Ex-PRESS Miniature Glaucoma Shunt Versus Ahmed Glaucoma Valve in the Surgical Treatment of Glaucoma in Pseudophakic Patients.

PURPOSE: The aim of this study was to compare the 3-year outcome of Ex-PRESS miniature glaucoma shunt versus Ahmed glaucoma valve in pseudophakic patients. PATIENTS AND METHODS: We retrospectively reviewed the records of patients with a history of clear corneal phacoemulsification alone, or failed trabeculectomy following phacoemulsification, who subsequently underwent Ahmed glaucoma valve (AGV) implantation or Ex-PRESS shunt surgery. The main outcome measure, surgical success, was defined as an intraocular pressure between 5 and 21 mm Hg and a 20% intraocular pressure reduction from baseline (with/without glaucoma medications) without glaucoma reoperation. RESULTS: In total, 92 patients (92 eyes) were included (43 AGV, 49 Ex-PRESS). Overall success at 3 years was 92.7% for AGV and 66.1% for Ex-PRESS (P=0.006). AGV had a higher success rate in patients with prior phacoemulsification and failed trabeculectomy (96% AGV vs. 64.1% Ex-PRESS; P=0.023). There was no difference in success rate for patients with only previous phacoemulsification (87.5% AGV vs. 69.4% Ex-PRESS; P=0.205). Glaucoma reoperation rates were 4.6% and 30.6% in the AGV and Ex-PRESS group, respectively (P=0.001). Both procedures had similar complication rates. CONCLUSIONS: AGV compared with Ex-PRESS shunt, had a higher success rate for secondary surgeries but not primary surgeries, in patients with prior clear corneal phacoemulsification. The AGV surgery also had a lower overall glaucoma reoperation rate.

Use of Autologous Scleral Graft in Ahmed Glaucoma Valve Surgery.

PURPOSE: To compare the efficacy of an autoscleral free-flap graft versus an autoscleral rotational flap graft in Ahmed glaucoma valve (AGV) surgery. PATIENTS AND METHODS: Medical records (2005 to 2012) of 51 consecutive patients (51 eyes) who underwent AGV surgery with the use of either an autoscleral free-flap graft or an autoscleral rotational flap graft to cover the external tube at the limbus were retrieved for review. The main outcome measure was the incidence of tube exposure associated with each surgical approach. RESULTS: Twenty-seven consecutive patients (27 eyes) received a free-flap graft and 24 consecutive patients (24 eyes) received a rotational flap graft. The mean follow-up time was 55.6 ± 18.3 months for the former and 24.2± 5 .0 months for the latter (P<0.0001). Two patients in the free-flap group (8.9%) developed tube exposure at 24 and 55 months postoperatively compared with none of the patients in the rotational flap group. Graft thinning without evidence of conjunctival erosion was observed in 15 patients (55%) in the free-flap group and in 7 patients (29.1%) in the rotational flap group. CONCLUSIONS: The use of an autoscleral rotational flap graft is an efficacious technique for primary tube patch grafting in routine AGV surgery, and yielded better results than an autoscleral free-flap graft. Its main advantages over donor graft material are availability and lower cost.

Retinal nerve fibre layer thickness measurements by optical coherence tomography in patients with sleep apnoea syndrome.

BACKGROUND: The study aims to investigate whether retinal nerve fibre layer (RNFL) abnormalities can be detected in patients with obstructive sleep apnoea/hypopnoea syndrome with normally appearing optic disc. DESIGN: This is an observational case-control study. PARTICIPANTS: One hundred and eight consecutive patients with moderate or severe obstructive sleep apnoea/hypopnoea syndrome (OSAHS) as determined by overnight polysomnography and normal looking discs and 108 age-matched healthy controls were included in the study. METHODS: All patients underwent RNFL examinations by optical coherence tomography using fast retinal nerve fibre layer thickness scan. MAIN OUTCOME MEASURES: The main outcome measure was RNFL thickness. RESULTS: Multivariate regression analysis results showed that the RNFL was thinner for a patient with OSAHS than that of a normal control in the average by 4.20 µm (P < 0.003), in the superior quadrant by 4.83 µm (P = 0.028) and in the inferior quadrant by 5.19 µm (P = 0.016). RNFL thickness did not correlate with the severity of the disease. CONCLUSIONS: RNFL thinning was detected in normal-looking discs of patients with advanced OSAHS, but the extent of this thinning did not correlate with the severity of the disease. Longitudinal follow-up is needed to clarify whether RNFL thinning in OSAHS patients with normal clinically appearing optic nerves will eventually lead to glaucoma.

Lowering of IOP by echothiophate iodide in pseudophakic eyes with glaucoma.

