Is the 1-day postoperative IOP check needed post uncomplicated phacoemulsification in patients with glaucoma and ocular hypertension?

Purpose

To determine whether the 1-day postoperative intraocular pressure (IOP) check following routine uncomplicated phacoemulsification is necessary in patients with pre-existing glaucoma and ocular hypertension (OHT), if acetazolamide prophylaxis is used. To investigate the practice of UK glaucoma specialists in IOP rise prophylaxis and follow-up regimes.

Patients and methods

The IOP 1-day postoperatively was analysed against the last recorded IOP before phacoemulsification in a cohort of patients with glaucoma or OHT who underwent uncomplicated phacoemulsification cataract surgery between December 2009 and September 2012, where it was routine practice to give acetazolamide postoperatively. UK and Eire Glaucoma Society members were surveyed via an online questionnaire to analyse practice among UK glaucoma specialists.

Results

One hundred and seven eyes were studied: 99 with glaucoma and 8 with OHT. The mean IOP change was −0.8 mm Hg with only two eyes measuring >30 mm Hg postoperatively (2%). Both these eyes received 750 mg acetazolamide. Eighteen (17%) eyes had an IOP rise of at least 30%. In the survey of practice there were 65 respondents. Twenty-one (32%) respondents did not use IOP prophylaxis. Only 17 (26%) of respondents routinely reviewed their patients 1-day postoperatively.

Conclusion

Our prophylactic acetazolamide regime does not completely eliminate the risk of an IOP >30 mm Hg on day 1 post routine phacoemulsification in glaucoma/OHT patients. Patients with pre-existing glaucoma, despite acetazolamide prophylaxis, will require IOP management decisions on the first postoperative day after uncomplicated phacoemulsification surgery. UK expert practice is non-uniform with regard to IOP prophylaxis, and the 1-day review, and further discussion and formulation of consensus appears necessary.     

Can early postoperative intraocular pressure predict success following mitomycin-C augmented trabeculectomy in primary angle-closure glaucoma

Purpose

To evaluate the association between early and late postoperative intraocular pressure (IOP) and determine if early postoperative IOP can predict the surgical outcome.

Methods

A total of 165 consecutive patients with primary angle-closure glaucoma (PACG) undergoing primary mitomycin-C-augmented trabeculectomy underwent a comprehensive eye examination before surgery and were followed-up on days 1, 7, 14, and 30, and months 3, 6, 12, and 18. IOPs on days 1, 7, 14, and 30 were stratified into groups A (<10 mm Hg), B (≥10 and <15 mm Hg), C (≥15 and <20 mm Hg), and D (≥20 mm Hg). Differences between groups were analyzed using analysis of variance (ANOVA) and Fisher''s exact test. Multivariable regression was used to exam the predictive ability of early IOP for final outcome.

Results

The mean age was 62.5±7.9 years and 41.21% (n=68) were males. Stratified by IOP on days 1, 7, 14, and 30, respectively, mean IOPs at month 18 were different among groups A, B, C, and D (ANOVA, P=0.047, P=0.033, P=0.008, and P<0.001, respectively). Once the IOPs were settled with interventions on day 7 a higher IOP level was associated with decreasing success rate under different outcome definitions, final IOP <15 mm Hg (Fisher''s exact P=0.001) and <20 mm Hg (P=0.039) without medication. Multiple regression showed early IOP predicted final IOP independently from baseline variables. A cutoff value of 13.5 mm Hg on day 7 achieved an accuracy of 80.0 and 57.1% in predicting IOP<15 mm Hg without medication and failure after surgery, respectively.

Conclusions

The IOP at 18 months following primary antifibrotic-augmented trabeculectomy in PACG patients is associated with and predicted by the postoperative IOPs at 1 month. Control of early IOP to 13.5 or less may provide better outcomes.     

Insertion of sequential glaucoma drainage implant in a piggyback manner

Purpose

This pilot study, the first of its type, was conducted to determine the clinical outcome of a sequential glaucoma drainage implant (GDI) inserted in piggyback manner, that is into the bleb of a primary GDI.

Methods

This was a retrospective chart study with a minimum 1-year follow-up involving 16 eyes of 14 uncontrolled glaucoma patients who had previously undergone sequential GDI performed using a technique to convert a one-plate into a two-plate implant system. Surgical success was defined as intraocular pressure (IOP) <21 mm Hg with at least a 30% reduction in IOP from baseline on two consecutive follow-up visits, IOP >5 mm Hg on two consecutive follow-up visits, and neither reoperation of glaucoma nor loss of light perception vision.

