Subconjunctival Injections of Mitomycin C Are Associated with a Lower Incidence of Hypertensive Phase in Eyes with Ahmed Glaucoma Valve.

PURPOSE: To evaluate the association of intraoperative and postoperative subconjunctival injections of mitomycin C (MMC) and rate of the hypertensive phase after implantation of the Ahmed glaucoma valve (AGV). DESIGN: Comparative case series. PARTICIPANTS: This retrospective comparative study included 37 eyes of 35 patients with uncontrolled glaucoma on maximum tolerated medical therapy who underwent implantation of AGV by a single surgeon. METHODS: Consecutive cases operated without the use of MMC from 2015 to 2017 were compared with consecutive cases operated from 2018 to 2019 under a standardized protocol of subconjunctival MMC injections. The MMC group received 0.1 ml of MMC (0.25 mg/ml) injected intraoperatively, at 1 and 4 weeks after the surgery. MAIN OUTCOME MEASURES: Incidence of the hypertensive phase (defined as intraocular pressure [IOP] >21 mmHg during the first 3 postoperative months) was compared across groups. Intraocular pressure and glaucoma medications were also compared during the course of the first 6 postoperative months. RESULTS: In the MMC and no-MMC groups, 17.6% (3/17) and 55.0% (11/20) of the cases exhibited a hypertensive phase (P = 0.04), respectively. Both groups were comparable in baseline characteristics, including age, preoperative IOP, preoperative glaucoma medications, and previous glaucoma surgeries. At 6 months, mean IOP was 14.0 ± 0.8 mmHg and 14.7 ± 0.9 mmHg for the MMC and no-MMC groups, respectively (P = 0.6). The mean number of glaucoma medications at 6 months was 1.2 ± 0.2 and 2.2 ± 0.3 in the MMC and no-MMC groups, respectively (P = 0.007). CONCLUSIONS: Eyes that underwent implantation of AGV experienced a lower incidence of hypertensive phase and required fewer medications when using a standardized protocol of intraoperative and postoperative subconjunctival MMC injections.

Effect of general anaesthesia on intraocular pressure in paediatric patients: a systematic review.

OBJECTIVES: Assessment of the impact of general anaesthetic agents on intraocular pressure (IOP) in children via systematic review. METHODS: Pubmed, Embase, and CENTRAL databases were systematically searched to identify randomised controlled trials, prospective, and interventional studies. The search included all studies through October 5, 2018 with no date or language restrictions. A linear mixed-effects regression analysis was performed to study the change in IOP after general anaesthesia (GA). RESULTS: The strategy identified 518 studies that met search criteria. Six studies (531 eyes) were included for quantitative synthesis. Seven categories of mixed and non-mixed induction and maintenance agents were compared. When assessing all agents utilising a model of mean IOP as a function of time, IOP decreased after induction phase at a rate of -0.59 ± 0.19 mmHg/min (P value = 0.006). CONCLUSIONS: This systematic review showed that most anaesthetic agents significantly decrease IOP over time after the induction phase of general anaesthesia in children. An understanding of the effects of GA on IOP is critical for those performing paediatric ophthalmic examinations under anaesthesia.

Ethnicity-Specific Database Improves the Diagnostic Ability of Peripapillary Retinal Nerve Fiber Layer Thickness to Detect Glaucoma.

PURPOSE: To determine the changes in optical coherence tomography (OCT) color probability codes and diagnostic ability for peripapillary retinal nerve fiber layer (pRNFL) and ganglion cell complex (GCC) analysis after applying Chinese and white subjects normative databases. DESIGN: Cross-sectional study. METHODS: This study enrolled 219 healthy eyes (108 white and 111 Chinese patients) to construct an ethnicity-specific normative database for pRNFL and macular GCC thickness, which was tested then in 180 eyes with or without glaucoma (102 white and 78 Chinese patients). The percent of change of color probability codes were evaluated after applying the original built-in and the ethnicity-specific normative databases, respectively. Sensitivity and specificity were calculated to evaluate the change in diagnostic ability to detect glaucoma. RESULTS: Healthy white subjects had a thinner pRNFL than Chinese subjects in the overall average thickness as well as the superior, inferior, and temporal quadrants (P < .001). Macular GCC did not differ between ethnicities. After applying an ethnicity-specific normative database, the percent of pRNFL abnormal color code labels decreased significantly for the overall average thickness in the white subjects. This resulted in a significant increase in the specificity to detect glaucoma in the white population (P < .001). No significant changes were seen when applying an ethnicity-specific normative database for macular GCC thickness. CONCLUSIONS: After applying an ethnicity-specific normative database, the percent of pRNFL abnormal color codes decreased significantly, improving the specificity to detect glaucoma in the white population. These findings suggest there may be utility in having ethnicity-specific normative databases for pRNFL thickness.

