-42 months) for the seton procedure. Graft rejection occurred in 12 (34%) of 35 eyes and was progressive in 9 eyes. Nonimmunologic failure was seen in 9 (26%) of 35 eyes. Grafts were repeated in ten eyes with eight of these (80%) remaining clear at a mean of 14.4 months. Considering the results of the repeat grafts, 25 (71%) of 35 eyes achieved clear transplants. Overall, 46% of patients had final visual acuities of 20/100 or better and 69% had final visual acuities of 20/400 or better. The mean preoperative intraocular pressure (IOP) of 34.54 mmHg (range, 14-68 mmHg; standard deviation [SD], 11.51) was lowered to a mean of 14.65 mmHg (range, 6-30 mmHg; SD, 4.49). In the final analysis, 30 (86%) of 35 eyes were judged successful from a glaucoma standpoint. We conclude that the Molteno- and ACTSEB-type implants are viable treatment alternatives in this difficult glaucoma group.     

Multifocal intraocular lens implantation in pediatric cataract surgery

OBJECTIVE: To evaluate implantation of a zonal-progressive multifocal intraocular lens (IOL) in children. STUDY DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Thirty-five eyes of 26 pediatric patients aged 2 to 14 years with multifocal IOL implantation at one institution with more than 1 year of follow-up. INTERVENTIONS: Standard surgical procedure comprised an anterior capsulorrhexis, lens material aspiration via two side-port incisions, temporal tunnel incision, and multifocal IOL (SA40-N; Allergan, Irvine, CA) implantation in all eyes. In 24 eyes (68%), a 5-mm posterior capsulorrhexis was created with forceps, followed by an anterior vitrectomy in 19 of those eyes (54%). RESULTS: Twenty-six patients (35 eyes) had an average follow-up of 27.4 +/- 12.7 months (range, 12-58 months). At last follow-up, best-corrected distance visual acuity improved significantly (P = 0.001), 71% of eyes with a visual acuity of 20/40 or better and 31% of eyes with a visual acuity of 20/25 or better. In the 9 bilateral cases, spectacle dependency was moderate, with only 2 children (22%) reporting the permanent use of an additional near correction. The remaining children were either using distance-correction only (4 patients; 44%) or no glasses at all (3 patients; 33%). Stereopsis also improved significantly after multifocal IOL implantation (P = 0.01). Sixteen eyes (46%) experienced obscuration of the entrance pupil that required intervention, with 10 requiring a second intraocular surgery. Four eyes required an anterior membranectomy for persistent fibrinous membrane. Intraocular lens decentration requiring surgical intervention developed in six eyes. CONCLUSIONS: Multifocal IOL implantation is a viable alternative to monofocal pseudophakia in this age group.     

Retinal detachment following laser in situ keratomileusis

OBJECTIVE: To report the clinical characteristics, surgical management and outcome of retinal detachment following laser in situ keratomileusis (LASIK) in myopic patients. PATIENTS AND METHODS: Retrospective review of 10 eyes of 10 myopic patients with retinal detachment who had previously undergone LASIK surgery were analyzed. Included in the study were 7 males and 3 females, aged 22 to 68 years (35.2+/-2.8). RESULTS: Mean spherical equivalent refraction was -10.51+/-3.90 D (ranging from -6.37 D to -17.00 D) before surgery. The time interval between the LASIK procedure and the development of retinal detachment varied from two months to nine months (5.2 +/- 2.78 months). The number of retinal breaks was one in 7 patients, two in 2 patients and three in 1 patient. The type of retinal breaks included 7 patients with horse shoe tears, 1 patient with a retinal hole, 1 patient with a giant retinal tear, and 1 patient with retinal dialysis. Retinal breaks were located anterior to the equator in 9 patients and posterior to the equator in 1 patient. Retinal reattachment was achieved with one operation in 8 eyes (80%) and the remaining 2 eyes required a second surgery for the reattachment of the retina. CONCLUSION: This study suggests the possible association between retinal detachment and LASIK procedure in patients with myopia. Clinicians should be aware of retinal pathology predisposing to retinal detachment in patients undergoing LASIK.     

