Gonioscopy-Assisted Transluminal Trabeculotomy in Uveitis-Related Ocular Hypertension and Glaucoma.

PRCIS: Gonioscopy-assisted transluminal trabeculotomy (GATT) may be an effective first-line surgery for decreasing intraocular pressure (IOP) and medication burden in patients with uveitis-related ocular hypertension (OHT) or glaucoma. OBJECTIVE: The purpose of the study is to determine the efficacy of GATT in lowering IOP in uveitis-related OHT or glaucoma. METHODS: Retrospective case series that included patients with uveitis-related OHT or glaucoma who underwent GATT with or without concomitant cataract extraction and intraocular lens implantation at 2 Canadian academic centres from July 2018 to May 2022. Primary outcomes were: complete (no medications) and qualified success (with medication), and failure defined as (1) IOP >21 mm Hg with maximal medical therapy, (2) the need for additional glaucoma procedure, (3) loss of light perception secondary to glaucoma, and (4) IOP <6 mm Hg for 3 months. RESULTS: Twenty-one eyes from 18 patients were included with a mean preoperative IOP of 26.2 ± 7.3 mm Hg on 4.3 ± 0.7 classes of glaucoma drops. The average follow-up was 29.2 ± 17.6 months and 76% of eyes (n = 16) had reached at least 12 months of follow-up. At the 12-month follow-up visit, there was a significant decrease in average IOP by 9.9 ± 7.9 mm Hg (38%, P = 0.005) and a decrease of 1.9 in glaucoma medication classes ( P = 0.002). Of eyes, 14% achieved complete success, whereas 80% of eyes achieved qualified success. Six eyes failed (29%) and 5 patients (24%) required additional glaucoma surgery. The most common postoperative complication was hyphema (n = 9; 43%). CONCLUSION: This small case series suggests that GATT may be an effective first-line surgery for decreasing IOP and medication burden in patients with uveitis-related OHT or glaucoma. Further studies with longer follow-ups should be conducted to assess its long-term outcomes.

Mid-term prognosis of type I Boston keratoprosthesis reimplantation.

AIM: To examine the mid-term visual and anatomical prognosis of patients who require reimplantation of a second Boston keratoprosthesis type 1 (B-KPro). METHODS: Retrospective observational case series of 122 patients (141 eyes) who received a B-KPro at a single institution were reviewed. Eyes that underwent a second B-KPro were included in the study. Primary endpoints were B-KPro retention, final visual acuity 20/200 and loss of light perception. Secondary endpoints included the occurrence of postoperative complications. RESULTS: Seventeen eyes (12%) required a B-KPro reimplantation. Corneal melt was the most common indication for replacement (88%). Mean follow-up time after the second B-KPro was 4.4±2.1 years. The Kaplan-Meier analysis estimated the second B-KPro retention rate at 79% over 8 years. Retroprosthetic membrane (RPM, 53%) was the most common complication. Forty-one per cent of the eyes suffered from corneal melt following their second B-KPro. One year after the second B-KPro, 47% of the patients retained a vision 20/200. Seven eyes (41.2%) lost light perception, which was secondary to an inoperable retinal detachment in five cases. Four eyes (24%) developed phthisis following inoperable retinal detachment (n=3) or endophthalmitis (n=1). CONCLUSION: B-KPro reimplantation is a potentially sight- and globe-saving procedure for eyes with B-KPro failure, but the prognosis is guarded. B-KPro reimplantation can salvage ambulatory vision in a third of patients while another third of patients progress to loss of light perception. RPM and retinal detachment were important obstacles to visual rehabilitation while recurrent corneal melt was responsible for most cases of anatomical failure.

Cost-effectiveness analysis : fibrin glue versus sutures for conjonctival fixation during pterygion surgery.

OBJECTIVE: Pterygium surgery requires the removal of pterygium tissue and repair of the conjunctiva with either sutures or fibrin glue. The literature suggests that the cost of fibrin glue could be compensated by reducing procedure time and be more cost-effective. However, to our knowledge, no formal studies have examined this hypothesis. METHOD: Retrospective chart review of patients who received pterygium surgery with only sutures between January 2008 and January 2010, and those whose surgeons used fibrin glue with or without sutures, between April 2017 and November 2018. Equipment cost, operating room (OR) maintenance, and surgeon's remuneration were compared between the groups. RESULTS: A total of 164 eyes were included. Three different procedure methods were noted: use of sutures only, combination of sutures and fibrin glue, or application of fibrin glue alone. The equipment cost was $97, $169.50, and $152.10 for the suture group, dual method, and fibrin-only method. Average procedure time was 35.8 minutes for the sutures-only group, 21.1 minutes for the dual method, and 25.6 minutes for the method using only glue. OR maintenance cost was $51.20 CAD per minute. The total cost for the method using only sutures was $2528.90, whereas the average cost for the protocol using only fibrin glue was $2063. CONCLUSION: Although using fibrin glue for conjunctival graft adhesion increases the equipment cost, it significantly decreases procedure time, which allows a reduction of the total surgery cost. Therefore, fibrin glue is a more cost-effective approach than sutures alone.

