Safety, efficacy, and timing of Nd:YAG laser goniopuncture after nonpenetrating deep sclerectomy for glaucoma: A retrospective cohort study.

BACKGROUND: Neodymium-doped yttrium aluminum garnet laser goniopuncture is an adjuvant procedure for nonpenetrating deep sclerectomy. We investigated optimal laser goniopuncture timing and the effect of laser iridoplasty on success rates. METHODS: This single-center retrospective cohort study compared intraocular pressure control in patients with early versus late laser goniopuncture after nonpenetrating deep sclerectomy and evaluated the effects of laser iridoplasty pretreatment. A 3-month cut-off was used to define early versus late laser goniopuncture. The primary outcome was the proportion of patients maintaining intraocular pressure control according to definitions of complete (no medications) and qualified (with medications) success at 15, 18, and 21 mmHg thresholds. Data were analyzed using right-censored Kaplan-Meier estimation and log-rank testing. RESULTS: A total of 124 eyes of 124 patients were analyzed. Complete success rates after 3 years were 9.2%, 14.6%, and 23.3% for early laser goniopuncture and 21.8%, 26.0%, and 55.4% for late laser goniopuncture for 15, 18, and 21 mmHg, respectively (all p < .01). Qualified success rates after 3 years were 16.6%, 24.8%, and 40.9% for early laser goniopuncture and 21.5%, 56.1%, and 69.6% for late laser goniopuncture for 15, 18, and 21 mmHg, respectively (p = .096, .0026, .0061). Late laser goniopuncture was associated with decreased risk of iris incarceration and bleb collapse. Iridoplasty pretreatment was not associated with improved outcomes. CONCLUSION: Late laser goniopuncture (3-month cut-off) was associated with better intraocular pressure control and less adverse events than early laser goniopuncture.

[Nd:YAG laser goniopuncture as a mandatory adjuvant procedure after non-penetrating deep sclerectomy (long-term observation results)]. / Nd:YAG-lazernaia goniopunktura kak obiazatel'naia ad''iuvantnaia protsedura posle nepronikaiushchei glubokoi skleréktomii (rezul'taty dolgosrochnogo nabliudeniia).

Today, Nd:YAG laser goniopuncture (LGP) is considered a mandatory non-penetrating deep sclerectomy adjuvant procedure. However, its indications and timing remain debatable. PURPOSE: To evaluate the effect of Nd:YAG laser goniopuncture on the long-term hypotensive effectiveness of non-penetrating deep sclerectomy. MATERIAL AND METHODS: The study included 114 patients after non-penetrating deep sclerectomy (NPDS). In the control group (n=58), Nd:YAG laser goniopuncture was performed within 3.4±1.9 (1.5-6.7) months, and in the main group (n=56) - within 1.12±0.08 (0.9-1.5) months after the surgery. Ultrasound biomicroscopy (UBM) was used to evaluate the semiotics of trabecular-Descemet's membrane (TDM), intrascleral canal (ISC) and filtering bleb. The follow-up period was 5 years. RESULTS: According to UBM data, the thickness (0.10±0.009 mm) and density (50±6%) of TDM (p=0.0001) increased before LGP in the control group, the height of ISC decreased to 0.49±0.19 (0.20-0.40) (p=0.03), the height of UBM scan - to 1.49±0.05 (1.41-2.9) (p=0.0001); IOP (P0) was 18.48±4.7 (11.2-22.9) mmHg (p=0.001). In the main group before LGP, TDM thickness was 0.08±0.006 mm, density was 40±5%, and IOP (P0) was 15.7±4.1 (9.1-18.5) mm Hg. Complete hypotensive success was achieved in 83.6% of cases in the control group and 96.2% in the main group in 6 months; 68.07% and 92.59% in 12 months; 41.3% and 75.8% in 24 months; 15.25% and 48.93% in 36; 15% and 34.8% in 60 months after the surgery, respectively (p=0.0001, 95% confidence interval). CONCLUSION: TDM is an additional level of retention of aqueous humor and plays key role in the formation of outflow pathways after NPDS. Performing LGP in the early postoperative period is an effective and safe adjuvant option, which excludes the influence of TDM on the formation of aqueous humor outflow pathways and significantly increases the long-term hypotensive efficacy of non-penetrating deep sclerectomy.

