Role of sodium hyaluronate (Healonid) in triangular flap trabeculectomy.

The role of sodium hyaluronate (Healonid) in trabeculectomy to prevent a shallow or flat anterior chamber and hypotonia in the immediate postoperative period is reported. Twenty-nine eyes of 27 patients were included in a randomised controlled study. Thirteen eyes had trabeculectomy alone, and 16 eyes had trabeculectomy performed with Healonid injected into the anterior chamber. The results showed that shallowing of the anterior chamber and hypotonia occurred in both groups until day 21 postoperatively. There was no statistically significant difference between the two groups (p greater than 0.05). Healonid has no significant value in maintaining anterior chamber depth and preventing hypotonia in the early postoperative period following trabeculectomy.     

A randomised,prospective study comparing trabeculectomy augmented with antimetabolites with a viscocanalostomy technique for the management of open angle glaucoma uncontrolled by medical therapy

AIMS: To compare trabeculectomy with viscocanalostomy for the control of intraocular pressure (IOP) in open angle glaucoma (OAG) uncontrolled by medical therapy. METHODS: 48 patients (50 eyes) with uncontrolled OAG were randomised to either trabeculectomy (25 eyes) or a viscocanalostomy technique (25 eyes). Preoperatively, eyes were graded in terms of risk factors for drainage failure. Those undergoing trabeculectomy were given intraoperative antimetabolites (5-fluorouracil 25 mg/ml (5-FU), mitomycin C (MMC) 0.2 mg/ml and 0.4 mg/ml) according to a standard protocol. Antimetabolites were not used intraoperatively in eyes undergoing viscocanalostomy, but they were randomised to the use of viscoelastic (Healonid GV) for intraoperative intracanalicular injection. RESULTS: There were no significant differences between the groups in age, sex, type of OAG, preoperative medications, risk factors for drainage failure, and preoperative IOP. Mean follow up was 19 months (range 6-24 months). It was 12 months or longer in all eyes, except one lost to follow up at 6 months. At 12 months, complete success (IOP <21 mm Hg without antiglaucoma medications) was seen in all eyes undergoing trabeculectomy (100%), but in only 64% of eyes undergoing viscocanalostomy (p<0.001). The mean IOP was lower at 12 months (p<0.001) with trabeculectomy and the number of eyes with IOPs of 15 mm Hg or less was greater (p<0.05). The mean IOP at 12 months was lower in eyes that had undergone viscocanalostomy using intraoperative intracanalicular Healonid GV injection compared to those where only balanced saline solution had been used (p<0.01). However, in terms of complete success there was no difference between the viscocanalostomy groups (p<0.1). With the exception of measurements at 1 week, visual recovery (logMAR acuity) was similar and laser flare and cell values showed little differences between the groups. Corneal topography and keratometry at 12 months were little different from preoperative values. Postoperative interventions (subconjunctival 5-FU and needling procedures) were similar between the groups. Transient complications such as early bleb leak and hyphaema were more common in the trabeculectomy group (p<0.05). Postoperative cataract formation was more common after trabeculectomy (p<0.05). CONCLUSIONS: IOP control appears to be better with trabeculectomy. Viscocanalostomy is associated with fewer postoperative complications, although significant complications permanently impairing vision did not occur with either technique.     

Traumatic hyphaema in Kaduna, Nigeria.

In a 2-year prospective study of 76 patients with traumatic hyphaema seen at the Ahmadu Bello University Hospital, Kaduna, 75% were under 20 years of age. A low male to female ratio of 3 to 1 relative to other reports was noted. Hyphaema occurred in the left eye 1.6 times more often than in the right eye. Thrown objects, such as sticks and stones, caused hyphaema in the largest number of patients in the series. Only 34.2% of the patients reported for care within the first 24 hours of injury, while as many as 46.9% of them had total hyphaema. These factors are vastly different from most other reports. Of 62 patients with known final visual acuity 40 (64.5%) had vision of counting fingers at 1 m or less in the affected eyes. The final vision was worse as the level of hyphaema increased. Thus of 13 patients with vision of no perception of light, 8 (61.5%) had total hyphaema. The reasons for some of the differences from other reports are discussed and suggestions are offered as to ways of improving the visual outcome from the disease.     

Effect on corneal endothelial cell count of traumatic microhyphaema and hyphaema

Purpose: This study investigates changes in the corneal endothelial count in patients after non‐penetrating ocular trauma (NPOT) with associated microhyphaema or hyphaema. Methods: A total of 48 patients were recruited and divided into grade 1 (microhyphaema) and grade 2 (hyphaema) injury groups. Both central and inferior corneal endothelial counts were measured with specular microscopy. Results: Neither central nor inferior corneal endothelial counts on the injured eye showed significant decrease compared to the normal contralateral eye across the two injury groups. The mean cell count of the central cornea of the hyphaema group showed a drop of 1.9% compared to the normal controls. Conclusion: The duration and severity of non‐penetrating ocular trauma with microhyphaema or hyphaema did not appear to show a statistically significant loss in corneal endothelial cell count compared to the normal control.     

