Non-penetrating filtration surgery versus trabeculectomy for open-angle glaucoma.

BACKGROUND: Glaucoma is the second commonest cause of blindness worldwide. Non-penetrating glaucoma surgeries have been developed as a safer and more acceptable surgical intervention to patients compared to conventional procedures. OBJECTIVES: To compare the effectiveness of non-penetrating trabecular surgery compared with conventional trabeculectomy in people with glaucoma. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to September 2013), EMBASE (January 1980 to September 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to September 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 27 September 2013. SELECTION CRITERIA: This review included relevant randomised controlled trials (RCTs) and quasi-RCTs on participants undergoing standard trabeculectomy for open-angle glaucoma compared to non-penetrating surgery, specifically viscocanalostomy or deep sclerectomy, with or without adjunctive measures. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed the titles and abstracts of the search results. We obtained full copies of all potentially eligible studies and assessed each one according to the definitions in the 'Criteria for considering studies' section of this review. We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included five studies with a total of 311 eyes (247 participants) of which 133 eyes (participants) were quasi-randomised. One hundred and sixty eyes which had trabeculectomy were compared to 151 eyes that had non-penetrating glaucoma surgery (of which 101 eyes had deep sclerectomy and 50 eyes had viscocanalostomy). The confidence interval (CI) for the odds ratio (OR) of success (defined as achieving target eye pressure without eye drops) does not exclude a beneficial effect of either deep sclerectomy or trabeculectomy (OR 0.98, 95% CI 0.51 to 1.88). The odds of success in viscocanalostomy participants was lower than in trabeculectomy participants (OR 0.33, 95% CI 0.13 to 0.81). We did not combine the different types of non-penetrating surgery because there was evidence of a subgroup difference when examining total success. The odds ratio for achieving target eye pressure with or without eye drops was imprecise and was compatible with a beneficial effect of either trabeculectomy or non-penetrating filtration surgery (NPFS) (OR 0.79, 95% CI 0.35 to 1.79). Operative adjuvants were used in both treatment groups; more commonly in the NPFS group compared to the trabeculectomy group but no clear effect of their use could be determined. Although the studies were too small to provide definitive evidence regarding the relative safety of the surgical procedures we noted that there were relatively fewer complications with non-filtering surgery compared to trabeculectomy (17% and 65% respectively). Cataract was more commonly reported in the trabeculectomy studies. None of the five trials used quality of life measure questionnaires. The methodological quality of the studies was not good. Most studies were at high risk of bias in at least one domain and for many, there was lack of certainty due to incomplete reporting. Adequate sequence generation was noted only in one study. Similarly, only two studies avoided detection bias. We detected incomplete outcome data in three of the included studies. AUTHORS' CONCLUSIONS: This review provides some limited evidence that control of IOP is better with trabeculectomy than viscocanalostomy. For deep sclerectomy, we cannot draw any useful conclusions. This may reflect surgical difficulties in performing non-penetrating procedures and the need for surgical experience. This review has highlighted the lack of use of quality of life outcomes and the need for higher methodological quality RCTs to address these issues. Since it is unlikely that better IOP control will be offered by NPFS, but that these techniques offer potential gains for patients in terms of quality of life, we feel that such a trial is likely to be of a non-inferiority design with quality of life measures.

Pneumatic trabecular bypass versus trabeculotomy in the management of primary congenital glaucoma.

