Modified 360-degree suture trabeculotomy combined with phacoemulsification and intraocular lens implantation for glaucoma and coexisting cataract.

PURPOSE: To assess the efficacy and safety of a modified 360-degree suture trabeculotomy combined with a cataract surgery technique in patients with glaucoma and coexisting cataract. SETTING: Hokkaido University Hospital, Sapporo, Japan. DESIGN: Retrospective case series. METHODS: Medical records of patients with glaucoma having a modified 360-degree trabeculotomy combined with cataract surgery (Group 1) were reviewed. Another group of patients who had the modified 360-degree suture trabeculotomy alone served as controls (Group 2). RESULTS: Both groups comprised 46 patients. In each group, eyes were diagnosed with primary angle-closure glaucoma in 2 eyes, primary open-angle glaucoma in 24 eyes, exfoliation glaucoma in 4 eyes, uveitic glaucoma in 15 eyes, and steroid glaucoma in 1 eye. The mean preoperative intraocular pressure (IOP) values were 27.2 mm Hg ± 7.3 (SD) on 3.0 ± 0.5 medications in Group 1 and 27.7 ± 10.7 mm Hg on 2.9 ± 0.6 medications in Group 2. Twelve months after surgery, the mean IOPs were 13.4 ± 3.7 mm Hg on 0.8 ± 1.1 medications in Group 1 and 13.9 ± 4.1 mm Hg on 0.6 ± 0.9 medications in Group 2. The success rate (<18 mm Hg) at 12 months was 89.1% and 93.5%, respectively. Major complications included transient IOP spikes (30.4% and 37.0%) and prolonged hyphema (10.9% and 6.5%) in Group 1 and Group 2, respectively. CONCLUSION: The data showed the equivalent effects of suture trabeculotomy combined with cataract surgery and suture trabeculotomy surgery alone on postoperative safety and efficacy. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Continuous Intraocular Pressure Monitoring During Nocturnal Sleep in Patients With Obstructive Sleep Apnea Syndrome.

PURPOSE: To evaluate intraocular pressure (IOP) changes during nocturnal sleep in patients with obstructive sleep apnea syndrome (OSAS) using a contact lens sensor (CLS). METHODS: This was a prospective cohort study. Seven OSAS patients who had no ocular diseases except mild cataract were enrolled. Each subject underwent CLS-based continuous IOP monitoring on one eye simultaneously with overnight polysomnography. We classified the nocturnal IOP records into nonapnea IOP and apnea IOP, according to the duration of apnea events on polysomnography within each IOP measurement time of 30 seconds every 5 minutes. RESULTS: Differences between IOP levels during nonapnea and apnea phases were statistically analyzed. The mean apnea-hypopnea index, the total number of these events per hour of sleep, was 44.2 ± 21.0, indicating the participants' severity of OSAS as moderate to severe. The mean range of IOP fluctuations during nocturnal sleep was 262.3 ± 59.5 mV eq. All patients showed lower mean IOP levels during apnea events than during nonapnea phases, with statistically significant differences detected in four of the seven patients. On average, in all seven eyes, IOP values significantly decreased by 23.1 ± 16.4 mV eq in association with apnea events. CONCLUSIONS: Obstructive apnea led to an immediate IOP decline during nocturnal sleep in patients with OSAS. Attention should be paid to IOP-independent etiology, such as episodic hypoxia, potentially linking OSAS and glaucoma.

Reduction of intraocular pressure using a modified 360-degree suture trabeculotomy technique in primary and secondary open-angle glaucoma: a pilot study.

PURPOSE: To investigate the effects of a modified 360-degree suture trabeculotomy technique for primary and secondary open-angle glaucoma (POAG and SOAG). METHODS: We modified the procedure for 360-degree trabeculotomy by using a 5-0 nylon suture, making a scleral flap to allow clear identification of Schlemm canal, and creating a corneal side port incision opposite to the scleral flap to retrieve the suture used to cannulate and cleave the canal. The modified 360-degree suture trabeculotomy (not combined with cataract surgery) was performed on 25 eyes with POAG and 18 eyes with SOAG, and the results were compared retrospectively with those of standard trabeculotomy with metal trabeculotomes (16 eyes with POAG and 19 eyes with SOAG). When the intraocular pressure (IOP) was reduced by 30% from the preoperative IOP and was also below 18 mm Hg at 3, 6, 9, 12, and 18 months after surgery and the patient was taking a similar number or fewer medications, the surgery was considered a "success." RESULTS: Using this modified technique, Schlemm canal was appropriately incised without resistance. At 12 months after the modified 360-degree suture trabeculotomy and trabeculotomy with metal trabeculotomes, the mean postoperative IOP values were 13.1 and 15.2 mm Hg, respectively, and the mean numbers of antiglaucoma medications were 0.5 and 1.4, respectively. The success rates of POAG at 12 months for the modified 360-degree suture trabeculotomy and trabeculotomy with metal trabeculotomes were 84% and 31%, respectively, and those of SOAG were 89% and 50%, respectively. The complications included a transient elevation of the IOP above 30 mm Hg in 22 eyes (47%) treated with the 360-degree suture trabeculotomy and 17 eyes (49%) treated with trabeculotomy with metal trabeculotomes. There was no significant difference between preoperative visual acuity and postoperative visual acuity in either procedure. CONCLUSIONS: This modified 360-degree suture trabeculotomy is a feasible surgical option for POAG and SOAG.

Arteritic anterior ischemic optic neuropathy with positive myeloperoxidase antineutrophil cytoplasmic antibody.