Neurotrophic keratitis after micropulse transscleral diode laser cyclophotocoagulation.

PURPOSE: To report two cases of neurotrophic keratitis (NK) after micropulse transscleral cyclophotocoagulation (MP-TCP). OBSERVATIONS: Two patients with predisposing factors for decreased corneal sensation developed NK 1 month after MP-TCP. Both patients did not heal with initial treatment with topical antibiotic and preservative free artificial tears. One patient required use of a bandage contact lens and the other patient required tarsorrhaphy. Both eyes experienced recurrence of NK. CONCLUSIONS AND IMPORTANCE: NK can be triggered after MP-TCP in patients with underlying predisposing factors for decreased corneal sensation. This uncommon but vision-threatening complication should be discussed preoperatively with high-risk patients as a possible adverse event after MP-TCP and followed closely postoperatively.

Anterior Segment Parameters of Filipino-Americans Compared to Chinese-Americans and Caucasian Americans Using Anterior Segment Optical Coherence Tomography.

PURPOSE: We compare anterior segment characteristics of Filipino- versus Chinese- and Caucasian-Americans to describe the differences in risk factors among each ethnic group. METHODS: A cross-sectional study was conducted among Filipino, Chinese, and Caucasian subjects without glaucoma who underwent a standardized set of ocular examinations and anterior segment optical coherence tomography (Visante ASOCT) imaging. Zhongshan Angle Assessment Program (ZAAP) 4 was used for ASOCT image analysis. The following quantitative parameters wereobtained from ZAAP: (1) angle opening distance (AOD500, AOD750), angle recess area at 750 µm (ARA), and trabecular-iris space area at 500 and 750 µm (TISA500, TISA750); (2) iris parameters, including iris thickness at 750 µm from the scleral spur (IT750), iris area (IArea), iris curvature or convexity (ICurv), and pupil diameter; 3) anterior chamber parameters; and (4) lens vault. RESULTS: The Filipino (122 eyes), Chinese (121 eyes), and Caucasian (111 eyes) subject groups were similar in terms of demographic and clinical characteristics. We reported pairwise comparisons of Filipino parameter values to Chinese or Caucasian values, represented as B-coefficients and P values. In multivariate analysis, Filipinos had narrower angles than Caucasians (AOD750, TISA 500, TISA 750, ARA, P < 0.001). Filipinos had thicker and more convex irises than Caucasians (IT750, IT 2000, ICurv P < 0.003). Angle and iris parameters were similar overall for Filipino and Chinese. CONCLUSIONS: Filipinos appear to have more convex and thicker irises, smaller lens vault and narrower angles compared to Caucasians. Filipino eyes closely resembled Chinese eyes with similar iris and angle parameters. TRANSLATIONAL RELEVANCE: The anatomic angle parameters of Filipinos may contribute to angle closure risk among this population, thus ASOCT and thorough angle analysis is recommended in this population.

How to Predict Intraocular Pressure Reduction after Cataract Surgery? A Prospective Study.

Purpose/Aim: To evaluate the best formula to predict intraocular pressure (IOP) reduction after cataract surgery. Materials and methods: In this prospective longitudinal study, we included consecutive patients with or without glaucoma, either with open or with narrow angles but without peripheral anterior synechiae, who underwent phacoemulsification. Clinical factors and anterior segment parameters measured with optical biometry and optical coherence tomography were evaluated as preoperative predictors for IOP reduction at 6 months postoperatively. To find the best combinations of predictors, model selection was conducted using least absolute selection and shrinkage operator regression with cross-validation. Results: A total of 156 eyes from 109 patients were enrolled. The mean age of the patients was 74.89 (±8.54) years and the average preoperative IOP was 15.6 (±3.68) mmHg with 0.7 (range 0-4) glaucoma medications. The mean IOP reduction after phaco was 3.1 (±2.49) mmHg at postoperative month 6. After multivariate analysis, preoperative IOP (ß = 0.49 [0.4-0.59] P < .0001), gonioscopy score (ß = -0.14 [-0.23 to -0.06] P = .0001), anterior chamber depth (ß = -0.85 [-1.64 to -0.07] P = 0.033), lens thickness (LT) (ß = 0.87 [0.12-1.62] P = .024), and angle open distance 750 (ß = -2.2 [-3.96 to -0.44] P = 0.014) were associated with IOP reduction. The best formula to correlate with IOP reduction was -4.76 + (0.46 × preoperative IOP) - (0.42 × LT) - (0.1 × gonioscopy score) - (0.66 × glaucoma status). Conclusion: Different formulas were developed and were able to improve the predictive value of the preoperative IOP. When used in combination, these formulas may help the clinician to know how much IOP reduction to expect after cataract surgery at 6 months postoperatively.

