[Primary phacoemulsification following acute primary angle closure glaucoma]. / Primäre Phakoemulsifikation nach akutem Winkelblock.

Recent developments and clinical studies indicate that primary phacoemulsification and intraocular lens implantation are safe and effective for the surgical treatment of primary angle closure glaucoma (ACG) compared to conventional iridectomy or laser-iridotomy. When compared to control eyes treated using standard peripheral iridectomy, the outcome in terms of intraocular pressure control, adjunct anti-glaucoma medication, visual acuity, and the necessity for successive surgical interventions favored primary phacoemulsification and intraocular lens implantation. Earlier biometric data underline the importance of the "lens factor" in the pathogenesis of relative pupillary block in ACG obtained by Scheimflug image processing and ultrasound biomicroscopy. The vast improvements in modern cataract surgery combined with our current understanding of the pathogenesis of relative pupillary block in ACG indicate that lens extraction is a better procedure in uncontrolled angle closure glaucoma than conventional iridectomy.

[Patient characteristics in a tertiary glaucoma center. Circumstances of treatment and attitudes of patients]. / Profil einer universitären Glaukomsprechstunde. Objektive Behandlungsumstände und subjektive Einstellungen der Patienten.

BACKGROUND: In order to look for conceptual improvements in the practical management of patients sent to our glaucoma department, we analyzed the structures, behaviour, and knowledge about the disease in this patient group. METHODS: Glaucoma patients who were sent for the first time to our department were included prospectively. Before being examined 129 patients were asked to answer a questionnaire concerning their individual characteristics, their behaviour, and patterns of treatment. RESULTS: Of the patients 74% had open-angle glaucoma (including normal tension, exfoliative, and pigment glaucoma), 22% had secondary glaucoma (including neovascular, congenital, and chronic closed-angle glaucoma), and 4% had suspected glaucoma. Written documentation of previously performed intraocular pressure measurements was not available for 84% of the patients. Younger patients had significantly more knowledge about glaucoma and used more possibilities to get information about the disease than elder patients. CONCLUSION: Education about glaucoma disease should be optimized especially for elder glaucoma patients. Documentation of intraocular pressure measurements is insufficient in our patient group.

Trabecular aspiration. A new mode to treat pseudoexfoliation glaucoma.

PURPOSE: The primary cause of intraocular pressure (IOP) elevation in pseudoexfoliation glaucoma is obstruction of the intertrabecular spaces by exfoliation material. The aim of the current study was to evaluate the efficacy of a novel surgical approach--trabecular aspiration--for the management of pseudoexfoliation glaucoma. METHODS: Twelve patients characterized by medically uncontrolled IOP level in pseudoexfoliation glaucoma underwent trabecular aspiration as a primary antiglaucomatous procedure. Aspiration treatment of the meshwork was performed in the inferior circumference of the chamber angle using a specially designed irrigation-aspiration device to fit the chamber angle. Trabecular debris and pigment were cleared with a suction force of 100 to 200 mm Hg. RESULTS: Before surgery, IOP ranged from 24 mm Hg to 52 mm Hg (mean, 37.4 mm Hg). Fifteen months after surgery, IOP ranged from 15 mm Hg to 23 mm Hg (mean, 18.3 mm Hg), which is equivalent to an absolute decrease of 18.7 mm Hg (50%). After surgery, the IOP of 10 eyes was less than 21 mm Hg, although 6 of these eyes still required topical medication. Two eyes attained a final IOP of 24 mm Hg. All treated eyes were aspirated once. Mean antiglaucomatous medication decreased from 4.3 medications daily before surgery to 1.39 medications daily at 15 months after surgery. CONCLUSIONS: This new surgical modality, removing intertrabecular and pretrabecular debris of the trabecular meshwork, can be effective in the management of pseudoexfoliation glaucoma. However, long-term follow-up and extended sample size must be prospected for further clinical evaluation.

Neuromodulatory effects of the renin-angiotensin system on the cat electroretinogram.

