Reoperations for complications within 90 days after gel stent implantation or trabeculectomy.

PURPOSE: To describe reoperations in the operating room for complications that occurred within the first 90 days after gel stent implantation or trabeculectomy at a single institution over 5 years. METHODS: In this retrospective chart review, patients who have undergone gel stent implantation with mitomycin C (MMC) or trabeculectomy with MMC were enrolled. Postoperative complications that required reoperations within the first 90 days were evaluated. RESULTS: A total of 510 surgeries were performed on 392 patients over a 57-month period by 2 glaucoma surgeons. Of these, 284 were gel stent implantation, and 226 were trabeculectomy. Combined phacoemulsification was performed in 52/284 (18.3%) in the gel stent group and in 26/226 (11.5%) of eyes in the trabeculectomy group (p = 0.03). Reoperations took place in 13/510 (2.5%) eyes, including 4/284 (1.4%) in the gel stent group, 9/226 (4.0%) in the trabeculectomy group (p = 0.07). In the gel stent group, indications for reoperation were bleb failure (2), suprachoroidal hemorrhage (1), bullous keratopathy (1). In the trabeculectomy group, indications for reoperation were bleb failure (3), overfiltration (2), persistent wound leak (2), aqueous misdirection (2). CONCLUSIONS: The rates of reoperation for early postoperative complications after gel stent or trabeculectomy was low and comparable with previous studies. A slightly higher number of reoperations within 90 days was observed in the trabeculectomy group than the gel stent group despite the more significant number of combined procedures in the latter group. Bleb failure was the most common indications for reoperation in both groups. Excessive outflow was a cause of reoperation mostly in the trabeculectomy group.

Trabeculectomy versus Xen gel implant for the treatment of open-angle glaucoma: a 3-year retrospective analysis.

OBJECTIVE: To compare the two surgical techniques in terms of efficacy, safety, and postoperative management over 36 months of follow-up. METHODS: This retrospective clinical cohort study compared the outcome of trabeculectomy surgery and Xen gel implant in patients having uncontrolled glaucoma. Patients were recruited using the following inclusion criteria: uncontrolled intraocular pressure (IOP) on maximally tolerated medical therapy, healthy conjunctiva freely mobile in the superior sector, open-angle, glaucomatous visual field damage, full follow upfollow-up of at least 36 months. Thirty-four patients were submitted to trabeculectomy and 34 to Xen gel implant. We set the lower limit at 6mmHg mm Hg and the upper limit ≤12 mm Hg for criteria A, upper limit to ≤15 mm Hg for criteria B and upper limit ≤18 mm Hg for criteria C. Criteria for success have been characterizedcharacterised according to whether or not this has been achieved without (complete success) or with IOP -lowering medications (qualified success). RESULTS: For all survival curves, trabeculectomy was superior to Xen gel implant. When considering complete success, the log-rank test for criteria A was statistically significant (pp=0.006), marginally significant for criteria B (pp=0.065) and not significant for criteria C (pp=0.23). When qualified success was considered, trabeculectomy was superior to Xen gel for criteria A, B, and C (pp=0.012, pp=0.033 and pp=0.025, respectively). Higher number of post-operative flat chamber and bleb leakage was observed in the trabeculectomy group. CONCLUSION: Xen gel implant techniques offer a better safety profile but a lower IOP reduction compared to compared with the gold -standard technique.

Moving beyond the Slit-Lamp Gonioscopy: Challenges and Future Opportunities.

After almost a century from its introduction in clinical practice, slit-lamp gonioscopy is still considered the reference standard for evaluating the anterior chamber angle (ACA). Gonioscopy is essential for diagnosing angle closure disease, and ACA features are included in glaucoma's diagnostics and treatments algorithms. However, shortcomings of slit-lamp gonioscopy include a steep learning curve, lack of agreement between examiners and poor documentation. Thanks to advances in miniaturization and computing, new instruments for digital gonioscopy have been developed and marketed. This narrative review focuses on the Gonioscope GS-1, which permits semi-automated circumferential documentation of the ACA in real-colour photographs. Advantages and disadvantages of GS-1 compared with slit-lamp gonioscopy and other ACA imaging technologies such as optical coherence tomography are discussed. Finally, potential opportunities offered by this device for telemedicine, virtual clinics, and automatic classification with deep learning are presented.