Results

The mean ±SD baseline IOP was 29.2±5.2 mm Hg, and the mean postoperative IOP was 17.3±3.4 mm Hg, with a mean pressure drop of 39.4±10.4% (P<0.001). Life-table analysis showed an 88% success rate after 12 months of follow-up. The mean preoperative best corrected visual acuity (BCVA) was 0.2±0.2 logMAR (Snellen equivalent 6/9.5), compared with 0.3±0.3 logMAR postoperatively (Snellen equivalent 6/12; P=0.497). Postoperative complications included a flat anterior chamber and choroidal detachment (one eye), uveitis and cataract (one eye), diplopia (one eye), and worsening of pre-existing pseudophakic bullous keratopathy (one eye).

Conclusions

In glaucoma eyes with useful vision the piggyback GDI seems to provide a significant IOP lowering with minimal complications in patients in whom an initial GDI had failed to control the IOP.     

Intraoperative testing of opening and closing pressure predicts risk of low intraocular pressure after Ahmed glaucoma valve implantation

Purpose

The aim of this study was to assess whether intraoperative testing of silicone Ahmed glaucoma valves (AGVs) would identify valves with an increased risk of low postoperative intraocular pressure (IOP).

Methods

In 30 consecutive cases of glaucoma surgery with AGV implantation, after priming the AGV, we intraoperatively measured the opening pressure A, closing pressure B, and re-opening pressure C using the active infusion pump of a phako-machine. IOP was checked postoperatively on the same day. Low IOP was defined as <5 mm Hg. Intraoperatively measured pressure characteristics of the valve function were analysed for their ability to predict postoperative IOP outcomes.

Results

Opening A, closing B, and re-opening C pressures (mean, (SD)) were 18.4 (5.1), 8.3 (4.7), and 11.7 (4.8)mm Hg, respectively. Ten patients (33.3%) had low IOP. An opening pressure of ≤18 mm Hg predicted low postoperative IOP with a sensitivity (10/10) of 100% (95% CI, 69.2–100) and a specificity (13/20) of 65.0% (95% CI, 40.8–84.6).

Conclusions

AGVs have a high variability of opening, closing, and re-opening pressures. An opening pressure of ≤18 mm Hg, a closing pressure of ≤10 mm Hg, or a re-opening pressure of ≤11 mm Hg identified all patients with low postoperative IOP.     

Long-term effect of phacoemulsification on trabeculectomy function

Purpose

To investigate the long-term effect of phacoemulsification on intraocular pressure (IOP) in trabeculectomized eyes and to identify the factors affecting the IOP changes.

Methods

In consecutive patients with previous trabeculectomy (TE) who underwent uncomplicated clear cornea phacoemulsification we evaluated intraocular pressure, need of antiglaucomatous medical therapy or glaucoma surgery, and length of glaucoma control without therapy. Glaucoma therapy was prescribed in the presence of IOP >18 mm Hg or worsening of the visual field. A group of trabeculectomized eyes that did not receive cataract surgery was retrospectively selected as a control. Multivariate analysis was used to test factors related to final outcome of the treatment.

Results

One hundred and eight eyes with previous TE that received phacoemulsification and 108 controls were included in the study. Phacoemulsification was performed 60±21 months after TE. After a mean follow-up of 66±28 months, mean IOP was significantly increased in the cataract surgery group (by 1.7±4.3 mm Hg) and in the control group (by 2.3±4.3 mm Hg)(both P<0.001); in two groups, respectively, 31 eyes (28.7%) and 17 eyes (15.7%) had received glaucoma therapy (chi-square P=0.030). Factors related to success (no need of therapy) were use of mitomycin-C (MMC) in previous TE (P<0.001), longer time from TE to cataract surgery (P=0.007), higher preoperative bleb score (P=0.021), and lower baseline IOP (P=0.042).

Conclusions

Cataract surgery reduces the function of filtering bleb in some eyes. Factors related to low rate of failure are the previous use of MMC during TE, longer time from TE to cataract surgery, and good preoperative aspect of the bleb.     