Decompression retinopathy following nonpenetrating deep sclerectomy for primary congenital glaucoma.

BACKGROUND: To describe a unique case of decompression retinopathy manifesting as pre-macular subhyaloid hemorrhage that occurs in a nine-day old child after undergoing a non-penetrating deep sclerectomy for primary congenital glaucoma. CASE PRESENTATION: We report a single case of a 9-day-old boy who was referred to our department of ophthalmology for bilateral buphtalmia and corneal edema. He presented marked elevation of the intraocular pressure in both eyes (22 mmHg and 26 mmHg, in the right eye and left eye respectively) associated with significant optic nerve cupping. Non-penetrating deep sclerectomy was performed for each eye, with effective reduction of the intraocular pressure during the first week postoperatively (11 mmHg and 7 mmHg in the right eye and left eye respectively). The right eye presented an isolated subhyaloid hemorrhage located in the pre-macular area, persisting 3 weeks after the initial surgery and requiring pars-plana vitrectomy to clear the visual axis. This uncommon complication was identified as decompression retinopathy. The intraocular pressure remained controlled in the normal range three years after initial surgery in both eyes, with reversal of optic disc cupping. CONCLUSIONS: Decompression retinopathy is a potential complication after non-penetrating deep sclerectomy in primary congenital glaucoma, requiring prompt treatment strategy to prevent potential organic amblyopia.

Nd:Yag laser goniopuncture for deep sclerectomy: efficacy and outcomes.

PURPOSE: To report on the safety and efficacy of Nd: YAG laser goniopuncture (LGP) for postsurgical intraocular pressure increase after deep sclerectomy (DS) in a consecutive cohort of open-angle glaucoma patients. METHODS: This case series included 56 eyes from 49 consecutive patients who underwent LGP between November 2008 and March 2015. Prior to LGP, patients had undergone DS augmented with mitomycin C and injectable cross-linked hyaluronic acid implant between October 2008 and May 2014. Demographic variables, type of glaucoma, prior phacoemulsification, intraocular pressure (IOP), best-corrected visual acuity, execution of post-LGP maneuvres, and post-LGP complications were analyzed. The success rate of the procedure was analyzed using the Kaplan-Meier survival curve. Univariate and multivariate analyses were performed using the Cox proportional hazard regression model in order to highlight variables associated with a failure to achieve surgical success. RESULTS: Mean IOP was 23.0 mmHg prior to LGP, and 12.5, 11.8, and 10.5 mmHg at 6, 12, and 24 months after LGP respectively. Post-laser IOP was significantly lower than pre-laser IOP at every time point. For an IOP ≤ 15 mmHg, success rates were 85 % at 6 months, 76 % at 1 year, and 62 % at 2 years. Thirty-eight eyes underwent prophylactic iridotomy and iridoplasty prior to LGP. Iris prolapse into the trabeculo-descemetic window following LGP occurred in 6/18 eyes (33.3 %) of the non-pretreated and in 1/38 eyes (2.6 %) of the pretreated group. One case of choroidal detachment and one delayed suprachoroidal hemorrhage occurred after LGP execution in two non-pretreated eyes. CONCLUSIONS: LGP is a relatively safe and effective complementary adjunct to deep sclerectomy that makes it possible to further lower IOP and avoid additional filtering surgery. Prophylactic iridotomy and localized iridoplasty may permit the frequency of post-LGP complications to be reduced.

Results of CO2 Laser-assisted Deep Sclerectomy as Compared With Conventional Deep Sclerectomy.