PURPOSE: Angiotensin-converting-enzyme (ACE) catalyses the formation of angiotensin II (ANGII), which presumably acts as a central neurotransmitter/modulator. ANGII-related effects have also been observed in the retina. Present in vivo experiments were designed to investigate further ANGII-related effects on retinal neuromodulation. METHODS: In 12 anesthetized cats, electroretinographic measurements were carried out in the dark-adapted state using corneal contact lens electrodes and a Ganzfeld stimulator. Quinapril was used to inhibit ACE. RESULTS: Reducing ANGII-concentration increased sensitivity (0.5 log units) and gain (50%) of the rod b-wave amplitude. The b-wave implicit time was stimulus dependent, shortening at high intensities. The scotopic threshold response and the oscillatory potentials were also influenced by ACE inhibition. However, a-wave and 30 Hz flicker remained unaffected. Effects of Quinapril on ERG-amplitudes were reversed by subsequent ANGII administration, except for the implicit time of the b-wave and scotopic threshold response. CONCLUSIONS: Although these results are accompanied by alterations in systemic blood pressure, several findings support the evidence that the renin-angiotensin system might have a neurophysiologic effect on retinal neurons outside the vascular system. These results are in accordance with immunohistochemical data found by others that point to angiotensinergic cell involvement and thereby further support the concept of angiotensinergic processes in the inner retina from a functional point of view.

Postoperative application of mitomycin for trabeculectomies.

BACKGROUND: Persistent hypotony is a severe complication following trabeculectomy with intraoperative application of mitomycin. OBJECTIVE: To reduce this rate of hypotony by using a lower concentration of mitomycin and applying the mitomycin only topically to the filtering bleb following surgery. METHODS: Patients were enrolled on a consecutive basis and prospectively followed up. Standard trabeculectomies were performed and mitomycin applied postoperatively on the 3 days following surgery (group 1). For comparison, data from previous studies were used for control eyes with intraoperative mitomycin application (group 2) and no mitomycin application (group 3). Preoperative and postoperative data, complications, and the need for further surgical procedures were evaluated. RESULTS: The study group (group 1) consisted of 22 cases. The mean follow-up was 13.4 and 13.5 months for groups 1 and 2, respectively. Average intraocular pressure values decreased from 33. 6 and 31.0 mm Hg (P =.32; t test) to 16.0 and 12.5 mm Hg in the 2 groups (P =.03; t test). The average number of medications decreased from 2.5 and 2.5 to 0.6 and 0.4 (P =.35; t test) in groups 1 and 2, respectively, at the last visit. Hypotony lasting for more than 3 months occurred only in eyes with intraoperative mitomycin application (14/22). Choroidal detachment (3/22) and hypotony maculopathy (2/22) also were only noted in eyes from group 2. In group 3, success rates were much lower. CONCLUSIONS: This is the first clinical study, to our knowledge, to evaluate the efficacy of this new technique of mitomycin application. From the results, it appears that the postoperative application of mitomycin following trabeculectomy is associated with a lower risk of severe and long-standing hypotony. This technique may be promising in eyes at low risk for failure.

A comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery.

OBJECTIVES: To evaluate and compare levels of patient discomfort and perioperative complications during phacoemulsification and implantation of a foldable intraocular lens under topical lidocaine hydrochloride and retrobulbar anesthesia in patients with cataract who also had exfoliation syndrome, uveitis, posterior synechia, phacodonesis, or previous intraocular surgery. DESIGN: A prospective, randomized, controlled trial was carried out at 2 institutions. PARTICIPANTS: A total of 476 eyes of 476 patients with various well-established risk factors fulfilled the inclusion criteria. In 238 eyes, phacoemulsification was performed under retrobulbar anesthesia, while the other 238 eyes received topical anesthesia. INTERVENTIONS: All patients underwent temporal clear corneal phacoemulsification and implantation of a foldable intraocular lens. Patients under retrobulbar anesthesia received a single injection (3. 5-5.5 mL) of a combination of 0.75% bupivacaine hydrochloride, 2% lidocaine, and hyaluronidase into the retrobulbar space. Patients in the topical anesthesia group received a minimum of 5 doses (approximately 40 microL per dose) of 2% topical lidocaine. No intracameral injection of any anesthetic was given. MAIN OUTCOME MEASURES: The number of complications and adverse events. The intraoperative conditions were judged by the surgeon (P.C.J. or F.K. J.), and a 10-point visual analog scale was used immediately after surgery to assess each patient's overall severity of intraoperative pain. RESULTS: The overall intraoperative complication rate was 1.9% for capsular tear, 3.8% for zonular tear, 1.5% for vitreous loss, and 1.0% for iris prolapse. Apart from the incidence of vitreous loss, which was significantly (P =.041) lower in the topical anesthesia group, no statistically significant differences in intraoperative and early postoperative complications were found between the groups. A supplemental posterior sub-Tenon space injection was required in 1.3% of the topical anesthesia group and in 0.8% of the retrobulbar anesthesia group. Chemosis (2.5%), subconjunctival hemorrhage (1.7%), and periorbital hematoma (0.8%) were seen only in the retrobulbar anesthesia group. The mean + SE pain scores estimated by the patients were 0.84 + 1.30 in the topical anesthesia group and 0.73 + 1.50 in the retrobulbar anesthesia group (P =.41). Patient preference for topical anesthesia (91%) appeared to be significantly (P =.01) higher than for retrobulbar anesthesia (62%). The surgeons found anesthesia-related intraoperative difficulty to be slightly lower in the retrobulbar anesthesia group (8%) than in the topical anesthesia group (14%). CONCLUSIONS: Surgery-related complications and patient discomfort were similar for the 2 methods of anesthesia. Topical anesthesia is justified as a means of improving safety without causing discomfort to the patient even in complicated cases of cataract surgery. Arch Ophthalmol. 2000;118:1037-1043