Refractive surgery for unilateral high myopia in children

PURPOSE: To evaluate the safety and efficacy of refractive surgery in children. METHODS: Pediatric patients with unilateral high myopia who were 9 years of age or older were offered refractive surgery to supplement optical correction. The patients and families were informed that the operation may not improve their best-corrected visual acuity. Photorefractive keratectomy (PRK) or laser in situ keratomileusis (LASIK) was performed on the more myopic eye with the use of topical anesthesia. Cycloplegic refraction, stereopsis, motility, and best-corrected visual acuity were measured before the procedure and at 2 months and 20 months after the procedure. All patients had completed amblyopia therapy before surgery. RESULTS: Fourteen eyes of 14 patients aged 9 to 14 years received refractive surgery. Average age at the time of surgery was 11.9 years (+/-1,6). Average corrected preoperative visual acuity was 20/147 (+/-0.065 in decimals). Average preoperative refraction was -7.96 D (+/-2,16) spherical equivalent. Twenty months after refractive surgery, the uncorrected visual acuity averaged 20/129 (+/-0.08 in decimals) and best-corrected vision averaged 20/121 (+/-0.08 in decimals). Average refraction was -0.46 D (+/-0,58) at 2 months and -0.67 D (+/-0,68) D at 20 months. An average myopic shift in refraction of -0.22 D was found in treated eyes during the 20 months of follow-up; this was not statistically significant (P =.69). Three patients had LASIK and 11 patients had PRK. LASIK patients averaged -0.875 D of myopic shift over 20 months of follow-up. Those with PRK averaged -0.025 D. This difference was not statistically significant (P =.10). The vision of 5 of 14 patients improved 1 or 2 lines after refractive surgery. Two patients who had 20/80 vision preoperatively improved to 20/60. No patients lost any lines of vision. Only 4 patients demonstrated stereopsis preoperatively, and all retained stereopsis postoperatively. No patient gained stereopsis. CONCLUSIONS: LASIK and PRK can be performed safely and effectively in children who are cooperative enough to undergo the procedures with topical anesthesia. Refractive surgery does not improve vision in densely amblyopic eyes but may give modest improvement in those that are mildly amblyopic. No significant complications were encountered aside from a myopic shift over time.     

Combined ICRS insertion and LASIK to maximize postoperative residual bed thickness in high myopia

PURPOSE: To describe a new technique and early outcomes of combined intrastromal corneal ring segment (ICRS) insertion and laser in situ keratomileusis (LASIK) to treat patients with moderate to high myopia and thin corneas. SETTING: University-based academic practice, Boston, Massachusetts, USA. METHODS: Combined ICRS insertion and LASIK was performed in 2 stages: ICRS channel formation (stage I) followed by LASIK and ICRS insertion (stage II). RESULTS: Fifteen eyes of 11 patients with a mean preoperative spherical equivalent of -9.98 diopters (D) +/- 2.60 (SD) (range -7.13 to -16.25 D) and mean preoperative astigmatism of 1.11 +/- 0.75 D (range 0.00 to -3.00 D) were treated with combined ICRS insertion and LASIK. The mean central pachymetry was 526.13 +/- 35.69 microm (472 to 579 microm). The uncorrected visual acuity was 20/40 or better in 7 of 15 eyes (46.67%) at 1 month, 6 of 12 eyes (50.00%) at 3 months, 5 of 12 eyes (41.67%) at 6 months, and 6 of 12 eyes (50.00%) at 12 months. The best spectacle-corrected visual acuity was 20/40 or better at all times. Postoperative maps confirmed the absence of ectasia. The postoperative spherical equivalent was within +/-1.00 D of the intended refraction in 11 of 15 eyes (73.33%) at 1 month, 9 of 12 eyes at 3 and 6 months, and 8 of 12 eyes (66.67%) at 12 months. CONCLUSIONS: Results of combined ICRS insertion and LASIK in moderately to highly myopic patients with relatively thin corneas were good. Long-term studies are needed to determine whether this procedure will decrease the risk of LASIK-induced keratectasia in these patients.     