PURPOSE: To evaluate the efficacy of CO2 laser-assisted sclerectomy surgery (CLASS) compared with classic nonpenetrating deep sclerectomy (NPDS) with implant in medically uncontrolled glaucoma patients. MATERIALS AND METHODS: Patients who underwent primary filtration surgery with CO2 laser system at the time interval between July 2010 and April 2011 were identified, their medical files were reviewed, and their results were compared with matched control group who underwent classic NPDS with intrascleral implant at the same time period. Intraocular pressure (IOP) was measured at baseline, 1 week, and 3, 6, 12, 18, and 24 months, respectively. Main outcome measures were: IOP, use of supplemental medical therapy, and failure (5 mm Hg>IOP>18 mm Hg, reoperation for glaucoma, or loss of light perception). RESULTS: A total of 58 patients were reviewed, including 27 in the CLASS group and 31 in the NPDS group. For the CLASS group the follow-up (mean±SD) was 20.7±6.8 months, the mean preoperative IOP was 23.3±8.2 mm Hg (range, 10 to 38 mm Hg), and the mean number of antiglaucoma medication before surgery was 3.0±1.0 (range, 1 to 4). At final follow-up visits, the mean IOP was 11.7±3.1 mm Hg (range, 6 to 19 mm Hg), and the mean number of antiglaucoma medication was reduced to 1.0±1.6 (P<0.0003). The complete success rate (IOP≤18 mm Hg without antiglaucoma medication) was 73% and the qualified success rate (IOP≤18 mm Hg with/without antiglaucoma medication) was 96%. For the control group the mean follow-up was 17.6±6.7 months, the mean preoperative IOP was 23.1±7.3 mm Hg (range, 14 to 44 mm Hg), and the mean number of antiglaucoma medication before surgery was 3.0±0.8 (range, 1 to 4). At final follow-up visits, the IOP was 13.3±3.6 mm Hg (range, 8 to 20 mm Hg), and the mean number of antiglaucoma medication was reduced to 0.7±1.1 (P<0.0004). The complete success rate and the qualified success rate were 71% and 89%, respectively. CONCLUSIONS: A new technique using a CO2-laser ablation system allows precise and easy creation of the scleral space and ablation of Schlemm canal. This technique has been shown to be as efficient as the standard NPDS surgery in terms of IOP-lowering effect. This would render the deep sclerectomy an easier glaucoma surgery.

Influence of silicone oil tamponade on self-sealing sclerotomy using 25-gauge transconjunctival sutureless vitrectomy: a retrospective comparative study.

BACKGROUND: Characteristic complications have been reported for transconjunctival sutureless vitrectomy, such as postoperative sclerotomy leakage and postoperative hypotony. Particular attention to sclerotomy closure is required in cases of silicone oil tamponade, because postoperative supplementation of silicone oil implies reoperation, whereas postoperative supplement of gas is comparatively easy. This study investigated sclerotomy closure in cases of silicone oil tamponade using 25-gauge transconjunctival sutureless vitrectomy. METHODS: We enrolled 19 consecutive eyes with silicone oil injection (Group A, self-sealing sclerotomies, n = 10) (Group B, sutured sclerotomies, n = 9) and 10 eyes with silicone oil removal (Group C, self-sealing sclerotomies) using 25-gauge TSV. Postoperative intraocular pressure was compared between Groups A and B, and between Groups A and C using repeated-measures analysis of variance (ANOVA), one-way factorial ANOVA, and the Tukey-Kramer test. RESULTS: No significant differences in age or axial length were seen among groups, but surgical time differed significantly between Group C and the other groups. Mean duration of silicone oil tamponade was 3.2 ± 1.4 months in Group C, and no sclerotomies in Group A or C required suture placement. Postoperative silicone oil leakage to the subconjunctival space was not encountered in Group A. No cases showed postoperative hypotony (defined as intraocular pressure <5 mmHg). Significant differences in intraocular pressure within the same postoperative period were not identified between Groups A and B. Conversely, significant differences in intraocular pressure within the same postoperative period were identified at postoperative days 1 and 2, although not at postoperative week 1 or postoperative month 1 between Groups A and C. CONCLUSIONS: The procedure for sclerotomy closure seems to have little influence on postoperative intraocular pressure in eyes with silicone oil tamponade using 25-gauge transconjunctival sutureless vitrectomy, because silicone oil tamponade may avoid postoperative hypotony by decreasing sclerotomy leakage in the early postoperative period.

Changes in lamina cribrosa and prelaminar tissue after deep sclerectomy.

