Primary glaucoma surgery in Fuchs' heterochromic uveitis: a comparison of trabeculectomy versus deep sclerectomy.

BACKGROUND: Deep sclerectomy offers the potential advantage of less postoperative inflammation and better survival in Fuchs' patients. The aim of this study was to compare survival and safety profiles of Fuchs' heterochromic uveitis patients undergoing trabeculectomy or deep sclerectomy. METHODS: A retrospective study was conducted of two separate cohorts who had undergone either trabeculectomy or deep sclerectomy. Patient demographics, best-corrected visual acuity, intraocular pressure, antimetabolite used, postoperative complications and subsequent procedures were analysed. RESULTS: In total, 13 trabeculectomy patients and 14 deep sclerectomy patients were included. Mean preoperative intraocular pressure was similar at 30.1 mmHg in the trabeculectomy group and 35.9 mmHg in the deep sclerectomy group, with no significant difference between the two (p = 0.22). Kaplan-Meier survival outcomes for success at <22 mmHg and <19 mmHg showed no significant differences between the groups and this was also the case for intraocular pressure at 3 years (analysis of variance; p = 0.47). CONCLUSION: Both procedures appear to have similar efficacy and safety profiles, suggesting that both are effective.

Cataract extraction after deep sclerectomy and its effect on intraocular pressure control.

PURPOSE: To estimate the incidence and predisposing factors for cataract extraction (CE) after Deep Sclerectomy (DS) with Mitomycin-C (MMC) and its effect on intraocular pressure (IOP) control. METHODS: Retrospective study of phakic eyes which had DS with MMC performed over a 5-year period. 179 eyes of 179 patients were included. RESULTS: Mean age at time of DS was 68.6 ± 9.7 years and mean follow-up was 89.4 ± 29.4 months. 63 eyes had CE and the probability of CE following DS was 0% at 1, 11.6% at 3, 21.0% at 5 and 33.2% at 7 years, with a 50% probability (median survival time) of 10 years. Age was association with increased risk for CE (Hazard ratio 1.05, 95% CI: 1.03-1.08, p < 0.0001). Mean IOP had increased from 11 mmHg to 15 mmHg in the first 3 months and remained higher up to a year (p < 0.001). There was no difference in the probability of maintaining an IOP < 16 mmHg without additional medications or needle revision (p = 0.05,Log-rank test). 20/47 eyes that failed were from the CE group, of which 14 (22.2%) failed prior to CE. Number of eyes on glaucoma medications before CE was 6 (mean edications 0.2 ± 0.5 m) and by last follow-up, 9 eyes were on medications (mean medications 0.2 ± 0.7). Post-CE needle revision was performed on 4 eyes. CONCLUSIONS: The probability of CE after DS is low, with a gradual increase with time. Increasing age was found to be a statistically significant risk factor. There was a modest increase in IOP after CE and increase use of glaucoma medications.

Patterns of ophthalmic referral and emergency presentations to an acute tertiary eye service in New Zealand.

BACKGROUND: To establish demographics, referral patterns and clinical characteristics of patients attending an emergency eye service within a major public tertiary teaching hospital and to identify possible targets to improve delivery of patient care. METHODS: Retrospective study of all patients (N=504) attending an acute eye clinic over a representative 2-week period within Greenlane Clinical Centre, Auckland. RESULTS: Mean age was 42.4 plus or minus 20.6 years with mean visual acuity of 6/10. Referrals came from: general-practitioners (GP) (26.2%), self-referrals (18.6%), hospital medical-officers (7.4%), accident and emergency clinics (6.6%) and optometrists (2.2%). 39.1% of patients were follow-up reviews. Main presenting symptoms were pain, red eye and reduced vision. Average waiting-time was 119 plus or minus 98 min. Major diagnoses were trauma, uveitis and adenoviral keratoconjunctivitis (AKC). Males were more likely to present with ocular trauma, whereas females were more likely to exhibit uveitis, contact-lens related keratitis and AKC. Outcomes included follow-up (48.2%), referral to speciality ophthalmology care (19.0%), referral to other clinics (5.75%), and discharge (33.7%). CONCLUSION: A significant proportion of presentations could have been appropriately referred to outpatient departments or potentially managed by primary healthcare providers. Potential initiatives to manage excessive workload demands might target prevention of ocular trauma, improved contact-lens education, limiting the spread of AKC and improved GP education.

Anatomy of the ward round: the time spent in different activities.