Modification of trabeculectomy to avoid postoperative hyphaema. The ''guarded anterior fistula'' operation.

The effect of varying the position of a trabeculectomy fistula on the rate of postoperative hyphaema was studied in a prospective randomised trial. One eye of each of 78 consecutive patients with primary open angle glaucoma and exfoliation glaucoma was allocated to one of two groups. In group A the fistula was fashioned anterior to the scleral spur, entirely in corneal tissue. In group B the fistula included cornea and sclera with trabecular meshwork and scleral spur. Seven out of 39 eyes (18%) in group A developed a postoperative hyphaema with detectable blood level, compared with 22 out of 39 eyes (56%) for group B (p less than 0.001). In addition, the severity of the bleeding was greater in group B, and the three cases of recurrent bleeding were all in this group. Group B patients remained in hospital for an average of 3.9 days, which was significantly longer (p = 0.004) than the average of 2.9 days for group A. This difference was related to the frequency and severity of the hyphaema. The type of dissection or the occurrence of hyphaema did not influence the intraocular pressure at 4 months after surgery.     

''In-the-bag'' hyphaema--a rare complication of posterior chamber lens implantation.

A 72-year-old woman developed a hyphaema on the first postoperative day after a combined trabeculectomy and extracapsular cataract extraction with posterior chamber intraocular lens implantation. On the second day the blood had redistributed to accumulate 'in the bag' posterior to the intraocular lens and had formed a fluid level. Postural drainage helped to clear the hyphaema from both locations, with no short-term effect on visual function or the filtering bleb.     

Medical and surgical management of spontaneous hyphaema secondary to immune thrombocytopenia.

The medical and surgical management of an unusual case of spontaneous 'black ball' hyphaema complicated by secondary haemorrhage, raised intraocular pressure and corneal blood staining, and secondary to immune thrombocytopenia is presented. The literature is reviewed with particular reference to the aetiology and treatment of spontaneous hyphaema and the role of intravenous immunoglobulins in the preoperative management of patients with thrombocytopenia who present for routine or emergency ocular surgery.     

Trabeculectomy and manual clot evacuation in traumatic hyphaema with corneal blood staining

Background: The management of traumatic hyphaema with raised intraocular pressure and corneal blood staining is difficult. Residual blood clots after anterior chamber washout are responsible for sustained postoperative elevation of intraocular pressure, even after trabeculectomy and clot evacuation.
Methods: Thirty-five patients with traumatic hyphaema, elevated intraocular pressure and varying degrees of corneal blood staining underwent a combined trabeculectomy with manual clot evacuation from the anterior chamber in a general hospital.
Results: The postoperative control of intraocular pressure was found to be adequate in all patients at the end of two months. Examination of the posterior segment was made possible earlier. Although the procedure is more complex, no significant complications were encountered.
Conclusion: In patients presenting with traumatic hyphaema, secondary glaucoma and corneal blood staining, trabeculectomy with manual extraction of the clot through a large incision appears to be a safe and reliable procedure where medical therapy fails to control the intraocular pressure.     

Iris microhaemangiomas and idiopathic juxtafoveolar retinal telangiectasis

We describe a case of iris microhaemangiomas (iris vascular tufts) causing spontaneous hyphaema and where examination showed that the patient also had idiopathic juxtafoveolar retinal telangiectasis. A systematic search through PubMed, EMBASE and reference lists revealed a total of 90 reported cases of iris microhaemangiomas. To our knowledge, no previous reports have described concurrent findings of iris microhaemangiomas and idiopathic juxtafoveolar retinal telangiectasis in a patient. Both conditions are acquired vascular diseases, but their pathogenesis and aetiologies are unknown. Iris microhaemangiomas are important clinically because they are occasionally a cause of spontaneous hyphaema and may induce transient elevation of intraocular pressure.     

Microhemangiomas iridianos: a propósito de un caso

Case reportA 74 year-old woman present with blurry vision of 12 hour duration in her right eye, and with no other symptoms. Biomicroscopic examination revealed a 3 mm hyphaema in her right eye and multiple nodular structures in the pupillary margin of both eyes.DiscussionIris tufts are vascular anomalies unrelated to ischaemia that must be included in the differential diagnosis of spontaneous hyphaema.     

Fibrinolysis and traumatic hyphaema.

Since January 1st 1975, 310 patients with traumatic hyphaema have been treated with the antifibrinolytic drug tranexamic acid. One secondary haemorrhage has occurred, corresponding to a frequency of secondary haemorrhage of 0.32%. Eighty-five of these patients were treated as out-patients. In four patients with traumatic hyphaema, who were not treated with tranexamic acid, the serum content of activator inhibitor was determined daily. An increase was seen during the first five days after the trauma, followed by a marked fall on the 6th day. In the same four patients, the central corneal thickness was followed by daily measurements and compared to the variation in activator inhibitor.     

