Step-along vergence procedures in stigmatic and astigmatic systems.

The traditional step-along vergence procedure applies to stigmatic systems, that is, systems that are not astigmatic. Computation is disrupted when a focus coincides with a thin lens or refracting surface. A small change to the procedure results in a modified procedure which overcomes the computational problems. The modified procedure is easier to execute than the traditional procedure and allows one to write down useful equations directly. Among the formulae are those for back-vertex power. A step-along vergence procedure also exists for astigmatic systems. It makes use of the dioptric power matrix and the reduced vergence matrix. Computational problems arise when a point or line focus coincides with a thin lens or refracting surface; however they are not overcome by an analogous modification to the procedure. Nevertheless the modified procedure has some advantages including the fact that, as for stigmatic systems, it allows one to write down useful formulae directly. Stepwise calculations of vergence are sometimes performed backward through a system; the advantages and disadvantages described for step-along procedures holds for such step-back procedures as well.     

Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement

OBJECTIVE: Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement as described by Jones has traditionally been performed as an "open" or external procedure by means of medial canthal incision. Application of endoscopic technique for CDCR with Jones tube placement has not been well described in the peer-reviewed literature. DESIGN: Retrospective nonrandomized comparative trial. PARTICIPANTS: Ten patients with epiphora secondary to canalicular stenosis. METHODS: A total of 13 consecutive CDCR with Jones tube procedures were reviewed. Five procedures (performed predominantly in the early study period) were done by means of a traditional external approach with a medial canthal incision. Eight procedures were performed with an intranasal endoscopic approach and instrumentation with Jones tube placement under direct endoscopic visualization. MAIN OUTCOME MEASURES: Total operative time, estimated blood lost, intraoperative, and postoperative complications and need for secondary surgery were evaluated. RESULTS: All procedures were successfully completed with no intraoperative complications. Average operative time was 59 minutes in the endoscopic group and 74 minutes in the external group. Average blood loss was 3.5 ml and 4.4 ml in the endoscopic and external groups, respectively. Postoperative adjustment of tube size or position (performed as an office procedure with topical/local anesthesia) was common: five of eight endoscopic and three of five external approach. Two patients in the endoscopic group required secondary surgery for anatomic reasons. Ultimately, all cases in both groups demonstrated patent, retained Jones tubes and relief of epiphora. CONCLUSION: Endoscopic technique appears to be a reasonable approach for CDCR with Jones tube placement. Operative time and blood loss were comparable in the two groups, with the endoscopic group being slightly lower for each variable. Endoscopic Jones tube placement can be accomplished with readily available instrumentation. In this series, we did not find it necessary to use laser, radiofrequency, or monopolar devices for intranasal hemostasis.     

Transcaruncular approach to medial canthal tendon plication for lower eyelid laxity

PURPOSE: A new operation to correct lower eyelid laxity was evaluated. METHODS: A new transcaruncular, orbital approach to posterior medial canthal tendon plication was performed on eight orbits of four cadavers, which were then analyzed with computed tomography or histologic techniques. The procedure was also performed on 23 eyelids of 15 patients with lower eyelid medial canthal tendon laxity, alone or in conjunction with other procedures. These patients were followed up for a mean of 12 months. RESULTS: Improved postoperative eyelid position, epiphora, and superficial punctate keratopathy were found. Radiographic and histologic analysis demonstrated consistency of suture placement without involvement of contiguous anatomical structures. CONCLUSIONS: This procedure appears to be a safe, reproducible, and effective corrective procedure for medial canthal tendon laxity and lagophthalmos. When combined with lateral lower eyelid tightening, it is also an effective treatment for lower eyelid retraction and superficial punctate keratopathy. Other potential advantages and complications of this procedure are described in comparison to other reported surgical methods used to address medial canthal tendon laxity and malpositions of the medial lower eyelid.     

