Combined endoscopic cyclophotocoagulation and phacoemulsification versus phacoemulsification alone in the treatment of mild to moderate glaucoma.

BACKGROUND: To evaluate the long-term effects of combined endoscopic cyclophotocoagulation and phacoemulsification (phaco) versus phacoemulsification alone on intraocular pressure control and medication reliance in the treatment of mild to moderate glaucoma. DESIGN: Retrospective chart review in private practice setting by glaucoma fellowship trained surgeons. PARTICIPANTS: A total of 261 eyes in the combined phaco-endoscopic cyclophotocoagulation group with 52 eyes in the phaco-alone group. METHODS: Comparison of phaco-endoscopic cyclophotocoagulation with phaco alone over 36 months. MAIN OUTCOME MEASURES: Full and qualified success cumulative survival, intraocular pressure and medication reliance 6-36 months compared with baseline. Full success was defined as minimum 20% intraocular pressure reduction with a decrease of at least one ocular hypertensive medication. Qualified success was defined as intraocular pressure no higher than baseline with a decrease of at least one ocular hypertensive medication. RESULTS: At 36 months, mean intraocular pressure in the combined phaco-endoscopic cyclophotocoagulation group was 14.6 mmHg, whereas the phaco-alone group was 15.5 mmHg (P = 0.34). Mean medication reliance in the combined phaco-endoscopic cyclophotocoagulation group was 0.2 medications, whereas the phaco-alone group was 1.2 (P < 0.001). Full success in the phaco-endoscopic cyclophotocoagulation group was 61.4%; the phaco-alone group was 23.3% (P < 0.001). Qualified success survival was 72.6% in the phaco-endoscopic cyclophotocoagulation group and 23.3% in the phaco-alone group (P < 0.001). CONCLUSIONS: Combined phaco-endoscopic cyclophotocoagulation effectively lowers or maintains intraocular pressure and results in ocular hypertensive medication reduction up to 36 months when compared with phaco alone. Therefore, phaco-endoscopic cyclophotocoagulation may help to increase medication compliance and reduce glaucoma progression in mild to moderate glaucoma.

Effect of focal lamina cribrosa defect on glaucomatous visual field progression.

OBJECTIVE: To evaluate the association between focal, structural defects of the lamina cribrosa (LC) and glaucomatous visual field (VF) progression. DESIGN: Retrospective, observational study. PARTICIPANTS: A total of 169 patients with glaucoma (169 eyes) with a range of glaucomatous damage. METHODS: Serial horizontal and vertical enhanced-depth imaging optical coherence tomography (EDI OCT) B-scans of the optic nerve head were obtained from patients with glaucoma with 5 or more prior Humphrey 24-2 VFs (Carl Zeiss Meditec, Inc, Dublin, CA). The EDI OCT scans were reviewed for the presence of focal LC defects (laminar holes or disinsertions with a diameter >100 µm). The VF progression was defined as having ≥ 2 significantly progressing test points (with a slope calculated using pointwise linear regression [PLR], worse than -1.0 dB/year at P<0.01). Age, intraocular pressure (IOP), baseline VF mean deviation (MD), disc hemorrhage, and central corneal thickness (CCT) were recorded. MAIN OUTCOME MEASURES: The relationship between focal LC defects and the rate and risk of VF progression. RESULTS: Mean age and VF MD at the time of EDI OCT were 69 ± 12 years and -11.49 ± 6.87 dB, respectively. Sixty eyes (36%) progressed according to PLR criteria. Progression was more common in eyes with, rather than without, focal LC defects (38/81 eyes [47%] vs. 22/88 eyes [25%], P = 0.003). Among the evaluated parameters, the presence of focal LC defects, disc hemorrhage, higher mean follow-up IOP, greater number of VFs, and longer follow-up period were significantly associated with VF progression in the multivariable analyses (odds ratios, 2.90, 4.66, 1.22, 1.25, and 1.27, respectively; P = 0.010, P = 0.002, P = 0.002, P<0.001, and P<0.001, respectively). The mean global progression rate was significantly faster in the group with focal LC defect than in the group with no focal LC defect (-0.54 ± 0.99 dB/year vs. -0.28 ± 0.52 dB/year; P = 0.031). Among the 60 progressing eyes, despite no significant difference in the mean number of progressing VF points per eye (6.7 ± 7.0 vs. 6.5 ± 4.4; P = 0.899), the mean localized progression rate was significantly faster in the eyes with focal LC defects than in the eyes with no focal LC defects (-2.85 ± 1.85 dB/year vs. -1.75 ± 0.56 dB/year; P = 0.009). CONCLUSIONS: Focal LC defects are strongly associated with glaucomatous VF progression, and eyes with focal LC defects tend to progress faster than those without.

Clinical experience with sulcus-implanted Baerveldt glaucoma tube shunts fully concealed behind the iris in undilated pseudophakic eyes.

