Conjunctival fibrosis following filtering glaucoma surgery.

Despite advances in surgical technique and postoperative care, fibrosis remains the major impediment to a marked reduction of intraocular pressure without the need of additional medication (complete success) following filtering glaucoma surgery. Several aspects specific to filtering surgery may contribute to enhanced fibrosis. Changes in conjunctival tissue structure and composition due to preceding treatments as well as alterations in interstitial fluid flow and content due to aqueous humor efflux may act as important drivers of fibrosis. In light of these pathophysiological considerations, current and possible future strategies to control fibrosis following filtering glaucoma surgery are discussed.

Ligament-induced sacral fractures of the pelvis are possible.

Pelvic ring stability is maintained passively by both the osseous and the ligamentous apparatus. Therapeutic approaches focus mainly on fracture patterns, so ligaments are often neglected. When they rupture along with the bone after pelvic ring fractures, disrupting stability, ligaments need to be considered during reconstruction and rehabilitation. Our aim was to determine the influence of ligaments on open-book injury using two experimental models with body donors. Mechanisms of bone avulsion related to open-book injury were investigated. Open-book injuries were induced in human pelves and subsequently investigated by anatomical dissection and endoscopy. The findings were compared to CT and MRI scans of open-book injuries. Relevant structures were further analyzed using plastinated cross-sections of the posterior pelvic ring. A fragment of the distal sacrum was observed, related to open-book injury. Two ligaments were found to be responsible for this avulsion phenomenon: the caudal portion of the anterior sacroiliac ligament and another ligament running along the ventral surface of the third sacral vertebra. The sacral fragment remained attached to the coxal bone by this second ligament after open-book injury. These results were validated using plastination and the structures were identified. Pelvic ligaments are probably involved in sacral avulsion caused by lateral traction. Therefore, ligaments should to be taken into account in diagnosis of open-book injury and subsequent therapy.

Additional Guidance on the Use of the PRESERFLO™ MicroShunt in the Treatment of Glaucoma: Insights from a Second Delphi Consensus Panel.

INTRODUCTION: The PRESERFLO™ MicroShunt (PMS) has been proven to significantly lower intraocular pressure (IOP) in patients with glaucoma and has been available for use since 2019. With increasing published evidence and growing experience of glaucoma surgeons, the aim of this modified Delphi panel was to build on the findings of a previous Delphi panel conducted in 2021 and provide further guidance on the role of the PMS to treat patients with glaucoma in Europe. METHODS: Thirteen European glaucoma surgeons experienced in the PMS procedure participated in a 3-round modified Delphi panel. A targeted literature review and expert steering committee guided Round 1 questionnaire development. Consensus was pre-defined at a threshold of ≥ 70% of panellists selecting 'strongly agree'/'agree' or 'strongly disagree'/'disagree' for 6-point Likert scale questions or ≥ 70% selecting the same option for multiple or single-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions. RESULTS: In total, 28% (n = 9/32), 52% (n = 16/31) and 91% (n = 10/11) of statements reached consensus in Rounds 1, 2 and 3, respectively. There was agreement that the PMS may be used in patients with pigmentary, post-trauma or post-vitrectomy glaucoma and for patients with uveitic glaucoma without active inflammation. The PMS may be more suitable for patients with contact lenses than other subconjunctival filtering surgeries, without eliminating bleb-associated risks. Consensus was reached that combining PMS implantation and phacoemulsification may be as safe as standalone PMS surgery, but further efficacy data are required. Following a late rise in IOP ≥ 4 months post-surgery, topical aqueous suppressant drops or bleb revision may be suitable management options. CONCLUSIONS: This Delphi panel builds on the considerations explored in the 2021 Delphi panel and provides further detailed guidance for glaucoma surgeons on the use of the PMS, reflecting the availability of novel evidence and surgical experience. Videos are available for this article.

Comparison of phacotrabeculectomy versus phacocanaloplasty in the treatment of patients with concomitant cataract and glaucoma.