Trends in operating room-based glaucoma procedures at a single eye center from 2016–2020

AIMTo evaluate trends in glaucoma procedures at the Peking University Eye Center in 2016–2020.METHODSA retrospective search of all glaucoma procedures performed at our institution were performed. Data were analyzed by calculating the absolute numbers and relative weightage of each procedure per year.RESULTSThe average age of glaucoma patients undergoing surgical procedures was 62.33±17.87y, and 55% were women. From 2016 to 2019, the number of surgical procedures performed in glaucoma patients showed an overall upward trend from 749 to 1460, although it decreased slightly in 2020 (n=1393), probably due to the COVID-19 pandemic. The number of trabeculectomies did not change significantly in 2016 (n=161) to 2018 (n=164) but decreased in 2019 (n=139) to 2020 (n=121), indicating a reduction in its relative weightage among glaucoma procedures (from 21.50% to 8.69%). The number of glaucoma drainage device implantations and minimally invasive glaucoma surgeries both increased (50 and 58 respectively in 2019), except in 2020. The number of transscleral cyclophotocoagulation procedures was relatively stable, increasing until 2017 (n=218) and then decreasing. Cataract surgeries with or without glaucoma procedures accounted for a large number of the total surgeries, increasing from 247 (32.97%) in 2016 to 967 (69.42%), among which cataract extraction combined with goniosynechialysis was the most frequent.CONCLUSIONThe overall increase in the number of operating room-based surgical procedures is significant. Trabeculectomy is one of the most commonly performed procedures, despite the relative decline in its weightage. Other procedures, including use of glaucoma drainage devices and mini shunts and minimally invasive glaucoma surgeries, are gaining greater acceptance. Notably, lens-related surgery plays an important role in glaucoma management.     

Comparison of the ASA, MOBS, and ZEST threshold methods

The modified binary search, or MOBS, technique is an adaptive, non-parametric procedure for estimating thresholds [Tyrrell, R. A, & Owens, D. A. (1988). A rapid technique to assess the resting states of eyes and other threshold phenomena: the modified binary search (MOBS). Behavior Research Methods, Instruments, and Computers, 20, 137-141.], which has recently been incorporated into a commercially available perimeter. Information regarding the performance of this technique is limited, however. We performed Monte Carlos simulations on the MOBS procedure, as well as on a Zippy Estimation by Sequential Testing, or ZEST, procedure (King-Smith, Grigsby, Vingrys, Benes & Supowit, 1994) and an Accelerated Stochastic Approximation, or ASA, procedure (Kesten, 1958) for comparison. The efficiency, convergence probability, and robustness to false positive and false negative responses were determined. Differences between the three procedures typically were small, the most prominent being the number of presentations required to estimate threshold.     

Factors associated with elevated rates of adverse outcomes after cyclodestructive procedures versus drainage device procedures

Objective

To identify factors associated with an increased risk of adverse outcomes after cyclodestructive or drainage device procedures.

Design

Retrospective, cohort analysis.

Participants

A total of 5570 Medicare patients who were older than 65 years of age and who underwent cyclodestructive or drainage device procedures in 1994 participated.

Intervention

The authors identified cyclodestructive and drainage device procedures from claims to the Health Care Finance Administration (HCFA) by International Classification of Diseases (ICD-9) procedure codes, Current Procedural Terminology procedure codes, and HCFA Common Procedural Classification System codes. The authors analyzed adverse outcome rates using hierarchical logistic regression. Race, age group, gender, length of observed follow-up, state in which surgery took place, ocular procedures performed before and at the same time as the index surgery, and ocular diagnosis were included as covariates in the model.

Main outcome measures

The authors defined an adverse outcome as the occurrence after the index surgery of at least one of the following: repeat cyclodestructive or drainage device procedure, retinal hole-tear repair, retinal detachment repair, surgery for endophthalmitis, vitrectomy, enucleation, evisceration, surgery for ocular hypotony, and/or extrusion or revision of drainage device. Adverse outcomes were also defined without the inclusion of repeat cyclodestructive or drainage device procedures.

