Safety and Efficacy of Resident-Performed Gonioscopy-Assisted Transluminal Trabeculotomy.

PRCIS: GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature. PURPOSE: Report outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) performed by PGY-3 and PGY-4 residents. METHODS: A retrospective chart review was performed for patients undergoing resident-performed GATT. Eyes with previous traditional glaucoma surgery (trabeculectomy or aqueous shunt) or neovascular glaucoma were excluded from this analysis. The primary aim was to assess whether resident-performed GATTs demonstrated success rates comparable with the GATT literature. Surgical success was defined as intraocular pressure (IOP)<21 mmHg, and an IOP reduction of 20% from baseline, and no subsequent IOP-lowering surgery. The secondary and tertiary aims were to describe complication rates and operating times for resident-performed GATTs, respectively. RESULTS: A total of 50 eyes from 40 patients with various types of glaucoma were included. Eyes either underwent resident-performed GATT-alone (N=9) or GATT+cataract extraction with intraocular lens implantation (CEIOL) (N=41). The surgical success rate at 6 months was 71% for GATT-alone and 42% for GATT+CEIOL. Three eyes required subsequent IOP-lowering surgery. The hyphema rate was 16% at postoperative week 1 and 6% at postoperative month 1. The IOP spike (>30 mmHg) rate was 18%. Mean surgical time for both GATT-alone and GATT+CEIOL was longer for PGY-4s than for PGY-3s, attributable to less attending assistance during PGY-4 cases and more resident-performed cataracts in PGY-4 GATT+CEIOL cases (85%) compared with PGY-3 cases (35%). CONCLUSIONS: GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature.

Ophthalmology Surgical Assessment of Tube Shunt Glaucoma Surgery.

PURPOSE: To develop an internationally standardized and validated tool to assess skill in performing tube shunt surgery. DESIGN: A panel of 6 glaucoma surgeons developed a tool for assessing tube shunt surgery using a modified Dreyfus scale for skill acquisition. The tool was reviewed by a panel of 10 international content experts, and their comments were incorporated into the final rubric. PARTICIPANTS: A different panel of 8 international glaucoma specialists independently graded videos of surgical procedures performed by 6 surgeons at various levels of ophthalmic training. MAIN OUTCOME MEASURES: Inter-rater reliability for each step in the rubric was calculated. RESULTS: The tube shunt rubric contained 13 steps specific to tube shunt surgery and 7 global indices. The Cronbach α statistic, a measure of internal reliability, ranged from 0.75 to 0.97, indicating strong internal reliability for all 13 steps. CONCLUSIONS: The tube shunt assessment tool has face validity, content validity, and interobserver reliability, and can be used to assess tube shunt surgery skills. Further studies are required to determine predictive and construct validity.

Management of severe epithelial versus fibrous downgrowth following trabeculectomy: Case report and literature review.

PURPOSE: To describe the presentation and management of a patient with epithelial versus fibrous downgrowth following trabeculectomy surgery and review relevant literature regarding this complication after intraocular surgery. OBSERVATIONS: A 52-year-old monocular African-American woman was referred for management of presumed epithelial versus fibrous downgrowth following trabeculectomy surgery. The patient was initially treated with intracameral injections of 5-fluorouracil (x2) and bevacizumab (x1). Cataract extraction, membranectomy, and a third intracameral 5-fluorouracil injection were performed. Intraocular pressure (IOP) elevation was subsequently managed with a superotemporal Ahmed FP7 glaucoma drainage device in the sulcus, followed by an inferonasal Baerveldt 350 glaucoma drainage device in the sulcus. The downgrowth has not progressed and the intraocular pressure remains controlled at the most recent follow-up. CONCLUSIONS: This case underscores the risk of this complication following trabeculectomy, the role of a combined medical and surgical approach to management, and the possible need for multiple surgical interventions to control IOP. A review of the literature regarding epithelial and fibrous downgrowth after intraocular surgery was conducted, which highlighted the aggressive nature of these conditions and the range of therapeutic approaches that have been described.

Resolution of Acanthamoeba Keratitis with Adjunctive Use of Oral Miltefosine.

Purpose: To report a series of cases demonstrating the resolution of Acanthamoeba keratitis (AK) with adjunctive use of oral miltefosine.Methods: Retrospective case series.Results: The first case was a 27-year-old female who presented with severe pain and photophobia. The diagnosis of AK was made with confocal microscopy, which revealed a significant burden of stromal cysts. After approximately 2 weeks of adjunctive oral miltefosine therapy, there was a severe inflammatory response within the cornea followed by quick resolution of the AK. The second case was a 31-year-old male in whom the diagnosis of AK was confirmed by culture and polymerase chain reaction. Adjunctive oral miltefosine was started 3 months after presentation, leading to a quick resolution.Conclusions: Oral miltefosine may have cysticidal properties and should be considered as adjunctive therapy for the treatment of AK, particularly in cases with a significant burden of cysts or in cases recalcitrant to other treatments.

Repair of Superior Chorioretinal Coloboma-Associated Retinal Detachments: Case Report and Literature Review.

Purpose: This case report discusses the management of a patient with a superior chorioretinal coloboma-associated retinal detachment (RD), including surgical management, along with a review of the literature. Methods: A case report is presented. Results: A 58-year-old man presented with a chronic RD of the right eye that was symptomatic for approximately 1 year prior to presentation. On examination, he was found to have a macula-off RD associated with superior chorioretinal coloboma. He underwent 23-gauge pars plana vitrectomy with membrane peel, endolaser, and perfluoropropane (14%) gas tamponade. Three months after his surgery, his best-corrected visual acuity in his right eye was 20/250 distance and 20/80 near, and his retina remained attached. Conclusions: This case report describes surgical management of a superior chorioretinal coloboma-associated RD.

Evaluation of the Effect of Cycloplegia on Anterior Chamber Depth in Cataract Patients Using Optical Low-Coherence Reflectometry.

PURPOSE: The study was performed to study the effect of cycloplegia on anterior chamber depth (ACD) in cataract eyes. One instrument (Lenstar) was used for all measurements. METHODS: Anterior chamber depth calculations were taken with the Lenstar in cataract eyes with a mean age of 71.9±8.8 years before instilling cycloplegic drops. Two drops of Tropicamide were then instilled in each eye and measurements were retaken between 30 to 45 min later. RESULTS: Cycloplegia with a mild agent used routinely in this practice location showed a statically significant effect on increasing ACD by 0.0647±0.01 in the OD and 0.0758±0.02 in the OS. CONCLUSIONS: Anterior chamber depth can be important in the final refractive result postcataract surgery. The results of a change in effective lens position would be most significant in higher intraocular lens powers.

Carcinoma Ex Pleomorphic Adenoma of the Lacrimal Gland with Epithelial-Myoepithelial Carcinoma Histologic Type.

A 53-year-old woman presented with a 1-month history of decreased vision and progressive left periorbital fullness. Exam and radiography confirmed a left lacrimal gland mass causing mass effect on the globe and a compressive optic neuropathy. Orbitotomy with excisional biopsy confirmed carcinoma ex pleomorphic adenoma with epithelial and myoepithelial differentiation. Following a negative systemic workup, the patient underwent radiation therapy and remains free of clinical or radiographic disease 24 months following surgery. Herein the presentation, radiography, histopathology, and treatment outcome of a rare case of lacrimal gland epithelial-myoepithelial carcinoma ex pleomorphic adenoma is described.