BACKGROUND: The optimal surgical management in primary congenital glaucoma (PCG) remains a subject of debate. The aim of this study was to assess efficacy of pneumatic trabecular bypass (PTB) in comparison to conventional trabeculotomy (T) in the treatment of PCG. METHODS: In a prospective comparative experimental study, one eye per child suffering from PCG underwent either PTB or T. Complete examinations were performed before surgery, postoperatively at one and seven days, then monthly for a minimum of six months. The main outcome measures were the IOP, number of IOP-lowering medications, change in cup/disc ratio, and corneal clarity. RESULTS: Seventeen eyes (patients) were operated on for PTB compared to 25 eyes (patients) in the T group. The mean (±SD, range) preoperative IOP in the PTB and T groups was 34.7 (6.4, 26-48) mmHg and 26.4 (6.6, 18-44) mmHg, respectively, and these dropped at six months of follow-up to 14.9 (3.6, 11-24) mmHg and 18.8 (8.0, 6-34) mmHg, respectively. The mean reductions of IOP were 55.87 %(±11) and 28.4 %(±28.8), (p = 0.001), where those for cup/disc ratio were 39.0 %(±29) and 17.5 %(±39.7) (p = 0.088) in the PTB and T groups, respectively. The number of IOP-lowering medications had dropped from 1.7 ± 0.5 to 0.7 ± 1.0 in PTB patients, compared to an insignificant change in the T group (0.64 ± 0.9 & 0.62 ± 0.9 pre- and post-operatively respectively). Corneal clarity improved in 13 eyes (76.5 %) in the PTB group, while three eyes (12 %) had worsened in the T group. Total cumulative chances for success were 88.2 % (15 out of 17 eyes), compared to 56 % (14 out of 25 eyes), in the PTB and T groups, respectively (p = 0.027). CONCLUSIONS: PTB is a promising surgical technique for the control of primary congenital glaucoma. A randomized controlled trial with a longer follow-up is recommended.

Eye trauma during the 2011 Egyptian revolution.

BACKGROUND: Cairo university hospitals are at the heart of Cairo with close proximity to Tahrir (Liberation) square and had received the vast majority of casualties during the Egyptian revolution. The aim of this study was to analyze the eye injuries during the uprising. DESIGN: Retrospective cohort study. METHODS: Data were obtained from patients' paper records, interview with treating ophthalmologists, and whenever possible patients were interviewed and examined. An electronic medical template had been specially developed for recording these data. Main outcome measures were the flow of patients and their demographics, diagnoses, visual acuities pre and post interventions, investigations and management. Whenever required results were compared at 95 % confidence interval. RESULTS: There were 184 patients (mean age 27.3 ± 9.6 years) with 195 injured eyes of whom 96.7 % were males and 11 patients had both eyes injured. Seventy seven percent of patients had been admitted within 24 h of injury. Open globe injuries comprised 87 % of the eyes of which 147 eyes received 259 imaging investigations. The presenting visual acuities were worse than 3/60 in 72.5 % of eyes which were even worse post interventions and that was significantly dependent on the presenting vision. Wound repair was the primary intervention in 85 % of eyes while 50 % of the secondary interventions were vitrectomies. CONCLUSIONS: Presenting visual acuity is a valid prognostic factor in the setting of mass eye casualty. Management of open globe injuries continues to pose difficult challenges especially bilateral ones.

Composite Classical Hodgkin Lymphoma and Mantle Cell Lymphoma: A Case Report.

Composite lymphoma implies the presence of two or more morphological and immunophenotypical subtypes of lymphoma in a single tissue or organ. Composite lymphoma with concurrent mantle cell lymphoma (MCL) and classical Hodgkin lymphoma is extremely rare. In this case report, we present the case of a 70-year-old male who was diagnosed with a composite of MCL and classical Hodgkin lymphoma (cHL) and achieved near-complete resolution with chemoimmunotherapy. To the best of our knowledge, this is the first case of this kind demonstrating the effectiveness of a combination chemoimmunotherapy regimen leading to complete remission in composite lymphoma involving MCL and cHL. We report the history, imaging findings, and pathology and illustrate the challenges in therapeutic decision-making in managing composite lymphoma patients involving MCL and cHL. We also review the literature on this rare entity and discuss its clinical implications.

Diabetic microaneurysms detected by fluorescein angiography spatially correlate with regions of macular ischemia delineated by optical coherence tomography angiography.