Results

When repeat cyclodestructive or drainage device procedures were not included in the definition of an adverse outcome, eyes with a drainage device procedure were 3.8 times more likely to have an adverse outcome than eyes with a cyclodestructive procedure (odds ratio [OR], 3.8; 95% confidence interval [CI], 3.07, 4.67). Subjects with concurrent corneal transplant had increased odds of an adverse outcome compared to subjects without a concurrent corneal transplant (OR, 2.00; 95% CI, 1.27, 3.15). When the definition of an adverse outcome included repeat cyclodestructive or drainage device procedures, the odds of an adverse outcome were similar for both cyclodestructive and drainage device procedures (OR, 0.94; 95% CI, 0.79, 1.13).

Conclusions

Cyclodestructive procedures need to be repeated more frequently than drainage device procedures. However, if the patient has a drainage device procedure, then that patient is more likely to have other types of adverse ophthalmic events than if he or she had a cyclodestructive procedure. Because the average follow-up of subjects in this study is 5 months (range, 0–12 months), outcomes that might take longer to manifest themselves would be excluded from this study.     

Submandibular gland transfer in the correction of dry eye

Following rabbit experiments which showed that microvascular submandibular gland transfer could ameliorate the deleterious effects of lacrimal gland ablation, a clinical transfer of the submandibular salivary gland to the temple region was performed. The beneficial results from this initial operation have led to the procedure being used in a total of eight patients with 12 transfers. The procedure has led to increased moisture in the eye and decreased symptoms but the assessment of change in corneal function and pathology is difficult.     

Submandibular gland transfer in the correction of dry eye.

Following rabbit experiments which showed that microvascular submandibular gland transfer could ameliorate the deleterious effects of lacrimal gland ablation, a clinical transfer of the submandibular salivary gland to the temple region was performed. The beneficial results from this initial operation have led to the procedure being used in a total of eight patients with 12 transfers. The procedure has led to increased moisture in the eye and decreased symptoms but the assessment of change in corneal function and pathology is difficult.     

Modified relaxing incision technique for postkeratoplasty astigmatism

A modified relaxing incision technique for postkeratoplasty astigmatism is described in this article. Following the initial, standard relaxing incision techniques, a planned spreading and recutting of the initial relaxing incision was performed at 1-3-week intervals following the initial surgery. The wound may be deepened and lengthened if more effect is needed. The number of spreading and recutting procedures is also dependent on the effect required. This additional procedure may be performed for late regression of the desired effect. The endpoint for the procedure is corneal astigmatism that will allow either spectacle or contact lens correction, depending on the patient's visual needs. Corrections of greater than 10 D of astigmatism are possible. The technique allows for evaluation of the corneal astigmatism with no sutures in place. No complications of the recutting and spreading procedure have been noted. There have been no microperforations or macroperforations requiring suturing, no infections, and no graft rejections following the procedures. Seven cases using the modified relaxing incision technique are described.     

Endoscopic pretrichial brow lift: surgical indications, technique and outcomes

PURPOSE: To present an alternative technique for rejuvenating the upper face of patients with high hairlines. METHODS: A chart review was performed to ascertain the longevity and aesthetic quality of endoscopically assisted pretrichial brow lifts. The charts of a single surgeon were reviewed (2000 to 2003). The technique was noted to be consistent, and in the majority of cases, additive to other concurrent procedures. Morbidity was defined as asymmetry, poor longevity, and patient dissatisfaction. All patients were included who had the procedure performed. No exclusions were recognized for race, age, gender, medical history, or any other patient demographic. RESULTS: Results for the clinical outcome were graded as excellent, good, fair, or poor. Subjective and objective assessments were made by using history, examination, and photos. A rating of excellent incorporates symmetry, longevity, smoothness of the brow skin, and patient satisfaction both with the recovery process and with the results. CONCLUSIONS: In properly selected cosmetic patients, the endoscopic pretrichial brow lift is an effective method for rejuvenating the upper face. A more youthful appearance is achieved with the procedure, and it is easily combined with eyelid rejuvenation. We believe that this technique is the procedure of choice for addressing brow ptosis in patients with high hairlines.     

Endoscopic dacryocystorhinostomy in children.