Augmented trabeculectomy in paediatric glaucoma

AIMS: To report the experience with trabeculectomy augmented with mitomycin C and 5-fluorouracil for the treatment of paediatric glaucoma. METHODS: Retrospective, interventional case series design was used. The sample included 17 children (29 eyes) with primary (19 eyes) or secondary (10 eyes) glaucoma who were treated with augmented trabeculectomy as the primary procedure between 1990 and 2002. Data were collected on age and family history, preoperative and end of follow up intraocular pressure, cup/disc ratio (evaluated by drawing), visual acuity, complications, and post-surgery treatment. RESULTS: Patient age at surgery ranged from 1 month to 8 years; most patients (n = 14, 82.3%) were aged less than 1 year (range 1 month-8 months, mean 3.95 (SD 2.56) months); three patients (17.7%) were aged 3, 5, and 8 years. The duration of follow up was 3-120 months (mean 46 months). Intraocular pressure significantly improved from 21 mm Hg to 60 mm Hg (mean 33.1 (10) mm Hg) before surgery to 6-26 mm Hg (mean 17.1 (6) mm Hg) after, (p <0.0001). There was no significant change in cup/disc ratio: 0.1-0.8 (mean 0.42 (0.26)) before and 0.1-1.0 (mean 0.511 (0.27)) after (p = 0.45). In 22 eyes (75.8%), intraocular pressure was controlled at less than 20 mm Hg and the cup/disc ratio remained stable or improved. The life table success rate for intraocular pressure control remained stable at 86% at the 12, 24, and 36 months and after 48 months decreased to 53%. There was no significant difference in the life table results between primary and secondary glaucoma. 14 eyes (48.2%) had a visual acuity better than 20/120 by the end of follow up. Repeated surgery was necessary in eight eyes (27.5%), and additional antiglaucoma treatment in 13 (44.8%). Complications included retinal detachment 1 year after surgery, choroidal detachment, and blebitis (one eye each). CONCLUSIONS: Augmented trabeculectomy with mitomycin C and 5-fluorouracil may serve as the primary procedure in a selected group of paediatric patients with glaucoma.     

Ritleng泪道插管术在儿童泪道手术中的应用

目的 探讨Ritleng泪道插管手术治疗儿童先天性泪道阻塞的疗效与并发症.方法 回顾性系列病例研究.2006年2月至2007年3月首都医科大学附属北京儿童医院眼科对148例(187只眼)常规施行泪道探通手术无效的先天性泪道阻塞患儿采用口服水合氯醛后局部麻醉下Ritleng泪道插管手术治疗.患儿年龄范围是5～40个月.对该方法治疗流泪等症状、恢复泪道排泄功能的疗效及术中出血或水肿、术后硅胶管脱出等并发症进行分析.随访时间为术后4～17个月.结果 术后1～3 d,157只眼(84.0%)流泪症状消失.术后3或6个月,187只眼均顺利拔管.其中178只眼(95.2%)治愈,7只眼(3.7%)好转,2只眼(1.1%)无效;46例(52只眼)5个月龄的患儿行泪道插管手术1个月后泪道排泄功能全部恢复正常.术中并发症包括鼻腔少量出血9只眼,泪小管水肿者9只眼.术后8只眼(4.3%)出现硅胶管脱出.结论 Ritleng泪道插管手术是一种便捷、安全的儿童泪道手术,可用于儿童先天性泪道阻塞的早期手术治疗.     