Outcomes of combined phacoemulsification and deep sclerectomy: a 10-year UK single-centre study

Purpose

To report the outcomes of combined phacoemulsification and -deep sclerectomy (phaco-DS) from a single UK centre over a 10-year period.

Methods

Retrospective analysis of phaco-DS data extracted from an ongoing glaucoma surgery database within Calderdale and Huddersfield NHS Trust. Two hundred and ninety-six eyes of 282 patients were included. Data included patient demographics, pre- and postoperative intraocular pressure (IOP), use of mitomycin C (MMC), spacer device implantation, and follow-up details including surgical success rates. IOP success criteria were: (A) IOP <19 mm Hg and/or 20% decrease from baseline and (B) IOP <16 mm Hg and/or 30% drop from baseline.

Results

Mean follow-up was 63.5±35.3 months. MMC was applied in 145 eyes (49%). Kaplan–Meier success rates in all eyes for criteria A were 89.1% and 80% with glaucoma medications (qualified success) and 81.2% and 68.3% without medications (unqualified success) at 2 and 5 years, respectively. Qualified success for criteria B was 72.4 and 61.4% and unqualified rates were 67.2 and 55.2% for the same time periods. Repeated-measures ANOVA showed significantly lower IOP in the phaco-DS with MMC group up to 3 years postoperatively (P=0.002). Cox''s proportional hazards for criteria B, however, showed no significant effect of MMC application in the long term (P=0.2). Increasing age and laser goniopuncture were positively associated with success, whereas the absence of spacer devices was negatively associated. At last follow-up, 20% of eyes were on glaucoma medications. Complication rates were low with hypotony rates of 0.68%.

Conclusions

This study confirms the long-term safety and efficacy of phaco-DS as a primary glaucoma procedure.     

Analysis of long-term outcomes for combined pars plana vitrectomy (PPV) and glaucoma tube shunt surgery in eyes with advanced glaucoma

Purpose

To analyze 12- and 24-month visual acuity, intraocular pressure, and complications associated with combined pars plana vitrectomy (PPV) and glaucoma tube shunt placement in eyes with glaucoma.

Patients and methods

A retrospective chart review was performed of patients with advanced glaucoma who underwent combined PPV and tube shunt surgery from 2006 to 2010. A minimum of 12 months of follow-up was required for their inclusion in the study. Visual acuity, intraocular pressure, complications, and number of glaucoma medications at 1 and 2 years postoperatively were analyzed.

Results

Twenty-eight eyes met the inclusion and exclusion criteria. Baseline visual acuity was 20/200 or worse in 14/28 eyes (50.0%) and 20/40 or better in 2/28 eyes (7.1%). Visual acuity remained 20/200 or worse in 50.0% (P=0.921) and 44.4% (P=0.973) of eyes after 1 and 2 years postoperatively, respectively. At baseline, the mean intraocular pressure was 30.4 mm Hg. There was significant improvement in mean IOP at 1 year (14.7 mm Hg, P=0.001) and at 2 years (15.2 mm Hg, P=0.001) postoperatively. Baseline number of glaucoma medications averaged 3.0±1.09 (SD), and improved to 1.8±1.28 (SD) at 1 year (P=0.0002) and to 1.4±1.33 at 2 years (P<0.0001) postoperatively.

Conclusion

In this retrospective interventional case series, surgical management of advanced glaucoma with a combination of PPV and glaucoma tube shunt resulted in significantly reduced IOP and glaucoma medications at 1 and 2 years postoperatively.     

Trabeculectomy ab interno (trabectome): yet another possibility in the treatment of uncontrolled glaucomatocyclitic crisis under systemic valganciclovir therapy?

Purpose

To assess the outcome of trabectome surgery in the treatment of glaucomatocyclitic crisis (Posner–Schlossman syndrome) in patients with uncontrolled intraocular pressure (IOP).

Patients/Methods

Trabectome surgery was performed in seven patients with diagnosed glaucomatocyclitic crisis and uncontrolled IOP where cytomegalovirus DNA was verified by polymerase chain reaction in aqueous humour samples. All patients were treated with oral valganciclovir. After surgery the patients were followed-up for 12 months.