AIM: To determine the response of the lamina cribrosa (LC) and prelaminar tissue to a reduction of intraocular pressure (IOP) after nonpenetrating deep sclerectomy (NPDS) using enhanced depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT). METHODS: A total of 28 eyes from 28 patients presenting with primary open angle glaucoma who underwent NPDS were studied. SD-OCT scans using EDI technology were obtained before surgery and 1 week, 1 month, and 3 months postoperatively. The OCT device was set to image a 15 × 10° vertical rectangle centred on the optic disc. The scan closest to the optic nerve head (ONH) centre was selected for analysis. The vertical distances from three equidistant points on the reference line (Bruch's membrane opening) to the anterior prelaminar tissue surface and the anterior and posterior surfaces of the LC were measured. RESULTS: The IOP decreased from 18.7 ± 4.3 to 9.1 ± 4.0 at the first week, 11.4 ± 3.7 at 1 month, and 13.1 ± 3.6 mm Hg at 3 months postoperatively (P<0.001). There was a significant reduction of the ONH cupping at 1 week (22.3%, P<0.001), 1 month (13.7%, P<0.001), and 3 months (9.8%, P=0.001) after surgery. Anterior displacement of the LC was slight but statistically significant at 1 week (4.5%, P=0.003), 1 month (3.8%, P=0.014), and 3 months postoperatively (3.3%, P=0.010). IOP reduction was significantly correlated with a reduction of ONH cupping and anterior displacement of LC at the first week and first month (P<0.05). CONCLUSIONS: Cupping reversal after NPDS is mainly due to changes in prelaminar tissue thickness, whereas the LC changes in position are less pronounced.

Combined posterior chamber intraocular lens, vitrectomy, Retisert, and pars plana tube in noninfectious uveitis.

OBJECTIVE: To assess the safety and efficacy of combined cataract extraction, posterior chamber intraocular lens placement, pars plana vitrectomy, fluocinolone acetonide intravitreal implant (Retisert), and Ahmed valves with pars plana tube (CPR-PT) in eyes with chronic, posterior, noninfectious uveitis. METHODS: Retrospective study of patients who underwent CPR-PT. Outcome measures included visual acuity, intraocular pressure, inflammation, and complications. RESULTS: Eight eyes were included, with a mean follow-up of 18 months. Mean visual acuity improved from 1.89 to 0.14 logMAR (Snellen, counting fingers at 2 ft [0.6 m]) to 20/30; P=.01). Mean intraocular pressure remained stable at 16 to 17 mm Hg (P=.35). The number of glaucoma medications per eye decreased from 2.9 to 0.25 (P=.01). Systemic prednisone therapy was discontinued in all patients by 9 months postoperatively. Inflammation was well controlled in all eyes. CONCLUSION: The CPR-PT procedure allows rapid visual rehabilitation without major short-term complications.

Interim results from the international trial of Second Sight's visual prosthesis.

PURPOSE: This study evaluated the Argus II Retinal Prosthesis System (Second Sight Medical Products, Inc., Sylmar, CA) in blind subjects with severe outer retinal degeneration. DESIGN: Single-arm, prospective, multicenter clinical trial. PARTICIPANTS: Thirty subjects were enrolled in the United States and Europe between June 6, 2007, and August 11, 2009. All subjects were followed up for a minimum of 6 months and up to 2.7 years. METHODS: The electronic stimulator and antenna of the implant were sutured onto the sclera using an encircling silicone band. Next, a pars plana vitrectomy was performed, and the electrode array and cable were introduced into the eye via a pars plana sclerotomy. The microelectrode array then was tacked to the epiretinal surface. MAIN OUTCOME MEASURES: The primary safety end points for the trial were the number, severity, and relation of adverse events. Principal performance end points were assessments of visual function as well as performance on orientation and mobility tasks. RESULTS: Subjects performed statistically better with the system on versus off in the following tasks: object localization (96% of subjects), motion discrimination (57%), and discrimination of oriented gratings (23%). The best recorded visual acuity to date is 20/1260. Subjects' mean performance on orientation and mobility tasks was significantly better when the system was on versus off. Seventy percent of the patients did not have any serious adverse events (SAEs). The most common SAE reported was either conjunctival erosion or dehiscence over the extraocular implant and was treated successfully in all subjects except in one, who required explantation of the device without further complications. CONCLUSIONS: The long-term safety results of Second Sight's retinal prosthesis system are acceptable, and most subjects with profound visual loss perform better on visual tasks with system than without it.

A novel technique of tangential, circumferential, scleral tunnel in 20-gauge transconjunctival sutureless vitrectomy: optical coherence tomography-aided analysis of wound integrity and clinical outcome.