Relationship of lifestyle, exercise, and nutrition with glaucoma.

PURPOSE OF REVIEW: Although reducing the intraocular pressure (IOP) through medications, laser or surgery remains the primary means of glaucoma treatment, there is increasing evidence during the last decade that environmentally modifiable factors may help to prevent glaucoma or its progression through different mechanisms that may or may not involve lowering IOP. Additionally, patients are increasingly interested in maintaining a healthy lifestyle and taking an active role in the management of their disease. Therefore, the aim of this review is to summarize the current evidence regarding environmentally modifiable factors such as lifestyle, exercise, and nutrition in the pathogenesis of glaucoma. RECENT FINDINGS: In the last decade, large population-based studies have helped to identify possible environmentally modifiable protective and risk factors with regard to glaucomatous disease. Smoking cessation; moderate aerobic exercise; recommended weight; and a balanced diet including green leafy vegetables, omega fatty-acids, and moderate intake of hot tea and coffee have been reported to be possibly protective against developing glaucoma or its progression. SUMMARY: Modifiable environmental factors such as lifestyle, exercise, and nutrition may play a role in glaucoma pathogenesis. Large prospective studies with long-term follow-up should be encouraged to corroborate these findings, which may guide future treatments for our patients, some of which may not be limited to IOP reduction.

Post-phacoemulsification iris changes in eyes with glaucoma or glaucoma suspect status.

PURPOSE: This prospective study used anterior segment optical coherence tomography (AS-OCT) to determine how phacoemulsification (phaco) changes iris parameters in eyes with glaucoma or glaucoma suspect status. METHODS: Using Visante AS-OCT (Carl Zeiss Meditec AG), the following pre- and post-phaco parameters were measured: IT750 = iris thickness at 750 µm from the scleral spur; IT2000 = iris thickness 2000 µm from the scleral spur; ITCM = the maximum iris thickness at the middle one third of the iris; ICURV = iris curvature; IAREA = iris area; and pupil size = pupil diameter (mm). Only high-quality images with an identifiable scleral spur were included, and only the nasal quadrant was analyzed. A single glaucoma specialist analyzed the parameters according to the Zhongshan Angle Assessment Program (ZAAP, Guangzhou, China). Multivariate analysis was performed using mixed effects regression correcting for age, gender, and ethnicity. RESULTS: 89 subjects and 110 eyes were included in this study. The mean age of subjects was 74.83 {+/-} 8.69 years old. Most common diagnoses were POAG and glaucoma suspect (23% and 52%, respectively), and 16% of subjects had an LPI. In multivariate analysis of AS-OCT parameters, decreases in IT750, IT2000, ITCM, ICURV, and pupil size were statistically significant (p<0.05). CONCLUSIONS: After phacoemulsification, eyes with glaucoma as well as glaucoma suspect eyes have thinner irises and smaller pupils. This may lead to less iris-mediated aqueous outflow obstruction, providing support for early phacoemulsification glaucoma treatment. TRANSLATIONAL RELEVANCE: Our AS-OCT imaging findings may guide clinical practice as iris parameters become increasingly relevant in preoperative phaco planning.

Efficacy of Cataract Surgery With Trabecular Microbypass Stent Implantation in Combined-Mechanism Angle Closure Glaucoma Patients.