Results

Mean IOP before trabectome surgery was 40±10 mm Hg (range 33–58 mm Hg). The mean number of antiglaucoma medication prior to surgery was 3.1±0.4. By the end of the 12 months, IOP in all patients was reduced to normal level (13±1 mm Hg) and their antiglaucoma medication was decreased to 0.8±1.1. No recurring attack of glaucomatocyclitic crisis occurred.

Discussion

In addition to oral valganciclovir therapy, trabectome surgery seems to be a reliable and effective tool for the management of glaucomatocyclitic crisis with uncontrolled IOP.     

Measures of socioeconomic status and self-reported glaucoma in the UK Biobank cohort

Purpose

To determine ocular, demographic, and socioeconomic associations with self-reported glaucoma in the UK Biobank.

Methods

Biobank is a study of UK residents aged 40–69 years registered with the National Health Service. Data were collected on visual acuity, intraocular pressure (IOP), corneal biomechanics, and questionnaire from 112 690 participants. Relationships between ocular, demographic, and socioeconomic variables with reported diagnosis of glaucoma were examined.

Results

In all, 1916 (1.7%) people in UK Biobank reported glaucoma diagnosis. Participants reporting glaucoma were more likely to be older (mean 61.4 vs 56.7 years, P<0.001) and male (2.1% vs 1.4%, P=0.001). The rate of reported glaucoma was significantly higher in Black (3.28%, P<0.001) and Asian (2.14%, P=0.009) participants compared with White participants (1.62%, reference). Cases of reported glaucoma had a higher mean IOP (18 mm Hg both eyes, P<0.001), lower corneal hysteresis (9.96 right eye, 9.89 left eye, P<0.001), and lower visual acuity (0.09 logMAR right eye, 0.08 logMAR left eye, P<0.001) compared with those without (16 mm Hg both eyes, hysteresis 10.67 right eye, 10.63 left eye, 0.03 logMAR right eye, 0.02 logMAR left eye). The mean Townsend deprivation index was −0.72 for those reporting glaucoma and −0.95 for those without (P<0.001), indicating greater relative deprivation in those reporting glaucoma. Multivariable logistic regression showed that people in the lowest income group (<£18 000/year) were significantly more likely to report a diagnosis of glaucoma compared with any other income level (P<0.01). We observed increasing glaucoma risk across the full range of income categories, with highest risk among those of lowest income, and no evidence of a threshold effect.

Conclusions

In a large UK cohort, individuals reporting glaucoma had more adverse socioeconomic characteristics. Study of the mechanisms explaining these effects may aid our understanding of health inequality and will help inform public health interventions.     

Evaluation the adjunctive use of combined bevacizumab and mitomycinc to trabeculectomy in management of recurrent pediatric glaucoma

Purpose

To evaluate the efficacy and safety of combined bevacizumab–mitomycin c (MMC) in recurrent cases of pediatric glaucoma.

Methods

A prospective non-masked controlled study that included bilateral cases of 12 patients (24 eyes) with recurrent (had previous glaucoma surgery before) pediatric glaucoma. One eye in each patient (12 eyes) was assigned to trabeculectomy operation with combined application of MMC (0.4 mg/ml for 3 min) under and around the scleral flap before trabeculectomy and bevacizumab (avastin) (2.5 mg in 0.2 ml) injected subconjunctivally around the bleb after completing the surgery (group I). The other eye of each patient (12 eyes) was assigned to trabeculectomy operation with application of MMC (0.4 mg/ml for 3 min) only (group II). The mean follow-up period was 13±1 months.

Results

The mean age was 2.16±1.5 (range 7 months to 4.1 years). No significant difference in preoperative intraoperative pressure (IOP) was observed between the groups (P>0.05). Recurrent primary congenital glaucoma represents 66.7% of the cases. Other cases included were recurrent aphakic and pseudophakic glaucoma 25% and recurrent post uveitic glaucoma 8.3%. The mean IOP was 12.1±4.2, 12.6±5.4, and 12.8±5.2 mm Hg in group I at 3, 6, and 12 months, respectively, and was 12.8±5.3, 13.7±6.7 and 15.6±5.9 mm Hg in group II at 3, 6, and 12 months, respectively. There was a statistically significant difference in the mean IOP between the studied groups at the 1-year follow-up visit (P<0.05). In addition, group I showed a higher statistically significant difference in absolute and total success (75 and 91.7%, respectively) compared with group II (58.3 and 75%, respectively) (P<0.05). The encountered complications included mild hyphema, which occurred in 8.33% in group 1, wound leakage, which occurred in 8.33% in each group, and shallow anterior chamber (AC), which occurred in 16.7% in each group and was the most common encountered complication in the study. One case of shallow AC in group I led to choroidal effusion (8.33%). One case in group II developed late bleb-related endophthalmitis after 3 months, which resulted in phthisis bulbi (8.33%).