Purpose: To characterize the relationship between diabetic macular ischemia (DMI) delineated by optical coherence tomography angiography (OCTA) and microaneurysms (MAs) identified by fundus fluorescein angiography (FFA). Methods: Patients with diabetic retinopathy (DR) who underwent OCTA and FFA were retrospectively identified. FFA images were cropped and aligned with their respective OCTA images using i2k Align Retina software (Dual-Align, Clifton Park, NY, USA). Foveal avascular zone (FAZ) and ischemic areas were manually delineated on OCTA images, and MAs were marked on the corresponding FFA images before overlaying paired scans for analysis (ImageJ; National Institutes of Health, Bethesda, MD, USA). Results: Twenty-eight eyes of 20 patients were included. The average number of MAs identified in cropped FFA images was 127 ± 42. More DMI was noted in the superficial capillary plexus (SCP; 36 ± 13%) compared to the deep capillary plexus (DCP; 28 ± 14%, P < 0.001). Similarly, more MAs were associated with ischemic areas in SCP compared to DCP (92.0 ± 35.0 vs. 76.8 ± 36.5, P < 0.001). Most MAs bordered ischemic areas; fewer than 10% localized inside these regions. As DMI area increased, so did associated MAs (SCP: r = 0.695, P < 0.001; DCP: r = 0.726, P < 0.001). Density of MAs surrounding FAZ (7.7 ± 6.0 MAs/mm2) was similar to other DMI areas (SCP: 7.0 ± 4.0 MAs/mm2, P = 0.478; DCP: 9.2 ± 10.9 MAs/mm2, P = 0.394). Conclusion: MAs identified in FFA strongly associate with, and border areas of, DMI delineated by OCTA. Although more MAs are localized to SCP ischemia, the concentration of MAs associated with DCP ischemia is greater. By contrast, few MAs are present inside low-flow regions, likely because capillary loss is associated with their regression.

First versus second eye intravitreal ranibizumab therapy for wet AMD.

PURPOSE: To evaluate the short-term visual outcomes after intravitreal ranibizumab for wet age-related macular degeneration, when used in first eyes (good vision in the untreated eye) compared with second eyes (significant visual impairment in the untreated eye). METHODS: Seventy-five consecutive patients who received intravitreal ranibizumab injection were divided into Group A, comprising 35 first eyed patients and Group B, comprising 40 second eyes. Visual acuity and contrast sensitivity was compared before treatment, and 3 months after the 3rd injection. Results were compared at 95% confidence interval. RESULTS: Mean pretreatment logMar visual acuity was 0.86 (standard deviation 0.28) in Group A whereas Group B was 0.66 (standard deviation 0.36) (P = 0.007). Posttreatment the mean visual acuity in Group A was 0.63 (standard deviation 0.37) and in Group B was 0.44 (standard deviation 0.33) (P = 0.02). The mean numbers of letters gained per patient were 11.1 (Group A) and 10.6 (Group B). Half of all patients showed significant improvement of visual acuity (> or =15 letters gain). Contrast sensitivity significantly improved in both groups and was usually, but not always, associated with visual gain. CONCLUSION: Second eye patients tend to present to clinical diagnosis at a better visual acuity than first ones and subsequently have better chances for better posttreatment visual acuity. However, both groups have an equal chance of significant visual improvement.

Novel CYP1B1 mutations and a possible prognostic use for surgical management of congenital glaucoma.