PURPOSE: To evaluate the effectiveness of trabecular microbypass stent (iStent) implantation in combined mechanism glaucoma (CMG). DESIGN: Retrospective cohort study. METHODS: We reviewed the medical charts of patients with the following scenarios: (1) primary open-angle glaucoma (POAG) undergoing phacoemulsification (PE), (2) POAG undergoing PE with iStent (POAG-PE/iStent), (3) CMG undergoing PE (CMG-PE), and (4) CMG undergoing PE with iStent (CMG-PE/iStent). CMG was defined as narrow-angle glaucoma patients whose angle had opened after iridotomy. Linear mixed-effects models were performed to determine the effect of iStent on postoperative 1-year success rate (intraocular pressure [IOP] ≤ 18 without medication), IOP, and number of medications. RESULTS: Data from 301 eyes were available. The number of eyes (subjects) was 61 (45) in the POAG-PE, 60 (50) in POAG-PE/iStent, 93 (76) in CMG-PE, and 87 (70) in CMG-PE/iStent group. Success criteria were achieved in 13.1% for POAG-PE, 33.3% for POAG-PE/iStent (POAG-PE vs POAG-PE/iStent B 3.01; P < .001), 37.6% for CMG-PE, and 43.7% for CMG-PE/iStent (CMG-PE vs CMG-PE/iStent B 2.25; P < .001). There was no difference in the IOP between POAG-PE and POAG-PE/iStent, and between CMG-PE and CMG-PE/iStent. The iStent significantly reduced number of medications in the POAG (B -0.70; P < .001) and CMG group (B -0.52; P < .001). Comparing the effect of iStent on POAG and CMG, the analysis showed similar iStent efficacy in terms of the success rate, IOP, and number of medications (P > .05). CONCLUSIONS: Combined PE/iStent significantly increased success rate and reduced number of medications in CMG patients compared to PE alone. The effects of iStent were comparable between POAG and CMG groups.

Comparison of Anterior Segment Optical Coherence Tomography Parameters Among Vietnamese, Chinese, and Whites.

PURPOSE: To evaluate the difference in anterior segment optical coherence tomography (AS-OCT) parameters among ethnic Vietnamese, Chinese, and whites. DESIGN: Cross-sectional study. METHODS: We prospectively recruited phakic nonglaucomatous participants (based on intraocular pressure < 21 mm Hg, normal optic nerve head and retinal nerve fiber, and cup-to-disc ratio < 0.6) of 3 ethnic groups-Vietnamese, Chinese, and white. AS-OCT parameters including angle (angle opening distance, trabecular-iris space area, and angle recess area), iris (iris thickness, iris area, and iris curvature [Icurv]), and anterior chamber parameters (anterior chamber depth, width [ACW], area, and lens vault [LV]) were obtained. A linear regression model with adjustment for age, sex, axial length, and pupillary diameter was used for analysis. Subgroup analysis was performed in closed- and open-angle subgroups, which were defined in eyes with gonioscopically visible posterior trabecular meshwork for less than 2 quadrants (closed) and equal to or more than 2 quadrants (open). RESULTS: Data were obtained from 126 Vietnamese, 124 Chinese, and 112 white participants. Mean (standard deviation) age of participants was 60.2 (11.8) years. Among overall subjects, Vietnamese had significantly smaller values in all angle and anterior chamber parameters than Chinese and white subjects (all P ≤ .001) except LV. Vietnamese had significantly higher Icurv than Chinese (B -0.065, P < .001) and white subjects (B -0.073, P < .001). In the open-angle subgroup, Vietnamese had significantly smaller angle and anterior chamber dimensions (P ≤ .001) and thicker iris (P < .001) than whites, whereas there was no significant difference in all parameters compared to Chinese except for smaller ACW in Vietnamese (P < .001). In the closed-angle subgroup, Vietnamese possessed smaller angle, smaller anterior chamber dimensions, and higher Icurv than Chinese and white subjects (P < .001). Vietnamese had significantly greater LV compared to Chinese (B -204.8, P = .001). CONCLUSION: Vietnamese subjects had more of the anatomic characteristics associated with risk for angle closure, including small anterior chamber dimension, high iris curvature, and high lens vault, compared to the other 2 ethnicities.

Normative Database and Color-code Agreement of Peripapillary Retinal Nerve Fiber Layer and Macular Ganglion Cell-inner Plexiform Layer Thickness in a Vietnamese Population.