Conclusion

The additive effect of subconjunctival bevacizumab to MMC-augmented trabeculectomy in the case of recurrent pediatric glaucoma was beneficial in improving the success rate. Better IOP control and prolonging the bleb survivalvia reducing the long-term need of using anti-glaucoma drugs postoperatively without adding complications had also been achieved with this technique. This offers a promising alternative for the treatment of this type of glaucoma.     

Short-term intraocular pressure trends following intravitreal ranibizumab injections for neovascular age-related macular degeneration—the role of oral acetazolamide in protecting glaucoma patients

Purpose

To determine the effect of oral acetazolamide on lowering the peak and duration of intraocular pressure (IOP) rise in glaucoma and glaucoma suspect patients, following intravitreal injection of ranibizumab for neovascular age-related macular degeneration.

Methods

The study was an open-label, parallel, randomised, controlled trial (EudraCT Number: 2010-023037-35). Twenty-four glaucoma or glaucoma suspect patients received either 500 mg acetazolamide or no treatment 60–90 min before 0.5 mg ranibizumab. The primary outcome measure was the difference in IOP immediately after injection (T0) and 5, 10, and 30 min following injection. ANCOVA was used to compare groups, adjusting for baseline IOP. The study was powered to detect a 9-mm Hg difference at T0.

Results

The IOP at T0 was 2.3 mm Hg higher in the non-treated group (mean 44.5 mm Hg, range (19–86 mm Hg)) compared with the treated group (mean 42.2 mm Hg, range (25–58 mm Hg)), but was not statistically significant after adjusting for baseline IOP (P=0.440). At 30 min, IOP was 4.9 mm Hg higher in the non-treated group (mean 20.6 mm Hg, range (11–46 mm Hg)) compared with the treated group (mean 15.7 mm Hg, range (8–21 mm Hg)). This was statistically significant after adjusting for baseline IOP (P=0.013).

Conclusions

Although the primary end points were not reached, 500 mg oral acetazolamide, 60–90 min before intravitreal injection, results in a statistically significant reduction in IOP at 3O min post injection. Prophylactic treatment may be considered as an option to minimise neuro-retinal rim damage in high-risk glaucoma patients who are most vulnerable to IOP spikes and undergoing repeated intravitreal injections of ranibizumab.     

Long-term outcomes of neovascular glaucoma treated with and without intravitreal bevacizumab

Aims

To compare the outcomes of neovascular glaucoma (NVG) treated with and without intravitreal bevacizumab in a large case comparison study.

Methods

The study is a retrospective, comparative, case series of 163 eyes of 151 patients with NVG, including 99 treated without and 64 treated with intravitreal bevacizumab. Medical and surgical treatments for NVG were assessed. The main outcome measures were visual acuity (VA) and intraocular pressure (IOP).

Results

At the time of NVG diagnosis, the median VA was count fingers (CF) in the non-bevacizumab group and 2/300 in the bevacizumab group. IOP (mean±SD) was 43.1±13.0 mm Hg in the non-bevacizumab group and 40.8±11.5 mm Hg in the bevacizumab group. IOP (mean±SD) decreased to 18.3±13.8 mm Hg in the non-bevacizumab group and 15.3±8.0 mm Hg in the bevacizumab group, and the median VA was CF in both treatment groups at a mean follow-up of 12 months. Panretinal photocoagulation (PRP) substantially reduced the need for glaucoma surgery (P<0.001) in bevacizumab treated NVG eyes.

Conclusions

Although bevacizumab delayed the need for glaucoma surgery, PRP was the most important factor that reduced the need for surgery. Vision and IOP in eyes with NVG treated with bevacizumab showed no long-term differences when compared with eyes that were not treated with bevacizumab. Thus, intravitreal bevacizumab serves as an effective temporizing treatment, but is not a replacement for close monitoring and definitive treatment of NVG. PRP remains the treatment modality that affects the course of NVG in terms of decreasing the need for surgery to control IOP.     