BACKGROUND: Cataract and glaucoma are both common comorbidities among older patients. Combining glaucoma surgery with minimal invasive phacoemulsification (phaco) is a considerable option to treat both conditions at the same time, although the combination with filtration surgery can produce a strong inflammatory response. Combined non-penetrating procedures like canaloplasty have shown to reduce intraocular pressure (IOP) comparable to trabeculectomy without the risk of serious bleb-related complications. The purpose of this retrospective study was to compare the outcomes of phacotrabeculectomy and phacocanaloplasty. METHODS: Thirty-nine eyes with concomitant cataract and glaucoma who underwent phacotrabeculectomy (n=20; 51.3%) or phacocanaloplasty (n=19; 48.7%) were included into this trial on reduction of IOP, use of medication, success rate, incidence of complications and postsurgical interventions. Complete success was defined as IOP reduction by 30% or more and to 21 mmHg or less (definition 1a) or IOP to less than 18 mmHg (definition 2a) without glaucoma medication. RESULTS: Over a 12-month follow-up, baseline IOP significantly decreased from 30.0 ± 5.3 mmHg with a mean of 2.5 ± 1.2 glaucoma medications to 11.7 ± 3.5 mmHg with a mean of 0.2 ± 0.4 medications in eyes with phacotrabeculectomy (P< .0001). Eyes with phacocanaloplasty had a preoperative IOP of 28.3 ± 4.1 mmHg and were on 2.8 ± 1.1 IOP-lowering drugs. At 12 months, IOP significantly decreased to 12.6 ± 2.1 mmHg and less glaucoma medications were necessary (mean 1.0 ± 1.5 topical medications; P< .05). 15 patients (78.9%) with phacotrabeculectomy and 9 patients (60.0%) in the phacocanaloplasty group showed complete success according to definition 1 and 2 after 1 year (P= .276). Postsurgical complications were seen in 7 patients (36.8%) of the phacocanaloplasty group which included intraoperative macroperforation of the trabeculo-Descemet membrane (5.3%), hyphema (21.1%) and bleb formation (10.5%). Although more complications were observed in the phacotrabeculectomy group, no statistically significant difference was found. CONCLUSIONS: Phacocanaloplasty offers a new alternative to phacotrabeculectomy for treatment of concomitant glaucoma and cataract, although phacotrabeculectomy yielded in better results in terms of IOP maintained without glaucoma medications.

Diurnal and nocturnal intraocular pressure fluctuations after trabeculectomy.

PURPOSE: The aim of this study was to compare diurnal and nocturnal intraocular pressure (IOP) fluctuations before and after trabeculectomy, and to evaluate the potential of trabeculectomy to even out IOP peaks. MATERIALS AND METHODS: Retrospectively, 35 diurnal and nocturnal IOP curves of patients (35 eyes) who underwent trabeculectomy were analyzed. Diurnal and nocturnal IOP profiles were recorded from 06:00 to 23:59 and 00:00 to 06:00, respectively. Follow-up was at least 300 days. Two criteria for success were defined: (1) IOP ≤21 mm Hg and at least a 20% IOP reduction from baseline; (2) <18 mm Hg without medication. RESULTS: The preoperative maximum diurnal and nocturnal IOP (IOP(max)) were 26.5 ± 5.9 and 23.4 ± 5.2 mm Hg, respectively. The postoperative diurnal and nocturnal IOP(max) were 16 ± 4.4 and 16 ± 5.4 mm Hg, respectively. Pre- to postoperative IOP reductions were statistically different (day 40% and night 32%; p < 0.001). Diurnal fluctuation was reduced significantly from 12.1 ± 4.2 mm Hg preoperatively to 5.6 ± 2.2 mm Hg postoperatively (reduction of 54%), and nocturnal fluctuation from 7.1 ± 4.5 to 3.9 ± 4.1 mm Hg (reduction of 46%, statistically insignificant due to large SD), respectively. Success criteria 1 and 2 were achieved in 71 and 54% of patients at daytime and in 63 and 57% at nighttime (no statistically significant difference detectable). Follow-up was 2.1 ± 1.7 years. CONCLUSIONS: Trabeculectomy achieves a leveling of IOP(max) in the diurnal-nocturnal comparison. The preoperative fluctuations could be nearly bisected. Relating to the success criteria, the statistical analysis did not reveal a difference in the diurnal-nocturnal comparison.

Expert Consensus on the Use of the PRESERFLO™ MicroShunt Device in the Treatment of Glaucoma: A Modified Delphi Panel.