PURPOSE: Evaluate the distribution and the color probability codes of the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thickness in a healthy Vietnamese population and compare them with the original color-codes provided by the Cirrus spectral domain-optical coherence tomography. METHODS: This is a cross-sectional study. We recruited nonglaucomatous Vietnamese subjects and constructed a normative database for peripapillary RNFL and macular GCIPL thickness. The probability color-codes for each decade of age were calculated. We evaluated the agreement with κ coefficient between optical coherence tomography color probability codes with Cirrus built-in original normative database and the Vietnamese normative database. RESULTS: In total, 149 eyes of 149 subjects were included. The mean age of enrollees was 60.77 (±11.09) years, with a mean spherical equivalent of +0.65 (±1.58) D and mean axial length of 23.4 (±0.87) mm. Average RNFL thickness was 97.86 (±9.19) µm and average macular GCIPL was 82.49 (±6.09) µm. Agreement between original and adjusted normative database for RNFL was fair for average and inferior quadrant (κ=0.25 and 0.2, respectively); and good for other quadrants (range, κ=0.63 to 0.73). For macular GCIPL κ agreement ranged between 0.39 and 0.69. After adjusting with the normative Vietnamese database, the percent of yellow and red color-codes increased significantly for peripapillary RNFL thickness. CONCLUSIONS: Vietnamese population has a thicker RNFL in comparison with Cirrus normative database. This leads to a poor color-code agreement in average and inferior quadrant between the original and adjusted database. These findings should encourage to create a peripapillary RNFL normative database for each ethnicity.

Novel Gonioscopy Score and Predictive Factors for Intraocular Pressure Lowering After Phacoemulsification.

PURPOSE: To evaluate a novel gonioscopy score as a potential predictor for intraocular pressure (IOP) reduction after cataract surgery. MATERIALS AND METHODS: This was a prospective study that included consecutive patients with or without glaucoma, either with open or narrow angles but without peripheral anterior synechiae, who underwent phacoemulsification. Eyes with intraoperative complications and secondary glaucoma were excluded. A preoperative gonioscopy score was created, summing the Shaffer gonioscopy grading in 4 quadrants (range, 0 to 16). To determine variables associated with IOP change at 6 months, univariate and multivariate linear mixed-effects regression analysis was performed adjusting for age, sex, and preoperative IOP. RESULTS: In total, 188 eyes from 137 patients were enrolled. The mean age of the patients was 75.0 (±8.5) years and the average preoperative IOP was 15.6 (±3.6) mm Hg with 0.7 (range, 0 to 4) glaucoma medications. The mean IOP reduction after phacoemulsification was 3.0 (±2.6) mm Hg at postoperative month 6. After multivariate analysis, preoperative IOP [ß=0.49 (0.41-0.58), P<0.0001], gonioscopy score [ß=-0.17 (-0.24 to -0.09), P<0.0001], anterior chamber depth (ACD) [ß=-0.88 (-1.64 to -0.14), P=0.02], and IOP/ACD ratio [ß=0.45 (0.07 to 0.83) P=0.021] were associated with IOP reduction at 6 months. CONCLUSIONS: Preoperative predictors for IOP reduction after cataract surgery were preoperative IOP, ACD, gonioscopy score, and IOP/ACD ratio. The IOP/ACD ratio and gonioscopy score can be easy parameters to obtain and may help clinicians to estimate the IOP reduction after phacoemulsification.

Use of Nd:YAG laser to recanalize occluded Cypass Micro-Stent in the early post-operative period.

PURPOSE: To report the first case of Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser use to recanalize a CyPass occluded with a clot in the early postoperative follow-up. OBSERVATIONS: A 66 year-old woman with primary open angle glaucoma and cataract received combined cataract surgery plus CyPass in the right eye. Surgery was uneventful, however, there was a small amount of hyphema related to bleeding around the site of Cypass insertion. Intraocular pressure (IOP) was between 6 and 7 mmHg in the first week on no glaucoma medications. At the second postoperative week, IOP jumped to 30 mmHg and a clot was observed obstructing the CyPass lumen. We disrupted the clot with a single shot from a Nd:YAG laser. Twenty minutes after the laser, the IOP was 8 mmHg. CyPass was recanalized without complications. IOP was 11 mmHg at 1 month postoperatively with timolol 0.5% twice a day. CONCLUSIONS AND IMPORTANCE: It is important to perform gonioscopy to evaluate for CyPass obstruction in cases of IOP spike. Nd:YAG laser may be a useful approach to recanalize the CyPass in the early postoperative follow-up.

Comparison of Anterior Segment Parameters among Koreans, Chinese, and White Persons.