Deep sclerectomy with mitomycin C in eyes with failed glaucoma surgery and pseudophakia

Purpose

To report outcomes of deep sclerectomy (DS) with intraoperative mitomycin C (MMC) application in eyes with previous failed glaucoma surgery (GS) and/or cataract extraction (CE).

Patients and methods

Single-surgeon case series of 82 eyes of 82 patients undergoing DS with MMC. The patients had previous CE with IOL and/or conjunctival GS and treated intraocular pressure (IOP) >18 mm Hg. MMC (0.2 mg/ml) was applied for 2–3 min before scleral flap dissection. Complete success was defined as IOP between 6 and 21 mm Hg or a reduction of 20% from baseline without medications. Reoperation for glaucoma or related complications, or loss of light perception vision was considered as failure.

Results

Mean follow-up was 57.7±22.4 months with 78% of patients completing the 3-year follow-up. Mean IOP decreased from 24.0 mm Hg (22.3–25.6, 95% confidence intervals) to 13.4 mm Hg (12.0–14.2) at 3 years after surgery (P<0.001). There was a significant decrease in the number of glaucoma medications from 2.0±1 preoperatively, to 0.3±0.7, 3 years after surgery. Kaplan–Meier cumulative success rates were 85.6% at 1 year, 80.0% at 2 years, and 76% at 3 years. At 3 years, IOP was maintained <19 and 15 mm Hg in 83 and 70% of eyes, respectively. Fourteen eyes (17.1%) had complications. Delayed hypotony (IOP <6 mm Hg) was the commonest complication in five eyes (6.1%).

Conclusion

DS with MMC appears to be a safe and effective surgical procedure for eyes with previous intraocular surgery.     

Changes in choroidal thickness,axial length,and ocular perfusion pressure accompanying successful glaucoma filtration surgery

Purpose

To investigate the changes in choroidal thickness (CT), axial length (AL), and ocular perfusion pressure (OPP) accompanying intraocular pressure (IOP) reduction after trabeculectomy.

Methods

Thirty-nine eyes of 39 patients with primary open-angle glaucoma uncontrolled by medical therapy were included in this prospective and interventional study. All patients underwent a fornix-based trabeculectomy. The CT was measured by enhanced depth imaging-optical coherence tomography. IOP, AL, and systolic/diastolic blood pressure were also measured, and OPP was calculated. All measurements were performed at baseline and 1 month after surgery.

Results

The mean IOP was 25.0±5.8 mm Hg at baseline and 11.7±2.6 mm Hg after trabeculectomy (P<0.001), and the mean subfoveal CT was 295±84 mm Hg at baseline and 331±82 mm Hg after trabeculectomy (P<0.001). The mean AL was 23.64±0.98 mm at baseline and 23.54±0.96 mm after trabeculectomy (P<0.001), whereas the mean OPP was 38.8±6.2 mm Hg preoperatively, and 51.1±7.3 mm Hg postoperatively (P<0.001). The change in CT negatively correlated with the change in IOP (r=−0.785, P<0.001) and AL (r=−0.693, P<0.001), whereas it positively correlated with the change in OPP (r=0.418, P=0.008).

Conclusion

These results suggest that the large IOP decrease following trabeculectomy causes choroidal thickening. In addition, CT changes are associated with IOP and AL reduction as well as OPP increase.     

Long-term outcomes following the surgical repair of traumatic cyclodialysis clefts

Purpose

To evaluate the long-term visual prognosis and intraocular pressure (IOP) control following direct and indirect cycloplexy for the surgical treatment of traumatic cyclodialysis clefts.

Methods

Retrospective consecutive case series of 17 eyes of 17 patients. All eyes showing signs of ocular hypotony were treated with either cleft cyclocryotherapy and/or direct surgical cycloplexy. Cycloplexy was performed by directly suturing the ciliary body to the scleral spur under a double-lamellar limbal-based scleral flap. The main outcome measures were IOP, best-corrected visual acuity (BCVA), and the occurrence of postoperative complications.