Corneal Melt after Boston Keratoprosthesis: Clinical Presentation, Management, Outcomes and Risk Factor Analysis.

PURPOSE: To determine the presentation, risk factors, and outcomes of keratolysis after Boston type I keratoprosthesis (B-KPro). METHODS: Retrospective chart review. RESULTS: A total of 16 (14%) of the 110 eyes (96 patients) which underwent B-KPro implantation developed keratolysis at an average 20 ± 11 months. Retroprosthetic membrane (RPM), infectious keratitis, and corneal dellen were identified in 31%, 25%, and 13% of corneal melts, respectively. Five eyes had keratolysis without a readily identifiable cause. RPM (odds-ratio, OR = 4.4, p = 0.02) and infectious keratitis (OR = 17.6, p<0.0005) were confirmed as significant risk factors. Retinal detachment (p = 0.001) and choroidal detachment (p = 0.003) were more common in eyes with keratolysis. Management included B-KPro removal or exchange (n = 7), amniotic membrane transplantation (n = 1), tectonic corneal transplantation (n = 2), medical treatment (n = 4), and observation (n = 2). CONCLUSIONS: The risk of keratolysis following B-Kpro increases with the development of RPM and infectious keratitis. Patients with keratolysis had higher complication rates and should receive rigorous monitoring.

Vitritis after Boston Keratoprosthesis Type 1 Implantation.

PURPOSE: To describe the incidence, presentation, and clinical course of vitritis occurring after Boston keratoprosthesis type 1 implantation. DESIGN: Retrospective chart review. PARTICIPANTS: Medical records of all patients undergoing type 1 Boston keratoprosthesis implantation over a 4-year period were reviewed. METHODS: Cases of vitreous inflammation were classified as either postoperative (within 1 month after surgery without endophthalmitis), reactive (secondary to ocular surface inflammation), idiopathic, or infectious endophthalmitis. The presenting features and postoperative course of all patients were reviewed. MAIN OUTCOME MEASURES: Postoperative inflammation. RESULTS: A total of 110 eyes underwent type 1 Boston keratoprosthesis implantation with a median follow-up of 5.6 years. Overall, there were 21 episodes of vitritis occurring in 17 patients; 6 cases of vitritis were postoperative, whereas 5 were reactive, 7 were idiopathic, and 3 were infectious endophthalmitis. Patients with vitritis sought treatment a median of 10 months after surgery (range, 1 week-7 years). Compared with patients in whom vitritis did not develop, those with vitritis were younger (50.8 years of age vs. 62.2 years of age; P = 0.01), but with a similar prevalence of autoimmune disease (P = 1.00). Eyes with postoperative vitritis had a benign and short course, and were all managed with topical medications. Reactive vitritis occurred in association with infectious keratitis (4 cases) or corneal melting (1 case). Patients with idiopathic vitritis and endophthalmitis demonstrated similar symptoms of pain and severe vision loss. The mean duration of inflammation in patients of idiopathic vitritis was 3.3 months; all patients later demonstrated retroprosthetic membrane, and 2 patients (29%) demonstrated retinal detachment. Three of 7 patients with idiopathic vitritis underwent a vitreous tap, which showed negative results in all cases. The 3 cases of infectious endophthalmitis had a prolonged and severe course, with only 1 eye retaining functional vision. CONCLUSIONS: Patients undergoing type 1 Boston keratoprosthesis implantation are at risk of postoperative vitreous inflammation, which may present in the immediate postoperative period or years later. Cases of idiopathic inflammation may present similarly to infectious endophthalmitis, and a low threshold should be taken for performing vitreous tap and injection of antimicrobials. Caution should be exercised using sub-Tenon corticosteroids, given the high prevalence of glaucoma and possibility of exacerbating fungal infections.