BACKGROUND: Persistent nasolacrimal duct obstruction (NLDO) often requires treatment by probing, intubation, or balloon dacryoplasty. Refractory cases have been managed by external dacryocystorhinostomy (DCR), which leaves a scar; however, this procedure is generally avoided in young children. Endoscopic DCR has been successfully performed in adults and described in children. We report the success of this procedure in a series of pediatric patients. METHODS: A retrospective review of all endoscopic lacrimal procedures performed in a 3-year period was undertaken. Seventeen children (22 ducts) with persistent NLDO after at least one failed probing, with or without silicone tube placement, underwent endoscopic DCR. Follow-up ranged from 6 to 36 months, and success was defined as resolution of tearing and discharge by follow-up clinical evaluation and by parental history. RESULTS: All but 2 patients (88%) with NLDO showed complete resolution of tearing and discharge. These 2 patients had recurrent symptoms after the Crawford tubes were removed and required revision endoscopic DCR. No complications from this procedure were noted. CONCLUSIONS: Endoscopic DCR is a safe and effective means of treating persistent NLDO in infants and young children when simple probing, intubation, or balloon procedures have failed. The team ophthalmology-otolaryngology endoscopic approach provides a highly successful alternative for patients with a persistent distal obstruction that might otherwise require an external procedure.     

Hemorrhagic complications of oculoplastic surgery

PURPOSE: To determine the incidence and risk factors of hemorrhagic complications associated with selected oculoplastic procedures. METHODS: A prospective study was performed to document the severity of intraoperative hemorrhage and postoperative bruising in patients undergoing oculoplastic procedures. The use of anticoagulant or platelet-inhibiting medications, systemic medical conditions, patient age, patient sex, and type of procedure were examined to identify risk factors for hemorrhagic complications. RESULTS: Troublesome intraoperative bleeding prolonged surgery in 9.2% of cases. Severe bleeding with the potential to affect surgical outcome was encountered in 0.4% of procedures. There was little correlation between severity of bleeding and degree of postoperative bruising. Male sex, a history of heart disease, or age >60 years imparted a slightly greater risk of intraoperative bleeding. Age >60 years, hypertension, or recent cessation of aspirin may increase the risk of postoperative bruising. A history of previous stroke increased the risk of postoperative bleeding. There was no statistical difference in the incidence of hemorrhagic complications among patients currently treated with antiplatelet/anticoagulant agents, those who had stopped these medications before surgery, and those who were not treated with these agents. No patient had permanent sequelae related to hemorrhage. Two patients had postoperative systemic complications possibly attributable to withholding anticoagulant/antiplatelet medications in preparation for surgery. CONCLUSIONS: Although serious hemorrhagic complications may be associated with oculoplastic procedures, the incidence of these complications is low. The decision to withhold antiplatelet or anticoagulant medications before surgery should be individualized. Selected procedures can be safely performed without stopping these agents.     

Costenbader Lecture. The efficacy of rectus muscle transposition surgery in esotropic Duane syndrome and VI nerve palsy.

BACKGROUND: Partial tendon transposition was first described by Hummelshein in 1907. Full tendon transposition was reported by Schillinger in 1959. Recently, full tendon transposition with posterior augmentation was reported by Foster in 1997. I will review current thinking concerning the anatomy and physiology of rectus muscle transposition and present our current clinical experience with this procedure in Duane syndrome. METHODS: A retrospective review of vertical rectus muscle transposition procedures in patients with VI Nerve palsy was performed comparing the postoperative field of single binocular vision, amount of improved abduction, and change in the primary esotropic angle. In addition, a consecutive series of vertical rectus muscle transposition cases for the treatment of esotropic Duane syndrome is presented, evaluating the improvement and head position, abduction, and reduction of the primary position esotropia. RESULTS: In VI Nerve palsy patients, vertical rectus transposition surgery produces 41 degrees to 71 degrees of binocular visual field with 10 degrees to 21 degrees of binocular field in abduction. In esotropic Duane syndrome the surgical procedure produces 42 degrees to 66 degrees of binocular field and a correction of approximately 15 degrees of face turn. Variability in the efficacy of the procedure is related to the degree of ipsilateral medial rectus contracture. CONCLUSION: Vertical rectus transposition with posterior fixation can create a binocular diplopia-free field of 40 to 70 degrees in patients with VI Nerve palsy and about 40 to 65 degrees in patients with Duane syndrome. Partial rectus muscle transposition is an effective procedure in cases where surgery on multiple rectus muscles has been or will be required. Orbital wall fixation of the lateral rectus muscle is an effective and reversible method to inactivate a lateral rectus muscle and may be useful in cases of Duane syndrome with marked anomalous innervation and severe cocontraction.     