PURPOSE: To evaluate anterior segment (AS) parameters obtained by AS OCT within an urban Korean population and to compare them with measurements seen in Chinese and white participants. DESIGN: Prospective, cross-sectional, clinic-based study. PARTICIPANTS: Three gender- and age-matched cohorts of Korean, Chinese, and white participants recruited from general ophthalmology clinics in urban academic hospital settings. METHODS: Anterior segment OCT (Visante OCT; Carl Zeiss Meditec, Dublin, CA) was used to image the AS of all participants. Customized software was used to calculate AS parameters. MAIN OUTCOME MEASURES: Five angle parameters (AOD500, AOD750, TISA500, TISA750, ARA), 5 iris parameters (IT750, IT2000, ITCM, Iarea, Icurv), and 5 anterior chamber parameters (ACD, ACW, ACA, ACV, LV) were compared. Anterior vault (AV), relative AV, and relative LV were also calculated. These parameters were compared across all cohorts using a Kruskal-Wallis test. General linear models were built to assess pairwise comparison between Korean and Chinese and between Korean and white cohorts. Two-sided P values less than 0.05 were considered statistically significant. We also considered Bonferroni correction to control family-wise type 1 error (ɑFW = 0.05 / 18 = 0.003). RESULTS: The study included 132, 124, and 112 participants in the Korean, Chinese, and white cohorts, respectively. Korean participants showed AS parameters similar to those of Chinese participants, with the exception of having a smaller average ACW and a larger average IT2000. Compared with white persons, Koreans showed smaller angle parameters (trabecular-iris space area measured at 500 µm and 750 µm from the SS and angle recess area), anterior chamber parameters (ACD, ACW, ACA, ACV), and thicker irises (iris thickness measured at 750 µm and 2000 µm from the SS, maximum IT at the middle one third of the iris). The Korean cohort also was noted to show a smaller average LV compared with both Chinese and white cohorts. CONCLUSIONS: The Korean cohort demonstrated smaller average LV and relative LV.

Algorithm approach for revision surgery following late-onset bleb complications after trabeculectomy: long-term follow-up.

PURPOSE:: The aim of this study was to introduce a reproducible algorithm for the surgical management of late-onset (>2 months) bleb complications after trabeculectomy with mitomycin C. METHODS:: We performed a retrospective review of eyes treated using a reproducible algorithm approach by a single surgeon for the surgical management of late-onset bleb complications from July 2006 to April 2014. Exclusion criteria were bleb revision with less than 3 months of follow-up or bleb revision combined with other glaucoma procedures at the time of surgery. Success was evaluated using the Kaplan-Meier survival method and defined as achieving all of the following criteria: primary surgery indication resolved, no additional surgery required for decreasing the intraocular pressure (IOP), and IOP of ≥6 mmHg and ≤18 mmHg. RESULTS:: Twenty-three eyes from 20 patients were evaluated. Indications for bleb revision were hypotonic maculopathy (47.8%), bleb leak (30.4%), and dysesthetic bleb (21.7%). The overall primary outcome success rate calculated using the Kaplan-Meier survival method was 65.2% at 48 months. When the IOP target was changed to ≤15 mmHg, the bleb survival rate was 47.8% at 48 months. At the most recent postoperative visit, 95.7% of eyes had an IOP of ≤15 mmHg and 56.5% were being treated with an average of one medication per eye. One eye (4.3%) required a second bleb revision for persistent hypotony and two eyes required glaucoma surgery to reduce IOP during follow-up. CONCLUSIONS:: An algorithm approach for the surgical management of late-onset bleb complications with a success rate similar to those reported in specialized literature is proposed. Randomized trials are needed to confirm the best surgical approach.

Algorithm approach for revision surgery following late-onset bleb complications after trabeculectomy: long-term follow-up / Algoritmo de abordagem para cirurgia de revisão nas complicações da bolha de início tardio após trabeculectomia: acompanhamento de longo prazo