BACKGROUND: Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) is related to smallvessel vasculitis. There have been some reports of optic nerve involvements with increased values of MPO-ANCA. We report two cases of anterior ischemic optic neuropathy (AION) in which ANCA-associated vasculitis was suspected to be responsible for the pathogenesis. CASES: A 66-year-old man and a 72-year-old man had ocular symptoms of AION in both eyes with positive MPO-ANCA. OBSERVATIONS: Both patients showed high erythrocyte sedimentation rate, C-reactive protein, and MPOANCA values at first. Temporal artery biopsies were negative for temporal arteritis, whereas small-vessel vasculitis was found only in the latter patient. Visual dysfunctions remained unchanged after steroid pulse therapy, although laboratory data returned to normal levels after the treatment. Fluorescein angiography revealed selective occlusion of capillaries, arterioles, and precapillaries in the retina and choroid as well as in the optic disc. CONCLUSIONS: The identical characteristics of the angiographic findings of both eyes in the two cases indicated that the obliteration of small vessels in the intraocular arterial system was closely related to MPO-ANCA-associated vasculitis.

Vergence eye movement signals in the cerebellar dorsal vermis.

We examined simple-spike activity of Purkinje cells (P-cells) that responded during a search task which required both vergence- and frontal-pursuit. Of a total of 100 responding P-cells, 16% discharged only for frontal-pursuit, 43% only for vergence-pursuit, and 41% for both. Thus, the majority of vermal pursuit P-cells modulated their activity during vergence-pursuit. These P-cells also discharged for vergence eye movements induced by step target-motion in-depth. The majority of vergence related P-cells carried convergence signals with both eye velocity and position sensitivities, and they discharged before the onset of convergence eye movements. Muscimol infusion into the sites where convergence P-cells were recorded resulted in a reduction of peak convergence eye velocity, of initial convergence eye acceleration, and of frontal-pursuit eye velocity. These results suggest specific involvement of the dorsal vermis in vergence eye movements.

Involvement of the cerebellar dorsal vermis in vergence eye movements in monkeys.

Frontal-eyed primates use both smooth pursuit in frontoparallel planes (frontal pursuit) and pursuit-in-depth (vergence pursuit) to track objects moving slowly in 3-dimensional (3D) space. To understand how 3D-pursuit signals represented in frontal eye fields are processed further by downstream pathways, monkeys were trained to pursue a spot moving in 3D virtual space. We characterized pursuit signals in Purkinje (P) cells in the cerebellar dorsal vermis and their discharge during vergence pursuit. In 41% of pursuit P-cells, 3D-pursuit signals were observed. However, the majority of vermal-pursuit P-cells (59%) discharged either for vergence pursuit (43%) or for frontal pursuit (16%). Moreover, the majority (74%) of vergence-related P-cells carried convergence signals, displaying both vergence eye position and velocity sensitivity during sinusoidal and step vergence eye movements. Preferred frontal-pursuit directions of vergence + frontal-pursuit P-cells were distributed in all directions. Most pursuit P-cells (73%) discharged before the onset of vergence eye movements; the median lead time was 16 ms. Muscimol infusion into the sites where convergence P-cells were recorded resulted in a reduction of peak convergence eye velocity, of initial convergence eye acceleration, and of frontal-pursuit eye velocity. These results suggest involvement of the dorsal vermis in conversion of 3D-pursuit signals and in convergence eye movements.

Mydriasis with light-near dissociation in Fisher's Syndrome.

BACKGROUND: Approximately 50% of patients with Fisher's syndrome show involvement of the pupillomotor fibers and present with mydriasis and light-near dissociation. However, it is uncertain whether this phenomenon is induced by an aberrant reinnervation mechanism as in tonic pupil, or is based on other mechanisms such as those associated with tectal pupils. CASES: We evaluated the clinical course and the pupillary responses in four of 27 patients with Fisher's syndrome who presented with bilateral mydriasis. OBSERVATIONS: The pupils of both eyes of the four patients were involved at the early stage of Fisher's syndrome. The pupils in patients 1 and 2 showed mydriasis with apparent light-near dissociation lasting for a significant period and had denervation supersensitivity to cholinergic agents. On the other hand, the pupils of patients 3 and 4 were dilated and fixed to both light and near stimuli. CONCLUSIONS: Our observations indicate that the denervated iris sphincter muscles, which are supersensitive to the cholinergic transmitter, may play an important role in the expression of light-near dissociation in Fisher's syndrome.

Ocular motor disorders in mitochondrial encephalopathy with lactic acid and stroke-like episodes with the 3271 (T-C) point mutation in mitochondrial DNA.

BACKGROUND: Ocular motor function can provide insights into areas of dysfunction within the nervous system. There are no published eye movement recordings in patients with mitochondrial encephalopathy with lactic acid and stroke-like episodes (MELAS). Our purpose in this study was to analyze the ocular motor features of a family with MELAS with a (T-C) mutation at nucleotide position 3271 in the mitochondrial tRNA-Leu gene. METHODS: The search coil method was used to record visually-guided saccades, antisaccades, and triangular pursuit tasks in the horizontal and vertical planes in three patients in a Japanese family with MELAS. RESULTS: The patients showed saccadic dysmetria and prolonged saccadic reaction times, deficits in the ability to suppress reflex eye movements, and increased reaction time during antisaccades, downbeat nystagmus, square wave jerks, and impairment in pursuit. CONCLUSIONS: On the basis of eye movement recordings, patients with MELAS have frontal cortex as well as cerebellar dysfunction.