Surgical management of the idiopathic uveal effusion syndrome

Twenty-three eyes of 20 patients with idiopathic ciliochoroidal effusion underwent quadrantic partial-thickness sclerectomies without decompression of the vortex veins. The mean postoperative follow-up interval was 41 months (range, 6-86 months). Resolution of subretinal and/or supraciliochoroidal fluid occurred within 6 months in 19 eyes (83%) after one procedure and in 22 eyes (96%) after one or two procedures. The mean interval to reattachment for the 19 successfully treated eyes with nonrhegmatogenous retinal detachment (RD) was 2.4 months compared with an average preoperative detachment duration of 18.5 months (P = 0.0005). Recurrences were seen in 23% of eyes; all resolved spontaneously or with a single reoperation. Final visual acuity was improved by two or more lines in 13 eyes (56%), stable in 8 (35%), and worse in 2 (9%). The efficacy of this surgical technique supports the hypothesis that an abnormality of transscleral protein transport plays a primary pathophysiologic role in this disorder.     

Two-stage laser in situ keratomileusis to correct refractive errors after penetrating keratoplasty

PURPOSE: To evaluate the effect of a two-stage laser in situ keratomileusis (LASIK) procedure on eyes with high astigmatism and/or anisometropia after penetrating keratoplasty. METHODS: Eleven postoperative penetrating keratoplasty eyes were included in a prospective, non-controlled study. All patients had at least 4.00 D of astigmatism and/or at least 3.00 D of anisometropia and were spectacle and contact lens intolerant. Two-stage LASIK was performed; in the first stage a hinged corneal flap 160 microm in thickness and 9 mm in diameter was created. After stabilization of corneal shape (1 to 3 months after keratotomy), the corneal flap was lifted and laser refractive treatment (second stage) was performed. RESULTS: After the first stage, a statistically significant reduction in refractive astigmatism (P<.01) was recorded. In all eyes but one, best spectacle-corrected visual acuity was maintained or improved after the procedure. Three months after the second stage, refractive astigmatism in 8 of 11 eyes (73%) was within +/- 1.00 D, and spherical equivalent refraction in 9 of 11 eyes (82%) was within +/- 1.00 D of intended correction. Preoperative irregular astigmatism persisted in three patients (3 eyes) who could not be corrected within +/- 1.00 D of refractive astigmatism and/or +/- 1.00 D of intended spherical equivalent refraction. In one eye, an interface infiltrate developed shortly after creation of the flap, and resulted in limited melting. CONCLUSIONS: A two-stage LASIK procedure improved visual acuity and refraction in postoperative penetrating keratoplasty eyes with high astigmatism and/or anisometropia. Complications were uncommon but can lead to loss of vision.     

Endothelial specular microscopy in children with retrolental fibroplasia undergoing open-sky vitrectomy

Thirty-three patients aged 4 to 63 months with extensive retinal detachment due to cicatricial retrolental fibroplasia (RLF) and two non-RLF patients aged 26 and 81 months with normal corneas underwent specular microscopy and ultrasonic pachymetry during examination under anesthesia. Thirty-six eyes of preoperative RLF patients without anterior synechiae and 4 eyes of the two non-RLF patients had high endothelial cell density (ECD) of 5,105 +/- 790.4/mm2 (mean +/- SD) and 4,377 +/- 141.7/mm2, respectively, and increased corneal thickness. The ECD value showed significant negative correlation with vertical corneal diameter (P less than 0.005), but not with age. The ECD values, corrected to average adult corneal size, were 3,900 +/- 550/mm2, which were close to values extrapolated from adult ECD data. The average cell loss for 10 eyes undergoing specular microscopy before and after open-sky vitrectomy was 15%, but 8 of these eyes showed an unchanged ECD ratio of 0.79-1.3 between the two measurements. Furthermore, 17 eyes which were examined only postoperatively also showed a high average ECD of 4,175 +/- 1,012/mm2.