AIM: To describe a novel technique of sclerotomy construction to facilitate 20-gauge transconjunctical sutureless vitrectomy (TSV) along with the evaluation of the wound integrity. METHODS: The surgical technique is described. One hundred consecutive patients who underwent TSV were evaluated for wound leaks, postoperative hypotony, endophthalmitis and any other complication related to surgery. The sclerotomies of eight patients (24 ports) were analysed by imaging with anterior segment optical coherence tomography immediately after surgery, and on the first postoperative day and after the first postoperative month. RESULTS: 104 eyes of 100 patients were evaluated with a mean follow-up of 9.6 months. All cases underwent surgery with standard 20-gauge instrumentation and vitrectomy techniques. Five sclerotomies were found to leak at the end of surgery, requiring a suture. Anterior segment optical coherence tomography images were obtained from eight eyes with good apposition of the tunnel noted in all the cases. Mean intraocular pressure was 18.7 mm Hg on the first postoperative day. One patient had hypotony without leak and this patient had pre-existing hypotony due to chronic panuveitis. There was no instance of postoperative endophthalmitis. CONCLUSIONS: This technique of 20-gauge TSV achieves good wound apposition with a low incidence of complications while using standard 20-gauge instrumentation and vitrectomy techniques.

Early results of suprachoroidal drainage tube implantation for the surgical treatment of glaucoma.

PURPOSE: To evaluate the efficacy and safety of suprachoroidal silicone tube shunt implantation in glaucoma. PATIENTS AND METHODS: Twenty-four glaucomatous eyes unresponsive to medical treatment were included, 7 of them had earlier trabeculectomy. After preparation of a limbus-based scleral flap, 1.5 mm deep sclerotomy was made adjacent to scleral flap opening. Posterior end of the silicone tube was placed posteriorly in suprachoroidal space, anterior end was placed into anterior chamber. Intraocular pressure (IOP) and best corrected visual acuities (BCVA) were measured preoperatively and postoperatively on the first day, at the first week, in the first, third, sixth, twelfth, and eighteenth months. Postoperative IOP >21 mm Hg, <5 mm Hg (after 3 months), or additional glaucoma surgery were accepted as failure. Eyes not failed and not on supplemental medical therapy are considered as complete success. Eyes that have not failed, with or without supplemental medical therapy, are considered as qualified success. Hypotony was defined as early, when IOP below 5 mm Hg was observed within 4 weeks. RESULTS: Mean postoperative follow-up period was 34.4±23.7 weeks (range 4 to 78 wk). Complete success rates were 95.8%±4.1 at the first week, 79.2%±8.3 in the first and the third month, 63.3%±12.0 for the sixth and twelfth month. Qualified success rates were 95.8%±4.1 in the first week, 87.5%±6.8 in the first, third, sixth, twelfth months. Mean postoperative IOP's (8.5±4.9mm Hg, 12.9±5.6 mm Hg, 17.0±7.9 mm Hg, 15.3±3.6 mm Hg, 18.3±6.0, 15.1±6.0 mm Hg, respectively for the first week, first, third, sixth and twelfth mo) were significantly lower than preoperative mean IOP's. The success rates in cases without earlier trabeculectomy were significantly higher than in cases with earlier trabeculectomy (P=0.035). Postoperative first day mean±SD BCVA value was significantly lower than preoperative value (P=0.004). Failure was seen in 7 eyes of which 3 of them underwent reoperation for glaucoma. Early hypotony was seen in 6 eyes. No infection, choroidal, or retinal detachment was seen. There was a fibrin reaction in the anterior chamber in 3 patients. Two patients had intracameral bleeding, 1 of them underwent anterior chamber lavage. CONCLUSIONS: Suprachoroidal tube drainage of aqueous humor from the anterior chamber to the suprachoroidal space is effective in reducing IOP in glaucoma patients, with lower serious complication rates, and may be preferred as initial surgery in cases without earlier trabeculectomy.

[Methods used and abandoned in glaucoma]. / Metode încercate si abandonate în glaucom.

The discovery of the disease called glaucoma dates back to the 17th century. Its important role as a cause of blindness has been known since the 19th century. Initial comprehension of this pathogenesis and treatment belong to the 20th century. Its prevention will hopefully be the work of the 21st century.