Comparative study of trabecular aspiration vs trabeculectomy in glaucoma triple procedure to treat pseudoexfoliation glaucoma.

OBJECTIVES: To establish the relative safety and effectiveness of trabecular aspiration in combination with phacoemulsification and intraocular lens (IOL) implantation (asp+IOL) for decreasing intraocular pressure (IOP), and to compare the outcome of this method of treatment with that of phacoemulsification and IOL implantation alone (IOL-alone) or standard filtering glaucoma triple procedure (triple procedure). DESIGN: Prospective, controlled study randomized with respect to assignment to trabecular aspiration, with a case-control design between the asp+IOL and triple procedure groups. PARTICIPANTS: Seventy-four eyes of 74 patients with uncontrolled pseudoexfoliation glaucoma without a history of previous intraocular or extraocular surgery and in need of cataract surgery. Forty-eight patients were randomized to those receiving adjunctive trabecular aspiration (asp+IOL group of 26 eyes) and those given no trabecular aspiration (IOL-alone group of 22 eyes). The triple procedure group consisted of 26 cases, closely matched to the asp+IOL cases in terms of age, sex, cup-disc ratio, glaucoma medication requirements, and systemic diseases. INTERVENTIONS: Temporal clear corneal phacoemulsification and foldable IOL implantation was performed in all eyes. In the asp+IOL group, trabecular aspiration was performed with a suction force of 100 to 200 mm Hg under light tissue-instrument contact using a modified intraocular aspiration probe. A modified Cairns-type trabeculectomy without adjunctive antimetabolites was performed superiorly in the triple procedure eyes after IOL implantation. MAIN OUTCOME MEASURES: Surgical outcome was assessed in terms of IOP change, need of adjunctive glaucoma medication, visual acuity outcome, and complications. Surgical failure was defined as an outcome requiring additional surgical intervention or more than 1 medication to achieve IOP control to the target pressure. RESULTS: Two years after surgery, success rates were 36%, 64%, and 78% in the IOL-alone, asp+IOL, and triple procedure groups, respectively (P<.001). Hyphema (46%) and ocular hypotony (11%) were observed in the triple procedure group only, whereas blood reflux (61%) and descemetolysis (19%) were seen exclusively in the asp+IOL group. CONCLUSIONS: In pseudoexfoliative eyes, asp+IOL is significantly more effective than cataract surgery alone in reducing postoperative IOP and the necessity for glaucoma medication. Although trabecular aspiration in the triple procedure did not achieve pressure control in all patients, especially in the low target pressure range, the risk profile appears to be more favorable in the trabecular aspiration-treated eyes than in the filtering glaucoma triple procedure group. Trabecular aspiration in the glaucoma triple procedure could serve as a possible first-line treatment for pseudoexfoliative eyes with coexisting cataract and glaucoma.

Prospective study of ab externo erbium:YAG laser sclerostomy in humans.