Results

The cyclodialysis clefts were post-traumatic in all the 17 eyes and extended for 2.1±1.6 clock-hours (range, 0.5–6 clock-hours). The mean follow-up time was 43.7±24.6 months (range, 12–110 months). Preoperatively, the mean IOP was 6.9±4.0 mm Hg (range, 2–14 mm Hg). Postoperatively, painful reversible IOP spikes of up to 70 mm Hg developed in 13 eyes. The final mean postoperative IOP was 12.2±4.1 mm Hg with no cases of secondary glaucoma. Preoperatively, BCVA was 6/12 or better in 4 eyes (24%), which rose to 12 eyes (71%) at final follow-up. Of the 12 patients who underwent direct cycloplexy, 75% achieved a final BCVA of 6/12 or better. There were no serious complications related to direct cycloplexy, including suprachoroidal haemorrhage or endophthalmitis.

Conclusions

Successful cyclodialysis cleft repair can lead to a good long-term visual prognosis and stable IOP control, even in cases with a protracted history of ocular hypotony.     

Surgical outcome of safe surgery system trabeculectomy combined with cataract extraction

Purpose

To determine the efficacy of safe surgery system trabeculectomy combined with manual small incision cataract surgery/phacoemulsification in primary glaucoma coexistent with cataract.

Methods

This is a retrospective analysis of 105 cases who underwent single-site combined surgery between January 2008 and December 2009. Safe surgery system trabeculectomy with diffuse and posterior application of mitomycin C was performed in all cases. Cataract extraction was done either by Manual Small Incision Cataract Surgery (MSICS) or phacoemulsification. Main outcome measures were success rate of trabeculectomy, as determined by four different IOP goals and incidence of postoperative complications. Analysis was performed using R-2.15, and the significance was tested at 5% level.

Results

The minimum follow-up period was 12 months. The overall success rates (with or without medication) when safe surgery system trabeculectomy was combined with MSICS were 91, 70, and 51% for IOP ≤18, ≤15, and ≤12 mm Hg, respectively, and target IOP was achieved in 72% cases. The mean IOP reduction was 43.8% with MSICS and 42.08% with phacoemulsification. The surgical outcome was not significantly different for both techniques. Postoperative complications were infrequent and comparable.

Conclusion

The Safe Surgery System Trabeculectomy combined with cataract surgery offers excellent IOP control with minimal postoperative complications. It offers an effective and improved solution for primary glaucoma coexistent with cataract found in developing countries.     

Vitiligo iridis and glaucoma: a rare sequelae of small pox

Purpose

Vitiligo iridis refers to focal areas of iris atrophy as sequelae of small pox infection. We report a series of patients with unilateral vitiligo iridis, some of whom presented with secondary open-angle glaucoma.

Methods

Three patients with vitiligo iridis underwent a comprehensive ophthalmic examination including intraocular pressure (IOP) measurement, slit lamp biomicroscopy, gonioscopy, and fundus evaluation. Patients'' facial features were also documented and photographed.

Results

All patients were in their sixth decade. Two out the three had elevated IOP (52 mm Hg and 36 mm Hg) in the same eye as vitiligo iridis, at initial presentation. Gonioscopy showed patchy iris hyperpigmentation and fundus evaluation showed glaucomatous optic disc changes in the involved eye. One patient responded favourably to topical antiglaucoma medications, whereas the other was taken up for combined phacoemulsification–trabeculectomy with good results. The third patient had normal IOP in the involved eye. All three patients gave a history of small pox in childhood and had pitted facial scars typical of previous small pox infection.

Conclusions

Vitiligo iridis may be associated with the secondary glaucoma as a long-term sequelae of small pox. It may be prudent to periodically follow-up such patients for development of raised IOP in the future.     

Incidence of deepening of the upper eyelid sulcus in prostaglandin-associated periorbitopathy with a latanoprost ophthalmic solution

Purpose

Among some local side effects of prostaglandin-associated periorbitopathy (PAP), deepening of the upper eyelid sulcus (DUES) is the most prominent clinical feature, and is one of the most significant adverse cosmetic events. Here, we prospectively investigated the incidence of DUES in Japanese open-angle glaucoma patients initially treated with latanoprost (Xalatan 0.005%) ophthalmic solution.

Methods

This was an open-label prospective study. Facial photographs and subjective reports of the recognition of DUES were obtained at the beginning of latanoprost treatment and at 2, 4, and 6 months thereafter. Intraocular pressure (IOP) was measured at three consecutive visits before and after treatment with latanoprost. The incidence of DUES was evaluated objectively by three blinded investigators who compared the series of photographs.