BACKGROUND: The ward round, central to inpatient care, has not been well studied. One recent trend is for hospitals to run at capacity by placing 'overflow' patients into 'outlying' beds. Bed occupancy rates are increased and ward rounds may require visits to many wards. The present study aims to identify the time spent in different activities on general surgical ward rounds, with particular reference to the impact of outlying patients. METHODS: For 4 days, the morning ward round was observed. Activity was timed to the second. The resulting data were analysed to compare outlying wards, acute wards and home ward patients. RESULTS: Seven hours and 7 min of ward rounds were documented. One hundred ten consultations were observed. Four hours and 4 min were spent at the bedside (58%). Sixty-six minutes were spent in transit between wards. The average times spent at the bedside and in patient discussion were similar for the different ward types. The mean average time per patient was nearly doubled for outlying patients compared with home wards (5:40 min versus 2:57 min, respectively). Although patient discussion and consultation were longer for outlying patients, most of the increased time was related to time travelling between wards (2:16 min average per patient consultation). CONCLUSION: Most of the time spent on surgical ward rounds is in patient contact. Travel time to outlying patients for morning ward rounds is more than an hour per week.

Laser scanning in vivo confocal microscopy reveals reduced innervation and reduction in cell density in all layers of the keratoconic cornea.

PURPOSE: The exact pathophysiological processes underlying keratoconus remain an enigma. In this study, laser scanning in vivo confocal microscopy (IVCM) was used to define further the microstructural abnormalities in the keratoconic cornea and to establish the relationship with disease severity. METHODS: This was a prospective, cross-sectional study comparing 52 subjects with keratoconus and 52 age-matched control subjects. Assessment included demographics, history, slit lamp biomicroscopy, computerized corneal tomography, and laser scanning IVCM. RESULTS: Significantly lower cell densities (in cells per square millimeter, mean +/- SD) were observed in keratoconus corneas than in normal ones: basal epithelial cells, 4340.6 +/- 595.2 vs. 5777.6 +/- 958.2 (P < 0.001), anterior keratocytes, 523.6 +/- 206.4 vs. 859.7 +/- 219.1 (P < 0.001), posterior keratocytes, 240.4 +/- 64.5 vs. 330.6 +/- 52.3 (P < 0.001), and endothelial cells 2412.2 +/- 339.5 vs. 2845.6 +/- 313.0 (P < 0.001). Subbasal nerve fiber density was 52.7% lower in keratoconus corneas than in the control (P < 0.001). Basal epithelial cell density (P = 0.001), subbasal nerve fiber density (P = 0.015), and anterior keratocyte density (P < 0.001) correlated with severity of disease. Lower subbasal nerve density also correlated with younger age at diagnosis (r = 0.397, P = 0.004). Severe disease was associated with diagnosis at a younger age (P = 0.023), a history of eye rubbing (P = 0.025), and Maori or Pacific Island ethnicity (P = 0.001). CONCLUSIONS: Significant microstructural abnormalities were identified at every level of the keratoconic cornea and were related to disease severity. IVCM offers a potential insight into the pathophysiology of the microstructural changes in keratoconus.

Corneal innervation and cellular changes after corneal transplantation: an in vivo confocal microscopy study.

PURPOSE: Although penetrating keratoplasty is generally considered a successful procedure, transplanted corneal tissue may exhibit abnormal epithelium, decreased sensation, and declining endothelial cell counts after surgery. This study aimed to use in vivo confocal microscopy to correlate corneal microstructure and recovery of the subbasal nerve plexus of the transplanted cornea with indications for, and time from, surgery. METHODS: This was a cross-sectional study comparing corneas from 42 patients after penetrating keratoplasty with those of 30 controls. Subjects were assessed by ophthalmic history and clinical examination, computerized corneal topography, and laser scanning in vivo confocal microscopy. RESULTS: Time from surgery ranged from 1 month to 40 years (mean, 85 +/- 105 months). Significant reductions in epithelial (P < 0.001), keratocyte (P < 0.001), and endothelial (P < 0.001) cell densities were noted in comparison with control corneas. Significant reductions in subbasal nerve fiber density (P < 0.001) and nerve branching (P < 0.001) were also noted. Endothelial cell density decreased with time after surgery (r = -0.472; P = 0.003), and nerve fiber density (r = .328; P = 0.034) increased. Keratoconus as an indication for transplantation was associated with higher subbasal nerve fiber densities (P = 0.003) than other indications for corneal transplantation. Neither nerve fiber nor cell density was correlated with best-corrected visual acuity. CONCLUSIONS: Laser scanning in vivo confocal microscopy highlights profound reductions in cell density at every level of the transplanted cornea and alterations to the subbasal plexus that are still apparent up to 40 years after penetrating keratoplasty.