挫伤性前房积血74例临床分析

前房积血发病率为眼外伤住院的14．45％。20岁以下占62．165，多为非职业性外伤。有24．32％继发青光眼，前房积血总致盲率为22．97％，其中41．18％是继发育青光眼。角膜血染致盲率100％，治疗着重止血、促进吸收、预防继发出血和眼压升高。     

The effect of aspirin and warfarin therapy in trabeculectomy

AIM: The management of patients on antiplatelet and anticoagulation therapy (APACT) in glaucoma surgery currently has no specific recommendations. We aimed to establish the risk of haemorrhagic complications and surgical outcome in patients on APACT in glaucoma surgery. METHODS: We retrospectively examined 367 consecutive trabeculectomies performed between 1994 and 1998. Preoperatively 60 (16.4%) patients were on APACT (55 on aspirin and five on warfarin). The incidence of hyphaema and haemorrhagic complications between patients with and without APACT was documented. Surgical success was defined in two categories as an intraocular pressure (IOP) <21 mmHg and an IOP <16 mmHg 2 years following trabeculectomy with and without antiglaucoma medication. RESULTS: None of the patients on aspirin suffered significant intra or postoperative haemorrhage. Aspirin was associated with a significantly higher risk of hyphaema (P=0.0015) but this was not found to significantly affect IOP control at 2 years. Patients on warfarin suffered haemorrhagic complications and trabeculectomy failure. CONCLUSIONS: Aspirin appears to be safe to continue with during trabeculectomy. Patients on aspirin have an increased risk of hyphaema following trabeculectomy. This however does not appear to affect surgical outcome. Warfarinised patients are at risk of serious bleeding complications. They require careful monitoring pre- and postoperatively and are at risk of trabeculectomy failure.     

Traumatic hyphaema in a haemophiliac.

A case is presented of a 9-year-old haemophiliac boy who sustained a traumatic hyphaema with secondary haemorrhage. Conservative management was successful in preventing complications, and normal vision was retained.     

Pupil size and reactivity following hydroxypropyl methylcellulose and sodium hyaluronate.

AIMS--A prospective randomised clinical trial was set up to compare the effect of hydroxypropyl methylcellulose (Ocucoat) and sodium hyaluronate (Healonid) on pupil size and reactivity following their use in cataract surgery. METHODS--Pupil measurements were recorded before and 6 weeks after surgery. RESULTS--There was no significant difference between the two groups with respect to pupil size (p = 0.69, Mann-Whitney U test) nor with respect to reactivity (p = 0.99, Fischer's exact test). Ninety six per cent of the surgery was performed using phacoemulsification. CONCLUSION--This trial suggests that both viscoelastic materials have similar effects on the pupil after their use in cataract surgery.     

Microhaemangiomas of the iris with spontaneous hyphaema and acute glaucoma.

A case of bilateral microhaemangiomas of the pupillary borders in a 69-year-old woman is described. When first seen she presented with acute angle closure glaucoma and spontaneous hyphaema. Photographs and iris fluorescein angiography are presented and microhaemangiomas are discussed.     

Traumatic aniridia and aphakia with scleral buckling: a case report.

A case is reported of a young man in whom blunt injury caused a horizontal corneal tear superiorly. Aniridia, aphakia, cyclodialysis with angle recession, minimal hyphaema, vitreous haemorrhage, choroidal rupture and striae, and scleral buckling resulted. Vision improved to 6/12+.     

Spontaneous resolution of corneal blood staining

Herein, a case of a 66-year-old man who developed corneal blood staining secondary to hyphaema after trabeculectomy is reported. No significant increase in intraocular pressure was recorded. The corneal staining spontaneously cleared from the periphery and resolved fully over the following 2 years.     

The use of tissue plasminogen activator in post-traumatic total hyphaema

Background: We wanted to evaluate whether intracameral injection of tissue plasminogen activator (tPA) is useful in managing traumatic hyphaema. Methods: Two eyes with total hyphaema after a severe penetrating injury were treated with a single intracameral injection of 25 g of tPA 5 and 14 days after the injury, respectively. Results: Most of the blood coagulum dissolved within 24 h, and in one of the two eyes the intraocular pressure decreased from 45 to 8 mmHg. The other eye was hypotonic. No re-bleeding or complications related to the use of tPA were noticed. Conclusion: The results in these two cases suggest that tPA is a useful adjunct in managing total hyphaema.     

Complicated hyphaema: think sickle

Two cases of complicated hyphaema associated with sickle cell trait are presented. The pathophysiology, diagnosis and management of raised intraocular pressure in sickle cell trait are discussed.