Results

A total of 52 eyes of 52 newly diagnosed open-angle glaucoma Japanese patients (28 males, 24 females) were evaluated. The objective rate of DUES was 1/52 (2% 95% CI 0.05 to 10.7%) at 2 months, 2/52 (4% 95% CI 0.5 to 13.9%) at 4 months, and 3/52 (6% 95% CI 1.2 to 16.9%) at 6 months. During this period, no patient self-reported an occurrence of DUES. Mean IOPs before and after treatment were 16.5±2.9 and 13.8±3.0 mm Hg, respectively. Latanoprost reduced the IOP significantly (P<0.0001, paired t-test).

Conclusions

Latanoprost caused DUES rarely and had a robust IOP-lowering effect in Japanese glaucoma patients.     

Ocular perfusion pressure and choroidal thickness in eyes with polypoidal choroidal vasculopathy,wet-age-related macular degeneration,and normals

Purpose

To measure the choroidal thickness and ocular perfusion pressure in eyes with polypoidal choroidal vasculopathy (PCV), wet-age-related macular degeneration (AMD), and age-matched normal subjects, and look for a possible association between the two.

Methods

This was a prospective study including 22 eyes with PCV, 33 eyes with wet-AMD, and 35 age-matched normal eyes. Choroidal thickness was measured using enhanced depth imaging (EDI) with spectral-domain optical coherence tomography (SD OCT). Mean ocular perfusion pressure (MOPP) was calculated using the mathematical formula 2/3[DBP+1/3{SBP × DBP}]−IOP (DBP—diastolic blood pressure, SBP—systolic blood pressure, IOP—intraocular pressure). Analyses were carried out using SPSS 14 software and comparisons of mean made using‘t'' tests.

Results

Eyes with PCV showed increased (285.9 μm; subfoveal) choroidal thickness, whereas eyes with wet-AMD (119.4 μm; subfoveal) showed reduced choroidal thickness in comparison with normal eyes (186.77 μm; subfoveal). MOPP in the PCV group was 57.85 mm Hg (P value 0.00), in the wet-AMD group was 52.1 mm Hg (P-value 0.12), and in the normal group was 49.79 mm Hg.

Conclusion

It is postulated that higher MOPP in eyes with PCV could have an etiologic implication in disease manifestation and progression. Larger studies with longer follow-up may help validate these findings.     

Combined trabeculotomy and trabeculectomy: outcome for primary congenital glaucoma in a West African population

Purpose

To evaluate the surgical outcome of combined trabeculotomy–trabeculectomy in Ghanaian children with primary congenital glaucoma.

Materials and methods

A retrospective case series involving 19 eyes of 12 consecutive children with primary congenital glaucoma who had primary trabeculotomy–trabeculectomy from 12 August 2004 to 30 June 2008, at the Korle-Bu Teaching Hospital, Ghana. Main outcome measures were preoperative and postoperative intraocular pressures, corneal diameter, corneal clarity, bleb characteristics, duration of follow-up, surgical success, and complications.

Results

A total of 19 eyes of 12 patients met the inclusion criteria. Six of the patients were males. Mean age at diagnosis was 4.4 (range 2–8) months. Mean age at surgery was 5.9 months (range 3–16). Eight (67%) infants had bilateral disease. Mean duration of follow-up was 13.1 (range 5–38) months. The preoperative mean horizontal corneal diameter was 13.4±1.1(range 12–16) mm. Complete success (intraocular pressure <21 mm Hg) was obtained in 15 (79%) eyes. The probability of success was 94.4, 83.3, 66.7, 44.4, 38.9, 33.3, and 13.3% at 3, 6, 9, 12, 15, 18, and 21 months, respectively (Kaplan–Meier analysis). All eyes had corneal oedema preoperatively. Seventeen eyes (90%) had clear cornea at their last follow-up. Mean preoperative and postoperative intraocular pressures were 30.3±8.8 and 18.1±6.8 mm Hg respectively (P<0.001, t-test). Twelve (63%) eyes had well-functioning blebs at the last follow-up. One eye (5%) developed seclusio pupillae and cataract postoperatively.

Conclusion

The overall success for combined trabeculotomy–trabeculectomy in Ghanaian children with primary congenital glaucoma was 79%. The probability of success reduced from more than 66% in the first 9 months postoperatively to below 45% after that.