Use of subconjunctival injections of 5-fluorouracil to rescue and prolong intraocular pressure reduction for a failing Ahmed glaucoma implant.

PURPOSE: 5-Fluorouracil (5-FU) has been well described for a failing trabeculectomy bleb, but not for aqueous shunts. We sought to determine whether subconjunctival 5-FU prolongs the intraocular pressure (IOP) efficacy of Ahmed shunts. METHODS: We included all patients with Ahmed FP-7 implantation by one surgeon at Yale University. Patients with <3 months follow-up were excluded. Injections were done on a case-by-case basis, usually for IOP > 21 on >2 medications. Five-milligram (0.1 cc) injections were made over the plate. The control group consisted of Ahmed FP-7 patients without injections. The main outcome measure was IOP. Secondary outcome was success (IOP <21 mmHg, 20% decrease from preoperative IOP, and no reoperation). RESULTS: The average age of controls was 72.5 ± 16.6 years, and 63.7 ± 18.8 with 5-FU (p = 0.02). Forty-four patients received 5-FU and 45 did not. Mean preoperative IOP in controls was 31.5 ± 11 mmHg on 3.1 ± 1 medications, and 31.9 ± 9.0 mmHg (p = 0.86) on 3.3 ± 0.9 medications with 5-FU (p = 0.18). At a mean 137 days after surgery, mean pre-injection IOP was 25.3 ± 7.7 mmHg on 2.0 ± 1.3 medications. Five years following implantation, control IOPs averaged 12.9 ± 7.1 mmHg (53% decrease from preoperative IOP, p < 0.001) on 1.4 ± 1.1 medications versus 17.2 ± 4.9 mmHg (46% decrease from preoperative, 32% decrease from pre-5FU IOP, p < 0.001) on 2.7 ± 0.8 medications with 5-FU. The IOP at 5 years was statistically similar in both groups (p = 0.23). Five-year success rates trended higher with 5-FU (77 vs. 67%, p = 0.38). CONCLUSIONS: Subconjunctival injection of 5-FU sustained a significant long-term decline in intraocular pressures in eyes with failing Ahmed shunts. Outcomes between eyes receiving injections and controls were statistically similar.

Irreversible Blindness Following Periocular Autologous Platelet-Rich Plasma Skin Rejuvenation Treatment.

A 49-year-old woman developed acute visual loss in the right eye following bilateral cosmetic platelet-rich plasma injections to rhytids in the glabellar region. External exam showed skin necrosis in the region over the right rhytids and restricted right ocular motility. Dilated fundus exam was significant for ophthalmic artery occlusion. Imaging revealed right eye extraocular muscle ischemia and optic nerve infarction, along with right frontal, parietal, and occipital lobe infarction. Work-up for thromboembolic and vascular etiologies were negative. To our knowledge, this is the first case reported of extensive ischemia following autologous platelet-rich plasma therapy.

Corneal crystalline deposits associated with topically applied gatifloxacin.

PURPOSE: To report a case of corneal crystalline deposits from the use of gatifloxacin 0.5% topical antibiotic after combined cataract extraction and trabeculotomy ab interno surgery. METHODS: A 59-year-old woman presented after combined cataract extraction and trabeculotomy ab interno with crystalline deposits in the anterior corneal stroma. Clinical examination and slit-lamp photography were performed. RESULTS: The slit-lamp examination showed inferior white crystal deposition in the anterior stroma with overlying punctate epithelial erosions 4 weeks postoperatively. The eye was asymptomatic, but the deposition was cosmetically noticeable to the patient. Serial slit-lamp photography demonstrated resolution of the crystalline deposits 30 days after the discontinuation of eye drops. CONCLUSIONS: The authors present a rare case of stromal crystallization from topical gatifloxacin treatment. Complete resolution of corneal deposits was seen 30 days after the discontinuation of the drops without sequelae.

Impact of simulator training on resident cataract surgery.

BACKGROUND: Virtual reality surgery simulation training improves resident performance as measured by the simulator itself and wet-lab performance. This study aims to determine whether virtual surgery simulator training improves actual resident cataract surgery performance. METHODS: The first 50 phacoemulsification cases of 20 residents, at a single residency program (Henry Ford Hospital), were retrospectively compared as two groups: before (2007-8) and after (2009-10) introduction of the Eyesi virtual surgery simulator to the surgical training program. Primary outcomes were the incidence of posterior capsule tears and operation duration. All residents received traditional didactic and wet-lab training. Instructor surgeons were surveyed for their impression of the simulator's contribution to resident surgical training. RESULTS: The nonsimulator and simulator groups each comprised 500 cases with 40 and 35 posterior capsule tears respectively. Capsular tear rates for the nonsimulator and simulator groups were 8.8 % and 10 % respectively for the first 25 cases, and 7.2 % and 3.6 % (P = 0.11) respectively for cases 26 through 50 . The percentage of long cases (defined as >40 min) for cases 10 through 50 was 42.3 % and 32.4 % (P = 0.005) for the nonsimulator and simulator groups respectively. CONCLUSIONS: Virtual reality surgical simulator training mildly shortens the learning curve for the first 50 phacoemulsification cases. The less adept residents appear to benefit most.

Insulin signaling regulates gamma-glutamylcysteine ligase catalytic subunit expression in primary cultured rat hepatocytes.

Decreased glutathione (GSH) levels and gamma-glutamylcysteine ligase (GCL) activity have been observed in diabetic patients, and insulin reportedly increases GSH synthesis via increased GCL catalytic subunit (GCLC) gene expression. The signaling pathways responsible for mediating insulin effects on GCLC expression and GSH levels, however, are unknown. The signaling pathways involved in the regulation of GSH synthesis in response to insulin were examined in primary cultured rat hepatocytes. GSH levels, GCL activity, GCLC protein, and mRNA levels were increased to 140, 160, 600, and 340% of that monitored in untreated cells, respectively, in hepatocytes cultured with 100 nM insulin. The phosphatidylinositol 3-kinase (PI3K) inhibitors, wortmannin and LY294002 [2-(4-morpholinyl)-9-phenyl-4H-1-benzopyran-4-one], dominant-negative Akt, or rapamycin, an inhibitor of mTOR (mammalian target of rapamycin) and ribosomal p70 S6 kinase (p70S6K) phosphorylation, inhibited the insulin-mediated increase in GCLC protein and GSH levels. Although the mitogen-activated protein kinases (MAPKs) extracellular signal-regulated kinase, p38 MAPK, and JNK (c-Jun N-terminal kinase) were activated in response to insulin, PD98059 (2'-amino-3'-methoxyflavone), an inhibitor of mitogen-activated protein kinase kinase, SP600125 (1,9-pyrazoloanthrone), an inhibitor of JNK, and SB203580 [4-(4-fluorophenyl)-2-(4-methylsulfinylphenyl)-5-(4-pyridyl)1H-imidazole], an inhibitor of p38 MAPK, failed to inhibit the insulin-mediated increase in GCLC protein levels. In conclusion, these data show that insulin signaling pathways involving PI3K/Akt/p70S6K, but not MAPKs, are active in the insulin-mediated regulation of GSH synthesis via increased GCLC expression.