Development of efficient threshold strategies for frequency doubling technology perimetry using computer simulation

PURPOSE: To develop new test procedures for frequency-doubling technology (FDT) perimetry that improve performance beyond those currently used. METHODS: Two novel threshold estimation procedures were evaluated: a rapid, efficient binary search technique (REBS) and a maximum-likelihood estimation (ZEST) procedure. A computerized visual field simulation model was developed to determine the accuracy and efficiency of these procedures. This model was constructed using previously derived characteristics of FDT perimetry from both normal observers (n = 506) and those with glaucomatous visual field loss (n = 352). The computer simulation program was used to determine the best parameters for the two new procedures and the effect of variability and response errors on algorithm performance. Comparisons were made to the performance of the modified binary search (MOBS) procedure used in the current commercial implementation of the FDT perimeter. RESULTS: Both the optimized REBS and ZEST procedures approximately halved the time required for FDT threshold testing without loss of accuracy or reproducibility. CONCLUSIONS: With suitable parameter choices, comparable performance was achieved using either ZEST or REBS. Simulation results indicate that accurate thresholds can be measured with an optimized ZEST or REBS procedure in approximately half the time required by traditional estimation methods.     

Preserved scleral patch graft for unexpected extreme scleral thinning found at the scleral buckling procedure: a case report

Pre-existing scleral pathology is an important risk factor for globe rupture during scleral buckling procedures. We report here, the surgical management of an unexpected scleral pathology found at the scleral buckling procedure in a retinal detachment patient. A 77-year-old white female with retinal detachment underwent a scleral buckling procedure. The surgery was converted into a scleral graft procedure, as extreme scleral thinning was found intraoperatively. An alcohol-preserved donor sclera graft was used. The second surgery for definitive retinal alignment was performed two weeks later. The presented case of an unexpected scleral pathology in a retinal detachment patient was managed with a combination of scleral grafting and pars plana vitrectomy, without any major complications. The anatomical outcome was excellent and the scleral rupture was prevented; the visual outcome was satisfactory. A conversion of the scleral buckling procedure into a scleral graft procedure has proved to be safe and effective for unexpected scleral pathology.     

Combined cervicofacial rhytidectomy and laser skin resurfacing

PURPOSE: To determine the safety and efficacy of simultaneous cervicofacial rhytidectomy (face lift) and laser skin resurfacing. METHODS: A retrospective study of 100 consecutive patients who underwent simultaneous face lift and carbon dioxide laser resurfacing procedures was performed. Patients received regional (periorbital and/or perioral), "T"-shaped (forehead and central face), or full face laser skin resurfacing, and were classified on this basis. All patients were assessed for flap necrosis, delayed reepithelialization, reactive hyperpigmentation, persistent erythema, scarring, or other unsatisfactory results postoperatively. RESULTS: One of 10 patients receiving full-face resurfacing, including the entire subcutaneously undermined flap, suffered full-thickness skin necrosis of the distal segment of one flap. Six of the 100 patients developed reactive hyperpigmentation postoperatively. One patient evidenced an imprint of the laser footprint over nonundermined skin, requiring a secondary procedure. Aside from the one patient with scar, no cases of delayed reepithelialization were identified. CONCLUSIONS: Carbon dioxide laser skin resurfacing combined with face lift procedures can achieve dramatic cervicofacial rejuvenation. Laser resurfacing over nonundermined skin during the face lift procedure does not appear to increase the risk of postoperative complication. Laser treatment over an undermined distal face lift flap appears to increase the potential for skin necrosis, and should not be considered a routine modality for facial rejuvenation.     

Treatment of primary retinal detachment. Minimal extraocular or intraocular?