ABSTRACT Purpose: The aim of this study was to introduce a reproducible algorithm for the surgical management of late-onset (>2 months) bleb complications after trabeculectomy with mitomycin C. Methods: We performed a retrospective review of eyes treated using a reproducible algorithm approach by a single surgeon for the surgical management of late-onset bleb complications from July 2006 to April 2014. Exclusion criteria were bleb revision with less than 3 months of follow-up or bleb revision combined with other glaucoma procedures at the time of surgery. Success was evaluated using the Kaplan-Meier survival method and defined as achieving all of the following criteria: primary surgery indication resolved, no additional surgery required for decreasing the intraocular pressure (IOP), and IOP of ≥6 mmHg and ≤18 mmHg. Results: Twenty-three eyes from 20 patients were evaluated. Indications for bleb revision were hypotonic maculopathy (47.8%), bleb leak (30.4%), and dysesthetic bleb (21.7%). The overall primary outcome success rate calculated using the Kaplan-Meier survival method was 65.2% at 48 months. When the IOP target was changed to ≤15 mmHg, the bleb survival rate was 47.8% at 48 months. At the most recent postoperative visit, 95.7% of eyes had an IOP of ≤15 mmHg and 56.5% were being treated with an average of one medication per eye. One eye (4.3%) required a second bleb revision for persistent hypotony and two eyes required glaucoma surgery to reduce IOP during follow-up. Conclusions: An algorithm approach for the surgical management of late-onset bleb complications with a success rate similar to those reported in specialized literature is proposed. Randomized trials are needed to confirm the best surgical approach.

RESUMO Objetivo: Descrever um algoritmo reprodutível para o tratamento cirúrgico das complicações da bolha de início tardio (>2 meses) após trabeculectomia com mitomicina-C. Métodos: Revisão retrospectiva de olhos que foram submetidos a um algoritmo reprodutível para o tratamento cirúrgico das complicações da bolha de início tardio por um único cirurgião, de julho de 2006 a abril de 2014. Os critérios de exclusão foram revisão de bolha com menos de 3 meses de seguimento ou revisão de bolha combinado com outro procedimento antiglaucomatoso no momento da cirurgia. O sucesso foi avaliado pelo método de sobrevida de Kaplan-Meier e definidos como ter atingido todos os seguintes critérios: indicação de cirurgia primária resolvido, nenhuma cirurgia adicional necessária para diminuir a pressão intraocular (IOP), IOP ≥6 mmHg e ≤18 mmHg. Resultados: Vinte e três olhos de 20 pacientes foram incluídos. Indicações para revisão bolha foram maculopatia hipotônica (47,8%), extravasamento da bolha (30,4%) e bolha elevada (21,7%). A taxa de sucesso do resultado primário global calculada pelo método de sobrevivência de Kaplan-Meier foi de 65,2% aos 48 meses. Quando a IOP foi diminuída para ≤15mmHg, a taxa de sobrevivência bolha foi de 47,8% em 48 meses. Na visita pós-operatória mais recente, 95,7% dos olhos apresentavam PIO ≤15mmHg e 56,5% estavam sob tratamento com uma média de um medicamento por olho. Um olho (4,3%) necessitou de uma segunda revisão da bolha para hipotonia persistente e dois olhos necessitaram cirurgia de antiglaucomatosa para reduzir a IOP durante o seguimento. Conclusões: Um algoritmo de abordagem para o tratamento cirúrgico das complicações tardias da bolha com uma taxa de sucesso semelhante aos relatados na literatura especializada é proposto. Ensaios clínicos randomizados são necessários para confirmar a melhor abordagem cirúrgica.

Trabeculectomy Combined With Collagen Matrix Implant (Ologen).

PURPOSE OF THE STUDY: The purpose of the study was to report and evaluate outcomes of trabeculectomy with use of a subconjunctival biodegradable collagen matrix implant. PATIENTS AND METHODS: Retrospective review of trabeculectomy with Ologen implant of 65 eyes of 58 patients by the same surgeon from October, 2011 to October, 2014. Exclusion criteria were <6 months of follow-up after surgery, and uveitic or neovascular glaucoma. Demographic characteristics of the study population, visual acuity, intraocular pressure (IOP), glaucoma medications, bleb characteristics, and early and late postoperative complications were recorded. Complete and qualified IOP control success, ≤15 and ≤18 mm Hg, was calculated with the Kaplan-Meier analysis. RESULTS: The mean age of the patients in the study was 65.9±15.1 years. IOP was reduced from a mean of 21.4±9.2 to 12.3±3.7 mm Hg at the last follow-up visit (P<0.0001). The number of IOP-lowering medications per eye was reduced from a mean of 1.86 preoperatively to 0.2 at the last follow-up visit (P<0.0001). The Kaplan-Meier survival curves of complete success for IOP≤15 mm Hg and ≤18 mm Hg were 47.2% and 62.9%, respectively, at 36 months. Postoperative complications occurred in 15% of the eyes, with bleb leakage (6%) and hypotony (5%), which were resolved medically. At the last postoperative visit, blebs were described as normal (86.4%), flat (9.1%), and polycystic (4.5%). CONCLUSIONS: Trabeculectomy surgeries with Ologen performed by the same surgeon were effective in lowering IOP with a low complication rate at mid-term follow-up.