INTRODUCTION: The implantation of the PRESERFLO™ MicroShunt (PMS) device has been shown to significantly lower increased intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG). However, guidelines on best practice for patient selection and pre-/peri-/postoperative care management are lacking. The aim of this modified Delphi panel was to achieve expert consensus on the role of the PMS to treat patients with glaucoma in Europe. METHODS: Twelve European glaucoma surgeons experienced with the PMS procedure participated in a three-round modified Delphi panel. A targeted literature review and expert steering committee guided round 1 questionnaire development. Consensus was set at a pre-defined threshold of at least 70% of panellists selecting 'Strongly disagree'/'Disagree' or 'Strongly agree'/'Agree' for six-point Likert scale questions, or at least 70% selecting the same option for multiple-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions. RESULTS: Consensus was achieved for 60.3% (n = 38/63), 60.0% (n = 18/30), and 100.0% (n = 11/11) of Likert/multiple-choice questions in rounds 1, 2, and 3, respectively. There was agreement that the PMS procedure is effective at reducing IOP in patients with high-tension POAG (greater than 21 mmHg). Although surgical techniques may vary slightly, consensus was reached on several points, including the importance of posterior application of mitomycin C (MMC). Panellists agreed that the PMS postoperative follow-up appointment schedule is reasonably predictable and mostly characterised by fewer visits than with trabeculectomy, particularly in the early phase. Although panellists agreed that combined cataract/PMS surgery and the use of non-MMC wound-healing modulators/antifibrotics during the procedure are possible, further data are needed to determine efficacy. CONCLUSION: The expert consensus reached in this panel will help inform best practice guidelines in the treatment of patients with glaucoma in Europe. Panellists also highlighted key areas for future research to improve understanding of the PMS in the treatment algorithm of glaucoma.

The prognostic value of the wuerzburg bleb classification score for the outcome of trabeculectomy.

BACKGROUND: the Wuerzburg bleb classification score (WBCS) aims at an objective and standardized assessment of the developing filtering bleb after trabeculectomy, in order to detect and treat bleb scarring at the earliest possible stage of development. The purpose of this retrospective study was to evaluate the prognostic value of the early postoperative WBCS for the long-term outcome of trabeculectomy. METHODS: the WBCS is a grading system for clinical bleb morphology. It evaluates the following parameters: vascularization, corkscrew vessels, encapsulation and microcysts. The WBCS of 113 eyes of 113 consecutive patients after trabeculectomy was determined 1 day, 1 and 2 weeks, 3, 6 and 12 months after surgery. Complete success was defined as an intra-ocular pressure (IOP) <21 mm Hg and >20% pressure reduction without glaucoma medication after 1 year. RESULTS: a complete success rate of 73.9% and a qualified success rate of 82.4% were achieved 1 year after surgery. The average total bleb score during follow-up in the success group was always higher than in the failure group, but there was no statistically significant difference at any time. The bleb average score for eyes with an IOP of ≤ 12 mm Hg after 2 weeks was significantly higher (p = 0.005) than for eyes with an IOP ≥ 13 mm Hg at the end of follow-up. CONCLUSION: patients with a higher early WBCS postoperatively had a significantly lower IOP 1 year after surgery. However, the study could not reveal a certain prognostic value of the early total bleb score using the WBCS for the long-term complete success of trabeculectomy.

An exploratory randomized controlled trial comparing wood-composite and synthetic fibreglass splint systems for the immobilization of paediatric upper limb fractures.

AIMS: This exploratory randomized controlled trial (RCT) aimed to determine the splint-related outcomes when using the novel biodegradable wood-composite splint (Woodcast) compared to standard synthetic fibreglass (Dynacast) for the immobilization of undisplaced upper limb fractures in children. METHODS: An exploratory RCT was performed at a tertiary paediatric referral hospital between 1 June 2018 and 30 September 2019. The intention-to-treat population consisted of 170 patients (mean age 8.42 years (SD 3.42); Woodcast (WCG), n = 84, 57 male (67.9%); Dynacast (DNG), n = 86, 58 male (67.4%)). Patients with undisplaced upper limb fractures were randomly assigned to WCG or DNG treatment groups. Primary outcome was the stress stability of the splint material, defined as absence of any deformations or fractures within the splint during study period. Secondary outcomes included patient satisfaction and medical staff opinion. Additionally, biomechanical and chemical analysis of the splint samples was carried out. RESULTS: Of the initial 170 patients, 168 (98.8%) completed at least one follow-up, and were included for analysis of the primary endpoint. Both treatment groups were well-matched regarding to age, sex, and type and localization of the fracture. Splint breakage occurred in three patients (3.6%; 95% confidence interval (CI), 0.007% to 0.102%) in the WCG and in three children (3.5%, 95% CI 0.007% to 0.09%) in the DNG (p > 0.99). The incidence of splint-related adverse events did not differ between the WCG (n = 21; 25.0%) and DNG (n = 24; 27.9%; p = 0.720). Under experimental conditions, the maximal tensile strength of Dynacast samples was higher than those deriving from Woodcast (mean 15.37 N/mm² (SD 1.37) vs 10.75 N/mm² (SD 1.20); p = 0.002). Chemical analysis revealed detection of polyisocyanate-prepolymer in Dynacast and polyester in Woodcast samples. CONCLUSION: Splint-related adverse events appear similar between WCG and DNG treatment groups during the treatment of undisplaced forearm fractures. Cite this article: Bone Joint J 2020;102-B(10):1405-1411.