PURPOSE: To evaluate the efficacy of ab externo erbium:YAG (Er:YAG) laser sclerostomy in controlling intraocular pressure in eyes with uncontrolled glaucoma. METHODS: We performed ab externo laser sclerostomy on eyes of 26 patients. Mean +/- SD postoperative follow-up was 11.4 +/- 0.9 months. Complete success was defined as intraocular pressure below 22 mm Hg with no adjunct medication; qualified success was defined as intraocular pressure below 22 mm Hg with medication. RESULTS: In all eyes, ab externo Er:YAG laser sclerostomy achieved a functioning fistula with a prominent filtering bleb. Twelve eyes had had neodymium:YAG (Nd:YAG) laser iridotomy at the site of laser sclerostomy 2 weeks before filtering surgery; 14 eyes had surgical iridectomy at the site of laser sclerostomy. Mean preoperative intraocular pressure of 30.7 +/- 7.3 mm Hg (range, 17.0 to 48.0 mm Hg) was significantly (P < .05) reduced to 18.3 +/- 1.0 mm Hg (range, 0 to 25.0 mm Hg) at 2 weeks postoperatively. thereafter, marked regression was noted: at 1 month postoperatively, intraocular pressure was 20.1 +/- 9.5 mm Hg (range, 4.0 to 44.0 mm Hg); half-life of complete success was 25 days; of qualified success, 56 days; and of a functioning filtering bleb, 36 days. CONCLUSIONS: Ab externo Er:YAG laser sclerostomy reliably created successful full-thickness fistulae with prominent filtering blebs in human glaucomatous eyes. However, a transient phase of ocular hypotony caused by aqueous overfiltration, followed by an ongoing rate of fistula patency failure, renders Er:YAG laser sclerostomy, as performed in this study, unsuitable for long-term pressure control.

Goniocurettage for removing trabecular meshwork: clinical results of a new surgical technique in advanced chronic open-angle glaucoma.

PURPOSE: To elucidate the long-term outcome of goniocurettage as a new technique in trabecular microsurgery for advanced open-angle glaucoma. METHODS: In a prospective, nonrandomized clinical trial, 25 eyes of 25 patients with a mean age +/- SD of 72.7+/-10.1 years (range, 50 to 89 years) with uncontrolled chronic open-angle glaucoma that had undergone failed filtering procedures were treated by goniocurettage. Trabecular tissue was scraped away from the chamber angle by means of an instrument similar to a microchalazion curette (diameter, 300 microm). RESULTS: Before surgery, intraocular pressure ranged from 29 to 48 mm Hg (mean +/- SD, 34.7+/-7.1 mm Hg), and mean number of antiglaucoma medications was 2.2+/-0.56. Follow-up averaged (+/-SD) 32.6+/-8.1 months (range, 30 to 45 months). Overall success, defined as postoperative intraocular pressure of 19 mm Hg or less with one pressure-reducing agent, was attained in 15 eyes (60%), with five eyes (20%) being controlled without medication. Considering all successfully treated patients, the mean intraocular pressure was 17.7+/-3.1 mm Hg (range, 10 to 19 mm Hg) at the final visit. Mean intraocular pressure reduction was 17.1+/-7.1 mm Hg in these eyes, representing a net decrease from baseline of 49%. Number of antiglaucoma medications dropped to 0.63+/-0.29. Complications included localized Descemet membrane detachment in five eyes (20%) and moderate anterior chamber bleeding in four eyes (16%). CONCLUSIONS: This new surgical technique can effectively control intraocular pressure for long periods of time in patients with open-angle glaucoma and a history of failed filtering procedures. Goniocurettage may be a suitable alternative to surgical treatment of glaucoma patients with excessive conjunctival scarification.

Bradykinin receptor inhibition affects the rod b-wave in the cat electroretinogram.

In 10 anaesthetized cats, electroretinographic (ERG) measurements were carried out to further elucidate the involvement of bradykinin as a substrate component of the renin-angiotensin system in retinal neurotransmission. Reducing angiotensin II concentration by angiotensin-converting enzyme (ACE) inhibition increased sensitivity (0.5 log units) and gain (50%) of the rod b-wave amplitude. The b-wave implicit time was decreased only at high stimulus intensities (> 10(-2) cd/m). Blocking bradykinin receptors specifically decreased rod b-wave implicit time for all intensities, while its amplitude remained unaffected. Bradykinin effects were independent of alterations of angiotensin II activity. We therefore suggest that bradykinin influences inner retinal signal processing, hereby further supporting the hypothesis of a renin-angiotensin system involvement in retinal neurotransmission.

Technique of goniocurettage: a potential treatment for advanced chronic open angle glaucoma.