Esotropia surgery in children with Down syndrome.

PURPOSE: To evaluate postoperative alignment in children with and without Down syndrome after surgical correction of esotropia. METHODS: The medical records of consecutive patients with Down syndrome who underwent corrective surgery for esotropia between August 1992 and July 2012 were retrospectively reviewed. Age range for eligibility was between 8 months and 17 years at surgery. The control group comprised randomly selected, age-matched patients without Down syndrome who underwent the same surgical procedure. Postoperative alignment within 10(Δ) of orthotropia at 6 months' follow-up and at the final postoperative visit was considered a successful outcome. RESULTS: A total of 17 children with Down syndrome and 27 control subjects were included. The control group and Down syndrome group did not differ significantly in either postoperative follow-up (5.2 ± 3.2 versus 5.6 ± 5.2 years, respectively) or magnitude of deviation before surgery (40 ± 18.2(Δ) versus 39 ± 12.8(Δ), respectively). Surgical success was achieved in 76% of patients with Down syndrome and in 85% of control patients at 6 months' follow-up. CONCLUSIONS: In this patient cohort, good surgical outcomes were achieved in children with esotropia and Down syndrome compared with those with esotropia but without Down syndrome using the same surgical technique.

Profile of inflammatory mediators in tonsils of patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome.

The purpose of this study was to analyze the levels of white blood cells and profile of proinflammatory Th1, Th2, Th17, and T regulatory tissue cytokines in the tonsils of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) patients to contribute to the pathophysiological understanding of the PFAPA syndrome. A cohort of PFAPA patients who had tonsillectomy during 2010 and 2011 was included and compared to control patients who had tonsillectomy for tonsillar hypertrophy. White blood cell counts were measured during flares in PFAPA patients and before tonsillectomy in the control group. Cytokine gene expression was analyzed in removed tonsils by real-time PCR. Nine PFAPA patients with a median age of 5.3 years (1.7-8 years) and 17 hypertrophic tonsils of patients with a median age of 4.8 years (2.3-8.4 years) participated in this study. Tonsillectomy was performed during afebrile period between PFAPA flares. Three of the nine patients had recurrent episodes of aphthous stomatitis without fever after tonsillectomy. Leukocyte and neutrophil counts were higher in PFAPA patients compared to controls (p < 0.05). Eosinophil counts were lower in PFAPA patients during flares (p = 0.006). IL-1ß, TNF-α, TGF-ß, IL-17, and IFN-γ levels were similar in the tonsils of patients and controls. IL-4 gene expression in the tonsils was lower in PFAPA patients compared to those of the controls (p = 0.04). Proinflammatory, effector, and regulatory cytokine gene expression in tonsil tissue of PFAPA children removed in a noninflammatory asymptomatic interval and in control patients were similar. However, IL-4 cytokine gene expression in the tonsils and peripheral blood eosinophils were lower in the PFAPA patients suggesting a potential pathogenesis pathway based on an inhibition of Th2 responses.

Operative technique with rapid recovery for ingrown nails with granulation tissue formation in childhood.

BACKGROUND: Ingrown toenail is a common disease that causes pain and discomfort. There are conservative and surgical treatments, but many have the drawbacks of recurrence and long recovery time. OBJECTIVE: To analyze for the first time the results of a technique called nail splinting using a flexible tube secured using a suture (FTSS) performed on a series of patients with ingrown toenails. METHODS AND MATERIALS: A retrospective descriptive study of 71 pediatric patients operated on using the FTSS technique between 2001 and 2009 was performed. The data were collected using medical record review or telephone survey. The main outcomes were high percentage of success and shorter recovery time than with partial matrix excision. RESULTS: Sixty-two patients (87.3%) were cured using a single procedure, with an average follow-up of 13.1 months. Recurrence occurred in nine patients (12.6%); three required the classic technique with resection of the matrix and nail bed plastic surgery, and in 6, FTSS was repeated with good results. CONCLUSION: Flexible tube secured using a suture has a lower recurrence rate than matricectomy. Additional advantages are the speed with which complaints can be monitored and quick return to school because recovery may be as short as 48 hours.