AIM: To identify CYP1B1 gene mutations and evaluate their possible role as a prognostic factor for success rates in the surgical management of Egyptian congenital glaucoma patients. METHODS: Totally 42 eyes of 29 primary congenital glaucoma patients were operated on with combined trabeculotomy/trabeculectomy with mitomycin-C and followed up at 1d, 1wk, 1, 6 and 12mo postoperatively. Genomic DNA was extracted from peripheral blood leukocytes. Coding regions of CYP1B1 gene were amplified using 13 pairs of primers, screened for mutations using single-strand conformation polymorphism followed by sequencing of both strands. Efficacy of the operation was graded as either a success [maintaining intraocular pressure (IOP) less than 21 mm Hg with or without anti-glaucoma medication], or a failure (IOP more than 21 mm Hg with topical antiglaucoma medications). RESULTS: Seven novel mutations out of a total of 15 different mutations were found in the CYP1B1 genes of 14 patients (48.2%). The presence of CYP1B1 gene mutations did not correlate with the failure of the surgery (P=0.156, odds ratio=3.611, 95%CI, 0.56 to 22.89); while the positive consanguinity strongly correlated with failure of the initial procedure (P=0.016, odds ratio=11.25, 95%CI, 1.57 to 80.30). However, the Kaplan-Meier survival analysis revealed a significantly lower time of IOP control in the subgroup with mutations in CYP1B1 versus the congenital primary glaucoma group without mutations (log rank test, P=0.015). CONCLUSION: Seven new CYP1B1 mutations are identified in Egyptian patients. Patients harboring confirmed mutations suffered from early failure of the initial surgery. CYP1B1 mutations could be considered as a prognostic factor for surgery in primary congenital glaucoma.

The socioeconomic impact among Egyptian glaucoma patients.

BACKGROUND/AIM: To evaluate the economic burden of intraocular pressure (IOP)-lowering medications on Egyptian patients with glaucoma, in addition to studying the social grounds of glaucoma education. METHODS: In a cross-sectional observational study, the clinical and socioeconomic data were collected from 68 glaucomatous patients who were attending the outpatient clinics of Cairo University Hospital, through interviews, questionnaires, and clinical examinations. RESULTS: Patients had a mean IOP of 22.9 mm Hg (SD 11.5). Just under half the patients had an IOP of over 30 mmHg although 88% were on medical treatment; average of 2.1 medications (SD 0.8). Patients had been spending 79.5 LE (SD 95.3) on glaucoma medications a month, which equals 30.1% of their monthly income. Forty per cent of patients did not know that glaucoma causes blindness. The primary source of knowledge about glaucoma for 79.4% of patients was the ophthalmologist. CONCLUSION: The lack of control of IOP is probably related to the economic burden associated with glaucoma medications. 'Glaucoma education' is an important issue to both the treating ophthalmologist and the patient.

Goldmann versus Disposable Applanation Tonometer Tips in Glaucoma Patients and Normal Subjects.

PURPOSE: To assess agreement of intraocular pressure (IOP) measured with Goldmann applanation and disposable Luneau SA applanation prisms in glaucoma patients compared with normal subjects. METHODS: In a prospective comparative study, one eye per primary open-angle glaucoma (POAG) patient was measured for IOP using Goldmann and disposable Luneau SA (Tonojet) applanation tonometry prisms. Glaucoma patients found with IOP < 21 mmHg were compared to an age-matched group of normal subjects. The main outcomes measured were IOP and the difference in IOP between either prism. Bland-Altman plots were used to study the agreement between measurements. Regression analysis was applied to either group. RESULTS: One hundred and four POAG patients (eyes) were enrolled into this study. Seventy-one of them were found with IOPs < 21 mmHg, and were compared to 71 normal subjects (eyes). The mean difference between either prism was almost similar, 2.0 ± 2.0 and 2.1 ± 1.7 mmHg in the glaucoma and normal eye groups, respectively. Bias of two SD from the mean ranged from -1.8 to 5.8 mmHg in glaucoma group and -1.2 to 5.4 mmHg with normal subjects (p < 0.0001 in either group). The inaccuracy was non-systematic with glaucoma patients while was systematic with normal subjects. CONCLUSIONS: The disagreement between disposables and standard Goldmann tips followed different patterns in glaucoma patients when compared with normal subjects. The use of the Goldmann tip is advised with glaucoma patients.

Personal A-constant in relation to axial length with various intraocular lenses.