AIM: To introduce a new concept of anterior chamber angle microsurgery, designed to scrape pathologically altered trabecular meshwork from the scleral sulcus as a potential treatment in primary open angle glaucoma. METHODS: Gonioscopically controlled ab interno abrasion of the trabecular meshwork was performed on six human eye banking eyes for morphological analysis. Thereafter, four eyes suffering from terminal glaucomatous optic nerve atrophy as a result of medically uncontrolled intraocular pressure were also treated by 'goniocurettage'. The newly designed instrument resembles a modified cyclodialysis spatula with a bowl-shaped tip, 300 microns in diameter, and with its edges sharpened. The treatment zone comprised 4-5 clock hours of the chamber angle circumference. RESULTS: Microscopic examination of the treatment zone revealed that in addition to a complete disruption of the trabecular meshwork and internal wall of Schlemm's canal goniocurettage also caused damage to intracanalicular septa. A splitting along the posterior wall of Schlemm's canal was also noted in one specimen. The clinical data of goniocurettage also showed some promising results. Mean pretreatment IOP averaged 40.7 (SD 8.8) mm Hg (range 32-51 mm Hg) and was significantly (p < 0.04) reduced to 18.0 (4.2) mm Hg (12-22 mm Hg) after 6 months, representing an absolute decrease in IOP of 22.7 mm Hg and a mean decrease in IOP of 56%. Clinically significant hyphaema occurred in one eye, caused by introgenic trauma to a prominent chamber angle vessel. In three eyes a minor reflux of blood occurred at the treatment site. However, no hypotony, choroidal effusion, flattened anterior chamber, or cyclodialysis were observed in these patients. CONCLUSION: Morphological analysis of treated postmortem eyes confirmed that goniocurettage completely removed the trabecular meshwork and opened Schlemm's canal, ensuring direct access into the anterior chamber. In a small number of patients over a limited period of time this new surgical procedure resulted in a clinically significant pressure reduction. However, longer term follow up and a greater number of patients are warranted before this experimental procedure is applicable to eyes that would do well with conventional surgery.

Prognosis of primary ab externo surgery for primary congenital glaucoma.

BACKGROUND: The strategy of pressure reducing surgery in primary congenital glaucoma has changed over the last decade. Ab externo filtering procedures--for example, trabeculectomy or trabeculotomy combined with trabeculectomy, have now been accepted even as primary intervention. METHODS: The authors reviewed 61 eyes in 35 consecutive patients with primary congenital glaucoma, who underwent different types of initial ab externo surgery between 1988 and 1996 (median follow up 36 months) to determine the efficacy of different surgical techniques and the influence of various risk factors. RESULTS: Trabeculotomy was performed in 17 eyes (27.9%), trabeculotomy with trabeculectomy in 15 eyes (24.6%), and trabeculectomy in 29 eyes (47.5%). Regarding age, preoperative intraocular pressure, corneal diameter, ocular axial length, and incidence of corneal haze the subgroups were comparable. Success rates of trabeculotomy, trabeculectomy, and a combined procedure did not significantly differ when assessed by life table analysis. Patient age under 3 months (p = 0.014) and an ocular axial length of 24 mm or more (p = 0.016) proved to be major risk factors for primary ab externo surgery failure. A second operation was necessary in 20 of 61 eyes (32.8%) during follow up. CONCLUSION: Prognosis of primary ab externo glaucoma surgery in primary congenital glaucoma seems to be governed more by the individual course and severity of the disease than by modification of surgical techniques.

Morphological variability of the trabecular meshwork in glaucoma patients: implications for non-perforating glaucoma surgery.

BACKGROUND/AIMS: Morphological variability of the trabecular meshwork could be of considerable importance for the proper intraoperative outcome of non-perforating antiglaucomatous surgery, such as deep sclerectomy and viscocanalostomy. The aim of this study was therefore to assess qualitative and quantitative characteristics of the trabecular meshwork in glaucoma patients undergoing trabeculectomy. METHODS: Trabeculectomy specimens from 177 glaucoma patients were prepared for light microscopy; 100 specimens were found to be suitable for qualitative assessment and quantitative computerised image analysis; measurements were taken of the meridional diameter of Schlemm's canal as well as the thickness of the trabecular meshwork at different positions. RESULTS: The mean meridional diameter of Schlemm's canal was 290 microm with the smallest values in the young patients with infantile and secondary glaucomas. the thickness of the trabecular meshwork ranged between 50-70 microm in the anterior region and between 100-130 microm for the posterior portion. The thickness of the anterior meshwork significantly decreased with age. The pigmentation of excised trabecular meshwork was found to be weak or even lacking in 68 patients. In 20 glaucoma patients the uveal meshwork was covered by an endothelial layer. CONCLUSIONS: From the morphological point of view the risk of inadvertent perforation during deep sclerectomy in older, white glaucoma patients should be taken into account even by an experienced surgeon, because the anterior meshwork in these cases is very thin and trabecular pigmentation that can be used as a topographic landmark is often lacking. The functional success of non-perforating glaucoma surgery in many patients may be limited by endothelial covering of the trabecular meshwork.