The influence of thalamosinusotomy under different constant intraocular pressures on aqueous outflow facility in isolated porcine eyes

OBJETIVO: Avaliar o efeito da thalamosinusotomia ab interno, que é um procedimento cirúrgico experimental similar a esclerotalamotomia ab interno, na drenagem do humor aquoso. MÉTODOS: Olhos de porco enucleados foram perfundidos com solução fisiológica de Krebs-Ringer e azul de tripan, sob diferentes pressões constantes de perfusão, após o procedimento cirúrgico experimental. A facilidade de drenagem e os tecidos corados/não corados foram medidos. RESULTADOS: A facilidade de drenagem e a área sob a curva (fluxo) aumentaram com o aumento do número de incisões da thalamosinusotomia (0 a 4). Olhos submetidos a thalamosinusotomia apresentaram mais tecido corado (conjuntiva, superfície externa e interna da esclera) que olhos submetidos a cirurgia sham, com diferença estatisticamente significativa (p< 0,05). CONCLUSÕES: Os resultados sugerem que a facilidade de drenagem aumenta com o aumento do número de thalamus, diferente vias de drenagem são estimuladas após a thalamosinusotomia, e a drenagem uveoscleral pode ser uma via importante após o procedimento cirúrgico experimental.

PURPOSE: To explorethe effect of the thalamosinusotomy ab interno, which is an experimental surgical procedure similar to sclerothalamotomy ab interno, on aqueous humor drainage. METHODS: Enucleated porcine eyes were perfused with Krebs-Ringer's physiologic solution and trypan blue, in vitro, under different constant pressures after the experimental procedure. The outflow facility and the stained/unstained tissue were measured. RESULTS: The outflow facility and the area under the curve (outflow) increased with the increasing number of thalamosinusotomy incisions (0 to 4). Thalamosinusotomy eyes showed more stained tissue (conjunctiva, outer sclera, inner sclera) than sham surgery eyes with significant statistical difference (P<0.05). CONCLUSIONS: The results suggested that outflow facility increases with the increasing number of thalamus, different pathways are stimulated after thalamosinusotomy, and the uveoscleral outflow could be an important route after the experimental surgical procedure.

[Estimation of the efficacy of deep sclerectomy in glaucoma surgery. One-year follow-up]. / Estimación de la eficacia de la esclerectomía profunda no perforante en el tratamiento quirúrgico del glaucoma al año de la cirugía.

PURPOSE: To evaluate the efficacy of deep sclerectomy in the surgical treatment of glaucoma one year after surgery. METHODS: 53 eyes of 43 patients (26 male, 27 female) with medically uncontrolled glaucoma of various types, were treated with deep sclerectomy surgery. RESULTS: The mean postoperative intraocular pressure (IOP) was 18.19 S.D. 5.22 mmHg., and the mean preoperative IOP was 26.66 S.D. 5.93 mmHg. We observed a statistically significant reduction in the IOP (p<0.05). Our success criteria were IOP lower than 21 mmHg with or without associated hypotensive medications, no advance in glaucomatous visual field defects and no advance in optic nerve cupping. This was achieved in 88.68% of the cases at 12 months follow-up. CONCLUSIONS: Deep sclerectomy is an efficient technique to control IOP, with few early post-operative complications.

Cataract surgery and transpupillary silicone oil removal through a single scleral tunnel incision under topical anesthesia; sutureless surgery.

The author evaluated the results of combined cataract extraction and transpupillary silicone oil removal through a single scleral tunnel incision, in eyes that had undergone pars plana vitrectomy with silicone oil tamponade. Twenty-four of the 46 eyes were operated on under topical anesthesia with Blumenthal mode mini-nucleus manual extracapsular cataract extraction technique (mini-nuc ECCE), and silicone oil was removed passively through planned posterior capsulorhexis via the scleral tunnel, followed by endocapsular intraocular lens (IOL) implantation. The operation was completed without any suturing. The remaining 22 eyes were similarly operated on with the same cataract extraction technique, but in these cases silicone oil was classically aspirated actively through pars plana sclerotomies. Results were evaluated by visual acuity measurement, duration of operation, and complications. The transpupillary silicone oil removal group had significantly less vitreous hemorrhage (0- 31.8%) and posterior capsule opacification (0-36.4%). Also, the mean duration of the operation was significantly shorter in this group. There was no significant difference between the two groups with regard to postoperative recurrence of retinal detachment (12.5-18.1%) and visual acuity outcome. The combination of mini-nuc ECCE with transpupillary silicone oil removal compares favorably with the combination of silicone oil aspiration through pars plana sclerotomies. This combined technique allows the surgeon to perform the operation under topical anesthesia and no sutures are required. The intervention period is shorter and no posterior capsule opacification or vitreous hemorrhage develops.

