Trabeculectomy: the limitations for registrar training.

BACKGROUND: Trainee exposure to glaucoma surgery was analysed and outcomes compared with those of consultant cases. DESIGN: Retrospective review was carried out at Princess Alexandra Hospital and Royal Brisbane and Women's Hospital, two major tertiary teaching hospitals in Brisbane, Queensland, Australia. PARTICIPANTS: Two hundred and forty-eight consecutive public patients undergoing primary trabeculectomy surgery between 2003 and 2010. METHODS: The rate of trabeculectomy performed by trainees, the success and complication rates were examined and compared with those of consultant ophthalmologists. MAIN OUTCOME MEASURES: Intraocular pressure was divided into two groups of ≤21 mmHg and ≤15 mmHg and visual field progression. RESULTS: Two hundred and forty-eight primary trabeculectomy cases were performed between 2003 and 2010. Trainees carried out 145 cases (59%), making the rate of trabeculectomy operations 1.1 per trainee per year (16-17 trainees) as compared with 1.6 per trainee per year from 1996 to 2002 at the same institutions. Complications rates in the first postoperative week were similar between consultants and trainees, the most common being wound leak and hyphaema. An intraocular pressure of ≤15 mmHg without the use of topical medications was achieved in 25 out of 50 (50%) glaucoma-interest consultant, 24 out of 53 (45.3%) general consultant and 68 out of 145 (46.9%) trainee cases (P = 0.951). The rate of visual field progression was also statistically similar between trainees and consultants (19.5% and 21.3%), respectively. CONCLUSION: With increasing trainee numbers, the rate of trabeculectomy surgery is declining compared with previous years, with less trainee exposure to trabeculectomy surgery and inability to achieve surgical competency levels.

Recurrent annular peripheral choroidal detachment after trabeculectomy.

We report a challenging case of recurrent flat anterior chamber without hypotony after trabeculectomy in a 54-year-old Black male with a remote history of steroid-treated polymyositis, cataract surgery, and uncontrolled open angle glaucoma. The patient presented with a flat chamber on postoperative day 11, but had a normal fundus exam and intraocular pressure (IOP). Flat chamber persisted despite treatment with cycloplegics, steroids, and a Healon injection into the anterior chamber. A transverse B-scan of the peripheral fundus revealed a shallow annular peripheral choroidal detachment. The suprachoroidal fluid was drained. The patient presented 3 days later with a recurrent flat chamber and an annular peripheral choroidal effusion. The fluid was removed and reinforcement of the scleral flap was performed with the resolution of the flat anterior chamber. A large corneal epithelial defect developed after the second drainage. The oral prednisone was tapered quickly and the topical steroid was decreased. One week later, his vision decreased to count fingers with severe corneal stromal edema and Descemet's membrane folds that improved to 20/50 within 24 h of resumption of the oral steroid and frequent topical steroid. The patient's visual acuity improved to 20/20 following a slow withdrawal of the oral and topical steroid. Eight months after surgery, the IOP was 15 mm Hg without glaucoma medication. The detection of a shallow anterior choroidal detachment by transverse B-scan is critical to making the correct diagnosis. Severe cornea edema can occur if the steroid is withdrawn too quickly. Thus, steroids should be tapered cautiously in steroid-dependent patients.

Optical coherence tomography changes in macular CMV retinitis.

Cytomegalovirus (CMV) retinitis characteristically causes peripheral retinitis with associated vasculitis. It rarely begins in the macula or causes macular necrosis exclusively. We report a case of unilateral macular CMV retinitis in a 65-year-old immunosuppressed patient and document changes in the macula during treatment through optical coherence tomography (OCT).

Augmented vertical rectus [corrected] transposition for the treatment of strabismus in Möbius syndrome.

Möbius syndrome is a rare congenital disorder characterized by bilateral facial nerve palsy and abducens nerve palsy. It is associated with a wide spectrum of systemic and ocular manifestations; esotropia is commonly the reason for ophthalmic referral. There are few published studies in the literature on strabismus surgery in Möbius syndrome. An augmented vertical rectus muscle transposition in which lateral fixation sutures are used on the transposed vertical rectus muscles (Foster augmentation) has been used to correct esotropia caused by severe sixth nerve palsy and type 1 Duane syndrome. We describe the surgical outcome after treating moderate- to large-angle esotropia in 3 patients with Möbius syndrome with the augmented vertical rectus muscle transposition.