Evaluating the diagnostic accuracy of the WHO Severe Acute Respiratory Infection (SARI) criteria in Middle Eastern children under two years over three respiratory seasons.

OBJECTIVE: The World Health Organization created the Severe Acute Respiratory Infection (SARI) criteria in 2011 to monitor influenza (flu)-related hospitalization. Many studies have since used the SARI case definition as inclusion criteria for surveillance studies. We sought to determine the sensitivity, specificity, positive predictive value, and negative predictive value of the SARI criteria for detecting ten different respiratory viruses in a Middle Eastern pediatric cohort. MATERIALS AND METHODS: The data for this study comes from a prospective acute respiratory surveillance study of hospitalized children <2 years in Amman, Jordan from March 16, 2010 to March 31, 2013. Participants were recruited if they had a fever and/or respiratory symptoms. Nasal and throat swabs were obtained and tested by real-time RT-PCR for eleven viruses. Subjects meeting SARI criteria were determined post-hoc. Sensitivity, specificity, positive predictive value, and negative predictive value of the SARI case definition for detecting ten different viruses were calculated and results were stratified by age. RESULTS: Of the 3,175 patients enrolled, 3,164 were eligible for this study, with a median age of 3.5 months, 60.4% male, and 82% virus-positive (44% RSV and 3.8% flu). The sensitivity and specificity of the SARI criteria for detecting virus-positive patients were 44% and 77.9%, respectively. Sensitivity of SARI criteria for any virus was lowest in children <3 months at 22.4%. Removing fever as a criterion improved the sensitivity by 65.3% for detecting RSV in children <3 months; whereas when cough was removed, the sensitivity improved by 45.5% for detecting flu in same age group. CONCLUSIONS: The SARI criteria have poor sensitivity for detecting RSV, flu, and other respiratory viruses-particularly in children <3 months. Researchers and policy makers should use caution if using the criteria to estimate burden of disease in children.

Influence of conjunctival suture removal on the outcome of trabeculectomy.

BACKGROUND: To evaluate the influence of early conjunctival suture removal following trabeculectomy on postoperative outcome. METHODS: In a prospective randomized clinical trial 73 eyes of 69 consecutive patients eligible for primary trabeculectomy were included in the study. Eyes were randomly assigned to a control or intervention group. Trabeculectomy was performed with a fornix-based conjunctival flap and a conjunctival running mattress-suture. In the intervention group, the conjunctival suture was removed 4 weeks postoperatively, in the control group the suture remained in place. Both groups were followed for up to 12 months and best corrected visual acuity (BCVA), refraction, corneal topography, intraocular pressure (IOP), anterior segment and fundus were assessed preoperatively and within a week, 1, 3, 6 and 12 months after surgery. Statistical analysis was performed using SPSS for Windows (t test for independent samples). RESULTS: Trabeculectomy induced similar astigmatism in both groups. Compared to the control group, suture removal seemed to improve BCVA at 6 and 12 months. This was associated with a significantly lower IOP at 6 and 12 months and a significantly higher complete success rate at 12 months (94 vs. 65%, p < 0.001). Astigmatism was not significantly altered by suture removal. CONCLUSION: Conjunctival suture material appears to hamper trabeculectomy success and postoperative visual acuity. This is independent of postoperative astigmatism. Early removal of conjunctival sutures is advisable.