PURPOSE: We retrospectively investigated the intraocular pressure (IOP)-lowering effects of echothiophate iodide (EI) as adjunctive treatment for pseudophakic glaucoma patients who were receiving maximal medical therapy (MMT), including the newer class of medications, i.e., prostaglandin analogs, alpha-2 agonists, and topical carbonic anhydrase inhibitors. METHODS: The medical records of all pseudophakic glaucoma patients (24 eyes) under MMT who received supplementary EI 0.125% between January 2002 and December 2003 were reviewed. IOP data and number of medications before, during and after EI treatment were collected. RESULTS: Adding EI to MMT further reduced IOP in 23 of 24 eyes. Three eyes (12.5%) showed some lowering of IOP, but not enough to be considered controlled (IOP above the target pressure). The mean baseline IOP of 30.4 +/- 8.2 mmHg (median 29 mmHg) dropped at final follow-up (11.2 +/- 3.9 months) to 16.6 +/- 4.2 mmHg (median 17 mmHg, p < 0.0001) in all eyes that had showed effective pressure reduction upon the addition of EI. Their IOP rose to 27.7 +/- 8.0 mmHg (median 28 mmHg, p < 0.001) when EI was discontinued because of commercial non-availability. IOP reduction was > or =20% in 18 (75%) eyes and > or =30% (a mean decrease of 16.7 +/- 8.3mmHg) in 15 eyes (63%). Four eyes (16.6%) required a trabeculectomy despite EI supplement. Five eyes were re-challenged with EI when a small amount was released for sale: their IOP of 26.6 +/- 7.1 mmHg after the first EI discontinuation had dropped to 16.4 +/- 4.3 mmHg (p < 0.0001) and rose to 29.6 +/- 7.1 mmHg when EI was again discontinued. The recorded EI-associated side effects were increased miosis in all eyes and headache (8/24 patients), neither of which were reasons for discontinuation of the drug in any patient. CONCLUSION: EI substantially decreased the IOPs in pseudophakic glaucoma eyes receiving maximal medical therapy, including the newer class of medications. This drug may be the last resort for post-cataract advanced glaucoma patients and may obviate the need for filtering surgery among the very elderly.

Refractive surgery in Israel Defense Forces recruits.

PURPOSE: To determine the prevalence of refractive surgery history in recruits for military service in the Israel Defense Forces (IDF) between 1998 to 2005 and to evaluate the effect of surgery on the recruits' fitness to serve in combat units. SETTING: Surgeon General's HQ, Medical Corps, Israel Defense Forces. METHODS: The computerized medical records of all ametropic Israeli army inductees were reviewed. They included spectacle-wearing, contact lens-wearing, and post refractive-surgery individuals who were examined in the recruitment office before their compulsory military service. The extracted data from the personal files consisted of the assignment to combat units of those who had refractive surgery and those who wore corrective eyewear and the first and last military position of all ametropic recruits who were assigned to combat units. RESULTS: Five hundred ninety-seven inductees (513 men, 84 women) had refractive surgery before their military service during the study period. The prevalence of recruits who had refractive surgery increased from 0.8/1000 ametropes in 1998 to 4.9/1000 ametropes in 2005. Significantly more recruits who had surgery (73.5%) than recruits who wore corrective eyewear were assigned to combat units (P<.001). The dropout rate from combat units of the former was significantly lower than that of the latter (13.1% versus 29.2%) (P<.001). CONCLUSIONS: More corrective eyewear users had refractive surgery before their IDF military service, and relatively more of them applied for combat duty. The high percentage of recruits who had refractive surgery who serve uninterruptedly in combat units indicates that the procedure has no deleterious effect on the recruits' fitness.

Ophthalmic complications of dental anesthesia: three new cases.

Two patients had ipsilateral optic neuropathy and one patient had an ipsilateral abduction deficit and a dilated, poorly reactive pupil immediately after anesthesia of upper alveolar teeth. In one patient with optic neuropathy, the optic disc was not swollen, brain and orbit computed tomography (CT) was negative, and vision recovered completely within 2 weeks. In the other patient with optic neuropathy, the optic disc was swollen, brain and orbit CT were negative, and vision did not recover. In the patient with ductional and pupil deficits, recovery was complete within 24 hours. Since 1960, 39 cases of ophthalmic complications have been reported in the English literature. A majority have followed anesthesia of upper alveolar teeth. In all but three cases, the deficits were temporary. Diffusion, inadvertent needle penetration into the orbit, venous injection, or retrograde arterial injection is postulated as the mechanism by which the anesthetic agent reaches the cavernous sinus or orbit to cause the deficits.

Long-term intraocular pressure control after clear corneal phacoemulsification in glaucoma patients.

PURPOSE: To evaluate long-term IOP control after sutureless clear corneal phacoemulsification in eyes with preoperatively controlled glaucoma. SETTING: Institutional study. METHODS: The charts of 345 patients who had uneventful sutureless clear corneal phacoemulsification with acrylic foldable lens (IOL) implantation were retrospectively reviewed. Included were 58 patients with medically controlled open-angle glaucoma and 287 normal controls. Follow-up was 1 to 2 years. Outcome measures were postoperative IOP and number of glaucoma medications. RESULTS: Postoperatively, there was an insignificant decrease in IOP in the glaucoma group; the mean decrease was 1.5 mm Hg +/- 4.4 (SD) at 12 months and 1.9 +/- 4.9 mm Hg at 24 months. The mean number of medications decreased significantly at 12 months (0.53 +/- 0.86) and at 24 months (0.38 +/- 0.9) (P=.04). The control group also had a significant decrease in IOP, with a mean decrease of 0.72 +/- 3.7 mm Hg at 12 months (P=.01) and 1.33 +/- 3.2 mm Hg at 24 months (P<.0001). The decrease in IOP was more pronounced in eyes with a higher preoperative IOP in both the glaucoma and control groups. CONCLUSIONS: These findings suggest that sutureless clear corneal phacoemulsification with foldable acrylic IOL implantation is a relatively simple and efficient surgical option in patients with cataract and well-controlled glaucoma. The approach combines long-term IOP control with fewer medications and leads to rapid visual rehabilitation.

Stabilization of post-trabeculectomy flat anterior chamber with Healon and sulfur hexafluoride.

We present the management of 2 cases of post-trabeculectomy flat anterior chamber with hypotony due to an overflowing fistula. When separate attempts to reform the anterior chamber by intracameral injection of sulfur hexafluoride (SF(6)) and sodium hyaluronate 1.0% (Healon) failed, we injected SF(6) 100% with Healon into the anterior chamber. This stabilized the anterior chamber without compromising the integrity of the filtering bleb. No complications were observed. This simple, safe, and effective procedure offers another option for the management of a flat anterior chamber due to overfiltration.