The developments in treatment modalities for a primary retinal detachment over the last 70 years have been reviewed. There was a change from a surgery limited to the area of the break to a form of prophylactic surgery including the extent of the detachment. In between Rosengren had limited the treatment to the break with an intraocular gas bubble. A change was brought about by Custodis in 1953 who limited surgery to the break and omitted drainage. This procedure had serious postoperative complications which were eliminated by Lincoff by developing the cryosurgical detachment operation which was subsequently refined to extraocular minimal surgery. The ultimate realization of a minimal extraocular approach was the operation with a temporary balloon. Two additional intraocular procedures evolved, pneumatic retinopexy and primary vitrectomy, following one or the other pattern of treatment. With all four methods reattachment can result in 94-99% of the cases but differences can be seen in the morbidity and rate of reoperations.     

Endoscopic laser recanalisation of presaccal canalicular obstruction

AIM: To document the results of erbium (Er)-YAG laser treatment in presaccal canalicular obstruction in combination with the use of a flexible endoscope. METHODS: For the first time an Er-YAG laser (Schwind, Sklerostom) was attached to a flexible endoscope (Schwind, Endognost) and used to recanalise a stenosis of the upper, lower, or common canaliculus. In 17 patients (mean age 41.5 (SD 11.9) years), 19 treatments (two bilateral) were performed. In all cases the scar was observed using the endoscope and was excised by laser ablation. A silicone intubation was performed in all cases. In addition to the endoscopy an irrigation was performed to prove the intactness of the lacrimal pathway system after laser treatment. RESULTS: Membranous obstructions with a maximum length of 2.0 mm (14 procedures) in the canaliculus were opened easily using the laser, and the silicone intubation was subsequently performed without difficulty. Scars thicker than 2.0 mm could not be opened safely without canaliculus penetration (five procedures). Irrigation was positive in all cases up to the end of a 6 month period, providing the tubes remained in place. The maximum follow up is now 17 months (minimum 8 months) and in 16 cases (84.2%) the canaliculi are still intact. CONCLUSION: Endoscopic laser treatment combined with silicone intubation enables us to recanalise presaccal stenoses of canaliculi under local anaesthesia up to a scar thickness of 2.0 mm. Best results can be achieved in cases where much tissue can be saved. Under such conditions this procedure can substitute for more invasive surgical techniques, especially a conjunctivo-dacryocystorhinostomy (CDCR).     

Treatment of encapsulated blebs with 30-gauge needling and injection of low-dose 5-fluorouracil.

We describe a simplified needling procedure, performed at the slit-lamp, with injection of low-dose 5-fluorouracil to treat encapsulated filtering blebs. Between August 1989 and December 1990 we treated 17 eyes of 14 patients with this procedure. At 2 months 13 of the eyes had needed only one needling procedure. Risk factors for reencapsulation of the bleb were a history of three or more previous surgical procedures (p less than 0.05) and prolonged preoperative use of topical adrenergic drugs (p less than 0.05). At 1 year all but one eye had an intraocular pressure below 21 mm Hg (median 15 mm Hg). Twelve of the eyes had needed more than one needling procedure. There were no serious complications of the 32 procedures performed. The incidence rate of minor complications (wound leaks, corneal erosion and small hyphemas) was 38%.     

SUPERIOR OBLIQUE MUSCLE SURGERY

The anatomy and actions of the superior oblique muscle are discussed as a basis for logical surgical procedures. Weakening procedures are indicated for overaction or for a short superior oblique tendon. Tenectomy is performed nasal to the superior rectus while selective tenotomies for bilateral overaction are performed temporal to the superior rectus. Recession of the whole tendon on an adjustable suture is preferred for unilateral superior oblique overaction. Tendon tucking for unilateral superior oblique palsy is performed temporal to the superior rectus and inevitably causes a degree of pseudo-Brown's syndrome. Tucks may be used bilaterally in bilateral cases. Alternatively, anterior tendon advancement corrects tensional symptoms. It may be graded from a maximum advancement to the upper border of the lateral rectus to suit the degree of tension. Adjustable sutures may be used. Superior oblique tendon transfer for long-standing third nerve palsies may produce paradoxical eye movements in the long-term due to scarring.