Practice of immediate sequential bilateral cataract surgery (ISBCS): A teaching hospital experience in United Kingdom.

BACKGROUND / OBJECTIVES: Utilisation of ISBCS has been encouraged since COVID-19 in line with the RCOphth recommendations. This study aims to share experience from a UK teaching hospital on ISBCS and to evaluate pre-, intra- and post-operative outcomes from the ISBCS cohort. METHODS: Of 3402 cataract surgeries performed between July 2020 and July 2021 (1 year since the reopening of the cataract service from COVID-19), 208 eyes of 104 patients (6.1%) undergoing ISBCS were retrospectively studied on their demographics, biometry, surgeon grades, and pre-, intra- and post-operative data. RESULTS: The mean age was 74.5 ± 9.4 years and 62% were female. Eighty-nine percent of the eyes were performed under local anaesthesia and 70% were 'routine' cases. Other risk factors included: short eyes requiring pre-operative mannitol infusion (10%), high myopia (8%), poor dilation (2%) and a 'glaucoma' cohort [angle closure (2%) and prior trabeculectomy (1%)]. Three eyes (1%) had complications intra-operatively in second eye (1 case each: posterior capsule rupture, corneal oedema and zonular dehiscence). Two patients (1%) had complications in the first eye (1 case each: suprachoroidal haemorrhage, conjunctival & iris haemorrhage), hence had their second eye postponed. Twelve months post-operatively, 20 eyes (10%) had recorded post-op complications with cystoid macular oedema being the commonest (4.5%) and no endophthalmitis. Eighty-six percent were discharged with satisfaction. No significant differences were found in pre-operative features, complication rates and post-operative outcomes between consultant and non-consultant surgeons (p > 0.05). CONCLUSIONS: Our experience which included a cohort of high-risk patients showed safe and successful practice of ISBCS without having a negative impact on training.

Early Results of Irrigating Goniectomy With TrabEx+: A Novel Device for the Treatment of Open-angle Glaucoma.

PRCIS: Irrigating goniectomy with the TrabEx+ device can lower intraocular pressure (IOP) in patients with glaucoma, as a standalone procedure or combined with cataract surgery. PURPOSE: The aim was to describe the efficacy and safety of irrigating goniectomy performed using the TrabEx+ device, either as a standalone procedure or combined with cataract surgery, in eyes with medically treated open-angle glaucoma. METHODS: A retrospective case series of eyes treated by a single surgeon at a single UK teaching hospital. Data was collected at follow-up visits at 1 week, 3, 6, 12, 18, and 24 months postoperatively. Primary outcomes included IOP and glaucoma medication reduction after surgery. Proportion of eyes achieving >20% IOP reduction, IOP <21 mm Hg, and no reoperation were classified as surgical success. RESULTS: Seventy-three consecutive eyes of 64 patients (mean age 68.4±13.7 y) were enrolled. 62% were treated as combined procedures with cataract surgery. Overall, mean IOP decreased from 31.3±7.3 to 20.9±10.4 mm Hg at the latest follow-up (34% reduction) (P<0.001) at the latest follow-up (16.1±10.3 mo) with mean preoperative medications decreased from 2.9±1.2 to 1.9±1.3 (P<0.001). 73% met the definition of success at latest follow-up. Postoperative complications were recorded including hyphaema (17%), uveitis (3%), hypotony (1%), and persistent vitreous hemorrhage (1%). Eighteen percent required reoperation because of treatment failure. CONCLUSION: TrabEx+ appears to be effective in lowering IOP and medication with or without cataract surgery. However, long-term safety and efficacy will be better understood in a prospective study with longer follow-up.

Sampling trabecular meshwork using TrabEx.

BACKGROUND: To report sampling of the trabecular meshwork using the TrabEx+ (MicroSurgical Technology, Redmond, Washington, USA) device in ab interno trabeculectomy. Specifically, this series focusses upon preservation of the trabecular meshwork architecture for assessment of glaucomatous features using common histopathological techniques. PATIENTS: This series features six glaucomatous eyes undergoing TrabEx+ with or without cataract surgery. Three patients had primary open angle glaucoma and the remaining had pigment dispersion glaucoma, ocular hypertension or uveitic glaucoma. Four eyes had simultaneous cataract surgery. METHODS: Trabecular meshwork was excised using the TrabEx+ device and retrieved using vitreoretinal forceps. The samples were then processed into formalin-fixed paraffin-embedded 4 micron tissue segments and stained with haematoxylin and eosin, periodic acid-Schiff and elastin Van Gieson. Collagen IV was labelled using immunohistochemistry for the purpose of identifying the basement membrane of trabecular beams. RESULTS: Presence of trabecular meshwork was confirmed in five of the six samples taken. One of six samples consisted of blood only, but this was expected following early termination of the procedure due to patient restlessness. In the five positive cases trabecular beams with associated trabecular meshwork cells were identified on hematoxylin-eosin and periodic acid-Schiff staining. The beams retained their lamellar structure. The basement membrane underlying the trabecular cells was evident in three specimens, whilst two specimens were of insufficient size for collagen IV labelling. CONCLUSIONS: This case series illustrates that TrabEx+ can be utilised to successfully retrieve trabecular meshwork samples with sufficient architectural perseveration of the tissue to enable histopathological and laboratory analysis.

Patient perspectives when switching from Cosopt(®) (dorzolamide-timolol) to Azarga™ (brinzolamide-timolol) for glaucoma requiring multiple drug therapy.