Delayed Re-epithelialization After Epithelium-Off Crosslinking: Predictors and Impact on Keratoconus Progression.

Purpose: To investigate the demographic and corneal factors associated with the occurrence of delayed reepithelialization (DRE) after epithelium-off crosslinking (epi-off CXL). Design:Retrospective case series. Methods:A chart review was performed to identify patients treated with epi-off CXL. DRE was defined as a corneal epithelial defect detected by fluorescein staining that persisted for more than 10 days. Slit-lamp examination, anterior segment optical coherence tomography, corneal topography, and corneal in vivo confocal microscopy (IVCM) were always performed preoperatively and at each follow-up visit (1, 3, 6, 12 months). A generalized estimating equation was used to assess the baseline factors associated with DRE. Results:Data from 153 eyes were analyzed. The mean age of patients was 24.9 ± 8.5 years, and 47 (30.7%) were women. The average reepithelization time was 4.7 ± 1.8 days. Six eyes (3.9%) experienced DRE. In the multivariate model, both the age of the patient (OR = 1.30; p = 0.02) and the corneal steepest meridian (OR = 0.44, p = 0.047) were associated with DRE. Baseline nerve count was also associated with DRE (0.87, p = 0.03). Male gender was associated with a slower early nerve regrowth (1-6 months) (p = 0.048), but not with the occurrence of DRE (p = 0.27). Preoperative central corneal thickness was not related to DRE (p = 0.16). DRE was not associated with keratoconus progression after epi-off CXL (p = 0.520). Conclusions:The association between DRE and age may reflect the age-related decrease in the corneal healing response. Also, low baseline corneal nerve count is associated with DRE. Gender seems to affect reinnervation measured by IVCM but not the reepithelization time. DRE does not seem to affect the efficacy of epi-off CXL.

Early Postoperative Intraocular Pressure is Associated With Better Pressure Control After XEN Implantation.

PRéCIS:: Gel stent implantation is a bleb-forming surgery designed to achieve predictable pressure drop. An early low intraocular pressure (IOP) is associated with the long-term success of the procedure. PURPOSE: To identify the variables associated with the success of the XEN procedure. PATIENTS AND METHODS: This was part of a prospective, uncontrolled, consecutive case series study. Patients with primary open-angle glaucoma or pseudo-exfoliative glaucoma were included. All the patients underwent surgical XEN implant procedure with mitomycin-C subconjunctival injection 20 minutes before surgery. Success criteria were an off-medication IOP of 6 to 16 mm Hg 12 months after surgery; no additional glaucoma surgery; no visual threatening complications, no visual acuity loss >1 Snellen line. One eye per patient was considered for statistical analysis. A univariate Cox proportional hazard regression analysis was performed to identify potential risk factors for surgical failure. Then, a multivariate Cox model was built. RESULTS: One hundred twenty-three patients were recruited in this study: 93 patients underwent XEN implantation alone whereas 30 the combined procedure with phacoemulsification and intraocular lens implantation. Univariate Cox regression showed that the day after surgery intraocular lens>9 mm Hg was associated with surgical failure (P=0.02) and a postoperative number of needlings ≥2 in the follow-up was also predictive of surgical failure (P<0.01). These data were confirmed by a multivariate model too. At 1 year the surgical success criteria were 76% in the group with 24-hour IOP≤9 mm Hg, whereas it was 43% when above 9 mm Hg (P=0.026). CONCLUSIONS: Our study shows that an early IOP≤9 mm Hg is predictive of the efficacy of the procedure during 1-year follow-up, whereas more than 2 needlings are predictive of failure.