Non-penetrating deep sclerectomy and collagen implant surgery in glaucoma patients with advanced field loss.

PURPOSE: The aim of the study was to determine the medium term intraocular pressure (IOP) lowering effects and the potential complications of non-penetrating deep sclerectomy and collagen implant (DSCI) surgery in glaucoma patients. PATIENTS AND METHODS: 54 eyes of 52 patients with medically uncontrolled open angle glaucoma with advanced field loss underwent DSCI under topical anaesthesia. Follow-up period was 24 months. RESULTS: The mean preoperative IOP was 24.7 +/- 6.2 mmHg and decreased to 15.1 +/- 4.0 mmHg at 24 months (p = 0.0068). During the follow- up period, 36 of 54 eyes (66%) received no topical antiglaucomatous medications. In 18 eyes, monotherapy with topical beta blockers (Betaxolol HCl) was added to the regimen. At last visit, only two patients (3.8%) had IOP greater than 18 mmHg. We did not detect any additional optic disc changes, visual field or visual acuity defects postoperatively. Detailed slit-lamp examination revealed no anterior segment complications regarding the probable complications of trabeculectomy. None of the patients developed surgery related cataract. As a complication, we diagnosed one case of self-limited, shallow choroidal detachment. CONCLUSION: DSCI appears to provide considerable medium term IOP decrease with few postoperative complications without deteriorating visual acuity. Owing to our medium term results, we believe that DSCI could be a valuable alternative to trabeculectomy especially in cases of advanced medically uncontrolled open angle glaucoma.

[Superficial sponge anesthesia in cataract surgery (with scleral tunnel incision)]. / Sponge-Oberflächenanästhesie in der Kataraktchirurgie (bei skleralem Tunnelschnitt).

BACKGROUND: The successful development of cataract operation and IOL implantation in the last decade has resulted in progressive shortening of the incision length as well as in developing safer and simpler anesthetic techniques. The purpose of the present study was to evaluate whether cataract surgery with scleral incision is possible using only topical sponge anesthesia with oxybuprocaine 0.4%. This method was compared with retrobulbar injection. METHODS: 150 patients (3 groups each consisting 50 eyes) underwent phaco with scleral incision. 1st group: oxybuprocaine sponge anesthesia. 2nd group: oxybuprocaine sponge anesthesia combined with mild systemic analgesia (tramadol p.o.). 3rd group: retrobulbar injection (prilocaine/etidocaine mixture). All patients received medazolam premedication (Dormicum, 3/10 of 1 cc). Pain and discomfort during and after operation were investigated and statistically analyzed. RESULTS: Neither in group 1, 2 or 3 an additional subconjunctival injection was necessary. Pain or discomfort during operation was felt in 14 percent of the patients anesthetized with the oxybuprocaine sponge but only in 6 percent of the patients additionally premedicated with tramadol (2nd group). Also 6 percent of the patients after retrobulbar injection felt pain during operation. Postoperatively no significant differences between group 1 and 2 were obtained: 6 percent felt pain, 30 percent had a short term foreign body sensation. After retrobulbar injection (group 3) only 10 percent felt postoperative pain or discomfort. CONCLUSIONS: Topically applied oxybuprocaine provides sufficient anesthesia during cataract surgery with scleral incision. A combination with mild systemic analgesia (tramadol) helps to minimize pain and discomfort. Retrobulbur injection yielded only in the postoperative period significantly better analgesia. In the operating room full cooperation of the patient is required. Therefore we recommend not to use sponge anesthesia in cases when communication between surgeon and patient is insufficient.

[Ab externo sclerostomy with the Er:YAG laser: report of outcome after 2 years]. / Ab-externo-Sklerostomie mit dem Er:YAG-Laser: Ergebnisbericht nach zwei Jahren.