Autoenucleation in a 84-year-old dementia patient.

BACKGROUND: Autoenucleation is a severe, rare form of self-mutilation. The majority of cases have been reported in the 15- to 60-year age group, usually in psychiatric patients with a history of depression or schizophrenia, sometimes caused by drug abuse. CASE REPORT: We report a case of left-sided autoenucleation in an 84-year-old dementia patient suffering from reactive depression. Medical reports mentioned a suicide attempt 2 weeks prior to the incident, whereupon the patient was admitted to the locked ward of a psychiatric hospital. During one night of inpatient stay, the patient manually autoenucleated his left eye. Inspection of the enucleated organ revealed a completely intact globe with an attached optic nerve 5.5 cm in length. The orbit was filled with a massive haematoma. A contrast-enhanced computed tomography (CT) scan showed an orbital haematoma, absence of the left globe and optic nerve and a chiasmatic lesion, accompanied by an intracranial bleeding into the subarachnoid space. Primary wound closure was performed without complications. Visual acuity of the right eye could not be tested due to the patient's lack of cooperation. CONCLUSION: To the best of our knowledge, this is the only reported case of an elderly patient with primary dementia who performed autoenucleation. Other aspects, such as patient history, suicide attempt, manual eye extraction and chiasma lesion are similar to cases reported earlier. The identification and evaluation of intracranial bleedings and chiasmatic lesions that can be associated with autoenucleation requires a contrast-enhanced CT, especially if a long optic nerve fragment is attached to the enucleated globe.

Comparison of 2-year-results of mitomycin C-augmented trabeculectomy with or without cataract extraction in glaucoma patients.

PURPOSE: Comparison of the 2-year results of phacotrabeculectomy (CET) and trabeculectomy (TE), both augmented with mitomycin C. METHODS: This prospective study enclosed 246 eyes in 246 consecutive patients that had undergone trabeculectomy (n = 85) or phacotrabeculectomy (n = 161, hereof n = 10 phacoretrabeculectomy) augmented by mitomycin C. Endpoints were best corrected visual acuity (BCVA), intraocular pressure (IOP), and number of antiglaucomatous medications at baseline, 3 months, and 2 years postoperatively. Postoperative management involved local steroid application and laser suture lysis according to a standardized protocol. RESULTS: Both interventions reduced IOP statistically significant and stable. In the phacotrabeculectomy group BCVA improved from 0.45 ± 0.47 logMAR units preoperatively to 0.28 ± 0.54 logMAR units at 2 years (p < 0.001) and remained unchanged in the trabeculectomy group. After 2 years IOP reduced from 22.5 ± 7.2 mm Hg preoperatively to 11.5 ± 3.1 mm Hg in the TE group and from 20.0 ± 5.4 mm Hg to 12.5 ± 4.8 mm Hg in the CET group (both p > 0.05). The mean number of antiglaucomatous medications was significantly reduced from 2 ± 1 in both groups to 0.3 in the trabeculectomy group and to 0.4 in the phacotrabeculectomy group. With this standardized surgical procedure and postoperative protocol, there was no need for local postoperative antimetabolites. No Tenon's capsule cysts developed. In the subgroup of patients with phacoretrabeculectomy BCVA and IOP improvements were comparable to the phacotrabeculectomy group outcomes. CONCLUSIONS: Phacotrabeculectomy is comparably as effective as trabeculectomy alone in reducing IOP and the need for antiglaucomatous medication over a time interval of 2 years. We found indications that this favourable therapeutic effect is also true for patients needing phacoretrabeculectomy treatment.

CO2, excimer and erbium:YAG laser in deep sclerectomy.

PURPOSE: Deep sclerectomy is a non-penetrating filtering procedure that is not generally accepted, as tissue dissection is difficult and varying success rates have been reported. The purpose of the present study was to compare the use of CO2, excimer and erbium:YAG lasers in dissection of the deep corneoscleral lamella. METHODS: In enucleated porcine eyes a superficial lamellar scleral flap of 5 x 5 mm was surgically dissected. The deep lamella was removed using a pulsed erbium:YAG, a CO2 or an excimer laser (10 eyes/group). All eyes were analysed histologically and 3 in each group by scanning electron microscopy (SEM). RESULTS: It is feasible to ablate the deep corneoscleral lamella with the CO2, excimer and erbium:YAG lasers without perforating the anterior chamber. The following histology and SEM showed a smoother surface after dissection with the CO2 and excimer lasers compared to the erbium:YAG laser. There was no thermal damage after excimer laser treatment, compared to a damage zone of 10-30 mum using the erbium laser and one of 70-100 microm with the CO2 laser. CONCLUSIONS: Excimer,erbium:YAG and CO2 lasers allow the microsurgical dissection of the deep lamella. The excimer and CO2 lasers achieve a more regular and smoother tissue surface. The excimer laser has the advantage to dissect without thermal tissue damage.