PURPOSE: To study the relationship between the axial length and personal A-constant for the 1-piece Tecnis (Abbott ZCB00), AcrySof MA60AC (Alcon) and the Quatrix aspheric preloaded (CROMA) intraocular lenses (IOL). MATERIALS AND METHODS: Patients matching the inclusion criteria were further subdivided according to the implanted IOL in this prospective comparative study. The obtained refractive outcomes were introduced into the formula installed in the biometry machine (Humphrey model 820 ultrasonic biometer) to obtain the personal A-constant for each eye. Polynomial regression analysis was done to study the individualized A-constant for each type of IOL in relation to preoperative axial length measurement. RESULTS: Two hundred and forty five eyes of 186 patients were enrolled into this study, of whom 73 eyes with Tecnis 1-piece, 116 eyes with MA60AC, and 56 eyes with Quatrix. The median of personalized A-constant for Tecnis 1-piece, MA60AC, and Quatrix were 119.21 (SD 1.3, Std. Mean error 0.15), 119 (SD 1.2, Std. Mean error 0.11) and 120.4 (SD 1.2, Std. Mean error 0.16) respectively. Regression plots for the same range of axial length among all the groups showed that the Tecnis1 group followed the same pattern of the Quatrix group in which there was a linear relationship of a trend towards myopia when the axial length had increased and a hyperopic shift when decreased. This relationship changed into a plateau when the axial length became in the range of 23.5 mm to 27 mm in the MA60AC group. CONCLUSIONS: Personal A-constant follows different trends with different IOLs even for the same range of axial length.

Surgically induced astigmatism following glaucoma surgery in Egyptian patients.

PURPOSE: The altered visual function induced by changes in corneal curvature following filtration surgery is distressing to patients. The aim of this study was to evaluate surgically induced astigmatism following trabeculectomy in comparison with deep sclerectomy. METHODS: In a prospective interventional comparative study, patients with primary open-angle glaucoma were randomly allocated to either group A or B; deep sclerectomy with mitomycin C 0.2 mg/mL and trabeculectomy with mitomycin C 0.2 mg/mL, respectively. Keratometry was performed using Topcon KR-7000P autokerato-refractometer preoperatively and at 6 months postoperatively. Vector analysis was used to analyze the surgically induced astigmatism. RESULTS: Sixty eyes of 45 patients in group A, and 60 eyes of 42 patients in group B were enrolled for vector analysis. The mean preoperative astigmatic vector power was -0.49±1.65 D and +0.47±2.18 D in groups A and B, respectively. The mean postoperative astigmatic vector power was -1.14±1.55 D in group A and -0.35±1.8 D in group B. The mean change in astigmatic vector powers was -0.67±1.63 D in group A and -0.82±2.0 D in group B. When compared with preoperative data in either group, the differences were significant, P=0.001 & 0.007 in groups A and B respectively, whereas the postoperative difference between either group was insignificant (P=0.723). A total of 40% of corneas got flatter in group B compared with 25% in group A, P=0.057. CONCLUSIONS: Both trabeculectomy and deep sclerectomy induced considerable postoperative astigmatism. A longer follow-up period is recommended to study the different patterns of astigmatism in either procedure.

Pneumatic trabecular bypass (PTB): pilot study.

PURPOSE: To evaluate the initial efficacy of Pneumatic trabecular bypass (PTB) for open angle glaucoma patients. DESIGN: Prospective case series study. METHODS: Ten eyes of 10 patients meeting the inclusion criteria had been operated for PTB. Patients were evaluated regarding to their intraocular pressure (IOP) and glaucoma medication score. They underwent regular follow-up starting with 1 day, reducing to 1 week, 1 month, and finally monthly for 6 months. RESULTS: Preoperative IOP ranged from 25 to 38 mm Hg with mean 30.9 mm Hg (SD 3.78) and medication score was 2.6 (SD 0.52). After 6 months, the mean IOP was 16.6 mm Hg (SD 4.43) and medication score decreased to 0.5 (SD 0.97). The percentage of IOP reduction ranged from 20% to 57.6%, mean 43.46% (SD 13.92). A rise in IOP was recorded in all cases between weeks 2 and 6. Total success was achieved in 70%, whereas qualified success was in 20%. CONCLUSIONS: There is an initial effectiveness for the procedure. The Schlemm canal rupturing pressure needs more detailed analysis.