OBJECT: Results over a period of 24 months of performing the Er:YAG laser ab externo sclerostomy. MATERIAL AND METHODS: The procedure was performed 81 times (chronic glaucoma with open angle (n = 55) and narrow angle (n = 15), 6 secondary glaucoma, 4 pigment glaucoma, 1 normal pressure glaucoma) in 74 eyes of 64 patients at the age of 70 +/- 10 years without any peribulbar anesthesia. The pulse energy was 11 mJ with a repetition rate of 7 Hz. Antimetabolites were not applicated. Success was defined as an IOP of less than 22 mm Hg or a decrease of at least 30%, with or without anti-glaucoma medication. RESULTS: The mean IOP of all cases decreased from preoperatively 28 +/- 8.1 mm Hg (Success group: 26.7 +/- 7.3 mm Hg) to 15 +/- 8.4 mm Hg (Success group: 14.6 +/- 7.8 mm Hg) on the first postoperative day. The success rate was about 50% within the period of two weeks to six months and decreased to about 15% in the 24th month. Complications were iris incarceration/synechia (n = 33), hypotony (n = 36) with consequent choroidal detachment (n = 8), hyphema (n = 19) and more pronounced inflammation symptoms (n = 10). In most cases, the early postoperative outflow failure is caused by iris incarceration into the internal ostium. The scarring tendency of the episcleral tissue leads to closure of the external ostium after months. Resurgery was necessary in 26 cases. CONCLUSIONS: Further efforts should be directed to maintain the intact corneoscleral morphology of the canal, created by an optimized method of the surgical technique. The application of antimetabolites in correct dosage or the implantation of modified silicon draining systems would be helpful.

Vitrectomy for pars plana placement of a glaucoma seton.

Trabeculectomy, even with supplemental antifibrosis agents, has a low success rate in controlling intraocular pressure (IOP) in certain cases; ones involving severe anterior-chamber-angle disease are particularly challenging. Ten patients with advanced, non-neovascular glaucoma underwent vitrectomy and pars plana placement of seton implants. The tube was placed through the pars plana sclerotomy in each case because severe anterior chamber angle narrowing, aphakia, or penetrating keratoplasty prevented standard placement. Previous trabeculectomy had failed to control IOP in 9 of the 10 patients. In each, the preoperative IOP was 25 mm Hg or more despite maximal medical therapy. In nine of the patients, the postoperative IOP was 19 mm Hg or less, without pressure-lowering agents. The seton appeared to be functional in all of the cases. Vision remained stable or improved in seven cases, but deteriorated in three due to graft failure, progressive traction retinal detachment, or rhegmatogenous retinal detachment (one case each). Pars plana placement of tubes for glaucoma seton implants should be considered as an alternative to anterior chamber placement in certain cases of refractory glaucoma in which the anterior chamber anatomy has been severely disrupted.

Intraoperative 5-fluorouracil for filtration surgery in the rabbit.

PURPOSE: Postoperative subconjunctival injections of 5-fluorouracil (5-FU) improve the success rate of filtration surgery, but there is still a 20% or greater failure rate at 1 year in pseudophakic and repeat trabeculectomy cases. The injections are inconvenient to give and may produce corneal epithelial toxicity and other side effects. An alternative method for administration of 5-FU is investigated. METHODS: A masked, randomized, prospective study was undertaken to compare bleb survival and complications in a rabbit model, after either a single intraoperative exposure to 5-FU (50 mg/ml concentration for 5 minutes) or five postoperative injections of 5-FU (5 mg injection on postoperative days 1, 3, 5, 7, and 9), or a combination of both, with controls that received only a 5-minute exposure to distilled water, intraoperatively. RESULTS: For the control eyes, all blebs were "flat" to masked grading, and intraocular pressure returned to preoperative levels by postoperative day 11. In the group receiving postoperative injections of 5-FU only, blebs were flat and the pressure normalized by postoperative day 14. Rabbits receiving intraoperative 5-FU only, or combined intraoperative and postoperative 5-FU, had consistently higher blebs than the former two groups, and some blebs survived until postoperative day 25. The mean intraocular pressure remained depressed in these groups until postoperative day 21 (P < 0.05 for days 5 through 18). A combination of intraoperative and postoperative 5-FU produced significantly higher blebs than intraoperative 5-FU alone on days 7 to 14. CONCLUSIONS: Intraoperative application of high-dose 5-FU to the filtration site either as a single 5-minute treatment, or in conjunction with postoperative injections of 5-FU greatly prolongs bleb function after filtration surgery in the rabbit.