Interobserver variability of the Würzburg bleb classification score.

BACKGROUND: The Würzburg bleb classification score (WBCS) serves to assess filtering blebs in a standardized fashion. The purpose of this prospective masked agreement study was to evaluate the WBCS interobserver variability. METHODS: The WBCS provides a scheme to grade clinical bleb morphology. It evaluates the following parameters: vascularity, corkscrew vessels, encapsulation, microcysts and bleb height. Thus, 113 eyes of 104 consecutive patients at various times after surgery were examined (slit lamp biomicroscopy) by 3 ophthalmologists with each observer being unaware of the findings reported by the others. To calculate the interobserver variability of the WBCS, the interobserver consistency and absolute agreement were determined with an intraclass correlation coefficient (ICC) using a 2-way random model. RESULTS: The ICC values of a single rater's judgment were: vascularity +0.62, corkscrew vessels +0.67, encapsulation +0.63, bleb height +0.53, microcysts +0.52 and total score +0.74. The ICC values of the mean of all 3 raters were: +0.83 vascularity, +0.86 corkscrew vessels, +0.84 encapsulation, +0.77 bleb height, +0.76 microcysts and +0.90 total score. CONCLUSION: The WBCS is a bleb morphology score with high levels of interobserver consistency and absolute agreement in clinical practice.

Catheter-assisted 360-Degree Trabeculotomy for Congenital Glaucoma.

PURPOSE: To determine feasibility, efficacy, and safety of ab externo 360-degree trabeculotomy with illuminated microcatheter for congenital glaucoma. PATIENTS AND METHODS: The postoperative results of 36 eyes in 23 consecutive patients who underwent 360-degree trabeculotomy for primary congenital glaucoma (PCG) or secondary congenital glaucoma using an illuminated microcatheter were retrospectively analyzed. Success criteria were defined as intraocular pressure (IOP) ≤18 mm Hg without (complete success) and with medication (qualified success). RESULTS: In all previously nonoperated eyes with PCG (group 1), the Schlemm's canal was identified and circumferentially cannulated for 360-degree trabeculotomy. In group 2 comprising of operated eyes with PCG and eyes with secondary congenital glaucoma, the performance of 360-degree trabeculotomy failed in 4 eyes because of the Schlemm's canal occlusion or high tissue resistance of the trabecular meshwork. Mean preoperative IOP was 28.6±5 and 29.6±9 mm Hg with 7 of 20 eyes and 7 of 9 eyes receiving IOP-lowering medication in group 1 and group 2, respectively. Mean postoperative IOP was reduced to 13±2.7 and 20.2±7.1 mm Hg after a mean follow-up of 15.3 and 12.7 months with 4 of 20 eyes and 5 of 9 eyes receiving medication in group 1 and group 2, respectively. Four eyes underwent further surgery. Complete success was achieved in 16 and 3 eyes, whereas qualified success was achieved in 20 and 4 eyes from group 1 and group 2, respectively. In all eyes, a mild to moderate postoperative hyphema was observed. CONCLUSIONS: Ab externo catheter-assisted 360-degree trabeculotomy controls IOP in a majority of patients with congenital glaucoma after a single operation. Moderate blood reflux in the anterior chamber is considered as a common postoperative finding. We did not observe hypotony or other severe complications in our series. In 1 patient, we experienced catheter misdirection in an eye that had previously undergone trabeculotomy.

Motivational Advising Workshop: Utilizing Motivational Interviewing Theory to Facilitate and Engage Intrinsic Motivation to Change Learners' Behavior.