[Aorto-oesophageal fistula due to an aortic endovascular prosthesis: case report and state of the art]. / Fistola aorto-esofagea da protesi aortica endovascolare: caso clinico e stato del'arte.

Aorto-oesophageal fistula is a rare and often fatal condition due to pathologies of the aorta and oesophagus. Recently, a new aetiology for aorto-oesophageal fistulas has been detected, namely, decubitus of an aortic endovascular prosthesis positioned in the presence of aneurysms. The symptoms are those of Chiari's triad: (1) chest pain and/or dysphagia (2) haematemesis (3) massive haematemesis. If the patient is haemodynamically stable the gold standard diagnostic examination is a CT scan with contrast medium. Aorto-oesophageal fistulas are characterised by a rapidly worsening acute clinical presentation and high postoperative morbidity and mortality. The treatment of aorto-oesophageal fistula is divided into three progressive steps: (1) control of bleeding; (2) prevention of mediastinitis; (3) oesophageal repair. We report a case of a 59-year-old male patient with an aorto-oesophageal fistula due to the decubitus of an endovascular aortic prosthesis previously positioned for a traumatic aneurysm of the descending aorta. We controlled the bleeding in emergency with a Sengstaken-Blakemore tube. Since the cardiovascular surgeons excluded any intervention, we executed a bipolar oesophageal exclusion in our department of general surgery and subsequently positioned a self-expanding oesophageal prosthesis by a retrograde route. The patient survived for 7 months, the cause of death being septic shock.

[Early stoma closure in colorectal resections after endoscopic monitoring of the anastomosis. Clinical results]. / Chiusura precoce di stomia dopp dopresezione del retto previo controllo anastomotico endoscopico. Risultati clinici.

The need for a protection of a colo-colonic or colorectal anastomosis (by a colostomy or ileostomy) does not always encounter a general consensus except in selected clinical settings such as a low or ultra-low colorectal anastomosis or a colo-colonic or colorectal anastomosis after resection for acute disease. Commonly, a protective stoma is closed within 3-6 months after x-ray or endoscopic monitoring of the anastomosis. We believe in the importance of an open debate on the timing of bowel reconstruction and on the ways of monitoring the anastomosis. The aim of our study was to confirm the feasibility of early closure of stomas without specific increased risks, and especially to demonstrate the usefulness of early endoscopic monitoring of the anastomosis. We present 26 consecutive patients who underwent a left colonic resection or a colorectal resection with a stoma constructed for protection. In these patients the early restoration of bowel continuity was achieved between postoperative days 8 and 15 after endoscopic monitoring. There have been no specific complications related to the endoscopic manoeuvre. The morbidity rate after early bowel continuity restoration was 4.1%, which is lower than the rates encountered in the literature (6-8.6%). We consider as innovative the concept of early endoscopic monitoring, which is commonly not indicated in the presence of a recent anastomosis. We believe that in selected conditions the risk of perforation due to this manoeuvre can be eliminated.

[Direct electric conduction glove for laparoscopic surgical instruments. Preliminary results of a prototype]. / Conduzione elettrica diretta guanto-strumento chirurgico laparoscopico. Risultati preliminari di un prototiopo.

The authors present their prototype of a system for electrical conduction in direct contact with laparoscopic tools, devised, designed and produced by them at the Politecnico di Torino Department of Mechanical Engineering. The system consists of a two-sided plate, one side being a non-conducting adhesive surface to stick to the surgical glove and the other a thin, flexible conductor shell. The authors used the instrument with surgical tools with metal handles during 4 laparoscopic procedures. Nowadays the method commonly used to electrify laparoscopic tools is by using a wire plugged to a fixed conducting point on the instrument. The prototype described here was devised and produced to avoid some of the awkwardness encountered during the numerous manoeuvres required to connect and disconnect the wire at the time of surgical intervention. This device permits the direct transfer (by contact) of electrical energy from the wire to surgical tools. The advantage is greater rapidity in changing surgical tools, with the possibility of immediately obtaining an electrified instrument in the surgeon's hand.