PURPOSE: To describe our clinical experience with ciliary sulcus-implanted Baerveldt glaucoma tube shunts entirely concealed behind the iris in undilated pseudophakic eyes (concealed tubes, CT group), compared with similarly implanted tubes whose openings remain fully exposed in the undilated pupillary area (nonconcealed tubes, NCT group). METHODS: A retrospective interventional nonrandomized comparative chart review. The main outcome measures were postoperative tube incarceration by the iris, and postoperative intraocular pressure (IOP) and the number of IOP-lowering medications. RESULTS: Fifteen eyes of 15 patients were identified in the CT group and 41 eyes of 41 patients in the NCT group. In the CT and NCT groups, the postoperative follow-up period was 14.4±10.2 months (mean±SD; range, 3 to 42 mo) and 22.9±18.1 months (mean±SD; range, 3 to 72 mo; P=0.08), respectively. Only 1 case of tube incarceration by the iris has occurred in the CT group (6.7%) and none in the NCT group. This eye was treated with laser iridotomy with no recurrence. Preoperative IOPs in the CT and the NCT groups were 27.2±9.6 mm Hg (mean±SD; range, 16 to 46 mm Hg) and 25.5±10.6 mm Hg (mean±SD; range, 12 to 59 mm Hg; P=0.6), respectively. The IOPs were significantly reduced to 13.3±4.1 mm Hg (mean±SD; range, 6 to 22 mm Hg; P=0.0001) and 10.8±4.4 mm Hg (mean±SD; range, 4 to 25 mm Hg; P=0.0001), respectively, at the final visit. The difference in the final visit IOP between the groups approached significance (P=0.056). The number of preoperative IOP-lowering medications was 3.9±0.7 (mean±SD; range, 2 to 5) and 4.0±1.0 (mean±SD; range, 1 to 6), respectively. It was significantly reduced to 1.9±1.2 (mean±SD; range, 0 to 4; P=0.0001) and 1.8±1.4 (mean±SD; range, 0 to 5; P=0.0001), respectively. There was no significant difference between the groups before (P=0.6) or after surgery (P=0.8). CONCLUSIONS: Although NCTs tend to have a lower final IOP compared with CTs, the latter are safe and effective and do not require surgical repositioning. Should a CT become occluded by the iris, an uncommon event in our study, it could be treated by laser iridotomy alone.

Glaucoma and obstructive sleep apnoea syndrome.

Glaucoma is increasingly recognized as a manifestation of both ocular and systemic risk factors. A number of disorders associated with reduced blood flow and ischaemia, collectively termed vascular risk factors, such as migraine, Raynaud's phenomenon, atrial fibrillation and reduced nocturnal blood pressure, lead to decreased ocular perfusion pressure. During sleep, alterations occur in cardiovascular physiology that are balanced by autoregulation to maintain homeostasis. However, in obstructive sleep apnoea (OSA), the normal physiological balance is upset. A potentially modifiable risk factor, OSA has been increasingly associated with glaucoma independent of intraocular pressure. OSA may alter blood flow to the optic nerve head and, in combination with other predisposing factors, lead to decreased ocular perfusion pressure. This in turn may directly affect the optic nerve or it may indirectly increase its susceptibility to other insults. The purpose of this review is to shed light on the association between OSA and glaucoma.

Intrauterine injury simulating abusive head trauma.

PURPOSE: The purpose of this study was to describe a patient with intrauterine injury simulating abusive head trauma and its management. METHODS: A case report of a premature infant born at 35 weeks 2 days through an uncomplicated vaginal delivery was found to have cerebral hemorrhages on magnetic resonance imaging after presenting with respiratory distress. The infant was referred to us for bilateral subconjunctival hemorrhages and periorbital edema. We performed serial ophthalmologic examinations, reviewed all prenatal history with the mother of the infant, and reviewed all relevant hospital notes, laboratory results, and imaging results. RESULTS: On ophthalmologic examination, the patient was found to have vitreous and retinal hemorrhages bilaterally. Prenatal history showed intrauterine trauma inflicted by the mother in the setting of an atraumatic delivery. The patient required bilateral vitrectomies to prevent amblyopia. CONCLUSION: Intrauterine injury may simulate abusive head trauma, and it is important for clinicians to recognize this presentation to prevent further harm to the infant and prevent devastating visual loss.

Manipulating the mandibular distraction site at different stages of consolidation.

PURPOSE: The purpose of this study was to define optimal timing and conditions for correcting an open bite side effect by manipulating the distraction site with orthodontic springs after mandibular distraction. MATERIALS AND METHODS: At 0, 1, 2, 3, and 8 weeks postdistraction, interarch springs were attached for 2 weeks to close distraction-produced open bites in 45 rabbits. Distractors were removed in half of the animals receiving spring treatment. Segment position was recorded by weekly direct measurements and radiographs. Tissue samples were collected at the end of spring application for microcomputerized tomography analysis and measurements of lateral symmetry. RESULTS: Orthodontic springs closed the open bite with or without distractors in place immediately after distraction and partially corrected the bite at later stages of bone consolidation. Distractor removal produced more rapid bite closure but also introduced lateral buckling of the distraction site during early consolidation. The lateral buckling was not observed if springs were applied after 2 weeks of consolidation. The amount of bite correction with orthodontic springs correlated with mineralization of the distraction site. CONCLUSION: During the consolidation period, a distraction site can be callus manipulated with orthodontic springs to correct an open bite. The amount of correction depended on when springs were placed and whether distractors were removed at the time of spring application.