Introduction: Motivational interviewing (MI) is a counseling method that utilizes a patient's own motivation to effect personal change. MI has been applied routinely and successfully to managing medical conditions (e.g., substance abuse). Employing MI techniques to engage medical learners (termed motivational advising [MA]) may help them overcome professional and/or personal challenges limiting their career development. Methods: Medical educators from four academic medical centers developed a module focused on teaching fellow educators MI theory and techniques for MA using didactic and interactive components. Participants participated in facilitated role-plays to practice MA delivery techniques and observed videos of a traditional advisor-advisee interaction as well as an MA-focused engagement. A postworkshop survey was used to evaluate the workshop. Results: In a survey of 48 educators attending the workshop at two medical conferences, over 80% of respondents demonstrated an interest in learning more about MA. Additionally, over 60% indicated that they would seek opportunities to practice and/or implement MA with their advisees. Knowledge of the technical components of MA also increased significantly in pre- and posttest analysis. Discussion: This module introducing the concept of MA was well received by medical educators and was viewed as a valuable tool in advising medical learners. The provided components enable replication of this workshop in other settings with or without an expert in MI techniques. Although the workshop has been conducted with physicians involved in medical education, it would be applicable to other health professionals who advise trainees such as nursing, dentistry, pharmacy, or veterinary medicine.

In vivo confocal microscopy of failing and functioning filtering blebs: Results and clinical correlations.

PURPOSE: To correlate clinical filtering bleb function with characteristics as detected by in vivo confocal microscopy. METHODS: In a case-matched cross-sectional study, 52 eyes of 48 patients were examined 1 day to 12.8 years after primary trabeculectomy (mean 375 d). The patients were examined clinically and by in vivo confocal microscopy (Rostock Cornea Module/Heidelberg Retina Tomograph II, Heidelberg Engineering, Inc, Heidelberg, Germany). Nine early and 17 late functioning blebs were pair-matched with malfunctioning blebs. Stromal fiber patterns, the number of intraepithelial and stromal cystic spaces, and the amount of cellular infiltrates were evaluated. RESULTS: Four stromal patterns (trabecular, reticular, corrugated, compacted) invisible to slit-lamp biomicroscopy could be distinguished by in vivo confocal microscopy. The trabecular pattern occurred only in functioning blebs, particularly early postoperatively. Intraepithelial cystic spaces were associated with functioning late blebs, whereas they were equally distributed in early blebs. In contrast, stromal cystic spaces indicate function in early blebs, whereas in late blebs the number of these cavities was similar in both groups. The density of intraepithelial and stromal round cells was higher in functioning late blebs compared with malfunctioning late blebs. CONCLUSIONS: In vivo confocal microscopy allows to assess filtering bleb structures that are invisible biomicroscopically. Some morphologic features detected by this technique seem to indicate filtering bleb function and time after surgery. The predictive value of these features deserves further clarification in a prospective longitudinal study.

The Prevalence of Visual Impairment in Retirement Home Residents.

BACKGROUND: Elderly persons often have eye diseases causing either reversible or irreversible visual loss. The prevalence of such problems among retirement home residents is unknown. METHODS: 203 residents of retirement homes in and around Würzburg, Germany, were examined. Clinical histories were taken, including information on prior ophthalmological care, and ophthalmological examinations were performed, including visual acuity, slit-lamp examination of the anterior segment of the eye, fundoscopy (with optical coherence tomography), and measurement of the intraocular pressure. RESULTS: 119 women and 84 men aged 55 to 101 were examined in 6 retirement homes. 44 (21.7% ) had ophthalmological findings that required acute treatment. The most common diagnoses in the anterior segment of the eye were keratoconjunctivitis sicca (160; 78.8% ), cataract (88; 43.3% ), secondary cataract (15; 7.4% ), glaucoma (33; 12.3% ), and eyelid malpositions (25; 12.3% ). In the fundus, 45 residents (22.2% ) had dry age-related macular degeneration (AMD), 7 (3.4% ) had fresh wet AMD, and 7 (3.4% ) had epiretinal gliosis. 81 (39.9% ) could give no information about earlier ophthalmologic examinations, and 42 (20.7% ) had not been to an ophthalmologist for at least 5 years. After correction of refractive errors, their mean decimal visual acuity improved from 0.25 to 0.33. CONCLUSION: The retirement home residents that we examined were not receiving adequate ophthalmological care; in particular, some of them had irreversible eye diseases that were not being treated. The ophthalmological care of retirement home residents needs to be improved through better collaboration of all types of personnel taking care of them.