BACKGROUND: This study aimed to determine the impact of switching patients requiring multiple drug treatment from the dorzolamide-timolol fixed combination to the brinzolamide-timolol fixed combination and potential effects on tolerability and compliance. METHODS: Patients were switched from dorzolamide-timolol to brinzolamide-timolol and questioned within a period of 4-26 weeks. Questions were asked to confirm if a specific side effect had been experienced, and then a numerical comparison between the two types of eye drop was made. RESULTS: Thirty-one consecutive patients (12 males and 19 females aged 41-89 years) successfully completed the questionnaire. Comparison of the severity and chronicity of the side effects of the two types of fixed-combination eye drops showed that brinzolamide-timolol caused significantly less stinging for a shorter amount of time than dorzolamide-timolol; it also produced less eye redness for a significantly shorter amount of time. Brinzolamide-timolol produced more blurring, although the length of time this was present was similar to that for dorzolamide-timolol. No differences between the two eye drops were found for taste, overall impression, and likelihood of compliance. CONCLUSION: Our study confirms the findings of other researchers pertaining to the side effect profile of brinzolamide-timolol after switching from dorzolamide-timolol, which is a reduction in stinging but an increase in blurred vision. The advantage of one eye drop over the other then becomes patient-specific, depending on which side effect they find most tolerable. We suggest that both eye drops are acceptable choices in treating patients with glaucoma, and are interchangeable if compliance becomes an issue because of a specific side effect of one eye drop or the other.

Underacting inferior oblique muscle following myectomy or recession for unilateral inferior oblique overaction.

PURPOSE: To assess the incidence and investigate the functional impact of postoperative overcorrection following primary unilateral inferior oblique muscle recession and myectomy for inferior oblique overaction. METHODS: A retrospective study of 79 consecutive patients undergoing inferior oblique myectomy (43) or recession (36) with a minimum 6 months of postoperative follow-up. All underwent ocular motility examinations preoperatively and postoperatively at approximately 2 weeks and 6 months. The vertical deviation in primary position and on contralateral gaze and inferior oblique versions and ductions on contralateral elevation were analyzed. RESULTS: At 6 months, 51 patients had no inferior oblique underaction (group 1), 23 of 28 who had developed inferior oblique underaction were asymptomatic (group 2), and the remaining 5 were symptomatic (group 3). The mean preoperative hyperdeviation was 12.9 (group 1), 13.1 (group 2), and 15 (group 3) prism diopters (PD) in primary position. Postoperatively, these measured 3.8 (group 1), 3.8 (group 2), and -7.8 (group 3) PD (- indicates deviation reversal). The mean preoperative and postoperative inferior oblique versions for these three groups were +2.7, +2.2, +2.2 units and +0.9, -1.0, -1.4 units, respectively. CONCLUSION: Inferior oblique underaction was common (28 patients, 35.4%), generally mild, persistent, and usually asymptomatic 6 months following surgery. Although uncommon (5 patients, 6.3%), symptomatic inferior oblique underaction required further surgery with a successful outcome. They included 2 patients with a history of head or orbital trauma and one with masked and one with highly asymmetric bilateral inferior oblique overaction.

Spectral Domain OCT: An Aid to Diagnosis and Surgical Planning of Retinal Detachments.

Regmatogenous retinal detachments need prompt intervention particularly when macula is on. Unfortunately this is not always easy to ascertain clinically and the chronicity of the event is often muddled in patient's histories. Developments in optical coherence tomography (OCT) have allowed high-resolution axial scans which have enabled the characterisation of retinal changes in retinal detachments. In this paper, we show the changes in retinal morphology observed by spectral domain OCT and how this can be used to plan appropriate surgical intervention.

The use of membrane translocating peptides to identify sites of interaction between the C5a receptor and downstream effector proteins.

The complement fragment C5a is a potent leucocyte chemoattractant and activator, mediating its effects through a G-protein-coupled receptor. Whilst the C-terminal domain of this receptor has been shown to be essential for receptor desensitization and internalization, it is not known which domains couple to the receptor's heterotrimeric G proteins. In this report we have used a membrane translocating sequence (MTS) to examine the effects of the four intracellular domains of the human C5a receptor (C5aR) on the receptor's signalling via G(alphai) family heterotrimeric G proteins in intact RBL-2H3 cells. The results indicate that all of the intracellular domains couple to downstream signalling, with the proximal region of the C terminus being a major binding site and intracellular loop 3 playing a role in G protein activation or receptor desensitization.

Alanine scanning mutagenesis of CCR3 reveals that the three intracellular loops are essential for functional receptor expression.

Intracellular signaling mediated by the eotaxin receptor, CCR3, has been implicated in allergic diseases involving the recruitment and activation of eosinophils. To investigate the structural requirements of the three intracellular loops (ICL) of CCR3, a panel of 15 alanine triplet mutants were generated and their effects on function assessed by assays of cell surface expression and chemotactic responsiveness. While the majority of constructs were efficiently expressed when compared with their wild-type counterpart, their abilities to migrate in response to eotaxin were relatively poor, suggesting that all three intracellular loops of CCR3 are involved to some degree in coupling to G proteins. - Another panel of 7 point mutants were then constructed to examine the DRY motif which resides in ICL2 and is highly conserved throughout the chemokine receptors identified to date. The conservative mutants D130E and R131K were well tolerated and gave chemotactic responses approaching 35 % of wild-type CCR3, but the less conserved substitutions D130A, D130N and R131L were non-functioning. Tyrosine 131 was particularly sensitive to mutation as both Y131F and Y131S mutants were poorly expressed and were chemotactically inactive. Together, this data suggest that the acidic / basic / polar nature of the DRY motif is a prerequisite for CCR3 function.