A prospective randomised trial of viscocanalostomy with and without implantation of a reticulated hyaluronic acid implant (SKGEL) in open angle glaucoma.

AIM: To prospectively assess the efficacy and complications of viscocanalostomy with a reticulated hyaluronic acid implant (VSRHAI) versus standard viscocanalostomy in patients with medically uncontrolled open angle glaucoma. METHODS: A consecutive series of 40 patients (40 eyes) with uncontrolled open angle glaucoma underwent non-penetrating antiglaucomatous surgery. After the excision of the deep scleral flap they were randomly assigned to either a standard viscocanalostomy or additional implantation of a reticulated hyaluronic acid implant. Follow up visits were over a period of 12 months after surgery. RESULTS: The mean preoperative intraocular pressure (IOP) was 26.5 (SD 6.1) mm Hg for all patients enrolled. The mean IOP was 8.1 (SD 5.6) mm Hg 1 day after surgery for the viscocanalostomy group (p<0.001) and 12.0 (SD 5.2) mm Hg for the VSRHAI group (p<0.001). The postoperative IOP difference between the two groups was statistically significant (p = 0.03). The success rate, defined as an IOP lower than 22 mm Hg without medication, was 40% in both groups at 12 months postoperatively (p = 0.90). The number of postoperative complications was equally low for both groups. CONCLUSIONS: Both surgical procedures, viscocanalostomy and VSRHAI, provide comparable success rates over a 1 year follow up period. The specific intraoperative and postoperative complications of non-penetrating surgery were seen in our series, although the overall rate of postoperative complications proved equally low for both techniques.

Ultrasound biomicroscopy and its value in predicting the long term outcome of viscocanalostomy.

AIMS: To examine whether the early postoperative morphology at the site of sclerectomy, as visualised by ultrasound biomicroscopy (UBM), is an indicator of the mechanisms that lower intraocular pressure (IOP) and/or predictors of the long term outcome of viscocanalostomy. METHODS: 15 eyes of 14 patients with medically uncontrolled open angle glaucoma and no history of surgery underwent viscocanalostomy according to Stegmann's technique. Ultrasound biomicroscopy was performed during the first month after surgery. The following parameters were assessed: dimensions of the intrascleral "lake," presence of a filtering bleb, presence of a subconjunctival cavity or a suprachoroidal hypoechoic area, and the thickness of the residual trabeculocorneal membrane. A complete ophthalmological examination was performed the day before and the day after surgery. Follow up visits were scheduled 1 week, 4 weeks, 6 months, and 12 months after surgery. RESULTS: At 1 year successful control of IOP (<20 mm Hg) was achieved without further manipulation or medication in six of 15 eyes. The size of the intrascleral "lake" (average 0.62 mm(3)) did not correlate with later IOP; however, a visible route under the scleral flap and accidental perforation of the trabeculocorneal membrane were associated with long term lowering of IOP. Normal thickness of the trabeculocorneal membrane (0.10-0.15 mm) was indicative of IOP control with and without medication. When UBM showed an early collapse of the intrascleral cavity, control of IOP was not achieved. Other UBM findings did not predict long term function. CONCLUSION: In accordance with previous studies, the authors found that UBM examination is a useful method to evaluate outflow mechanisms after glaucoma surgery. This study shows that UBM imaging of external filtration during the early postoperative period can be used to predict the success of viscocanalostomy. However, to establish conclusively what parameters of UBM predict successful viscocanalostomy a larger number of patients must be studied.

Effect of age and astigmatism on the AMO Array multifocal intraocular lens.

Multifocal intraocular lenses (MIOLs) have been designed to provide better uncorrected near visual acuity than monofocal IOLs. However, the increase in depth of focus is combined with a significant decrease in contrast sensitivity and glare. We implanted a new zonal-progressive MIOL (AMO Array) in 31 eyes of 25 patients whose mean age was 60.8 +/- 13.5 years. At 12.1 +/- 2.4 months postoperatively, the uncorrected visual acuity averaged 0.56 +/- 0.09 (20/32) for distance and 0.54 +/- 0.12 (20/40) for near focus. Seventy-five percent of patients achieved a best corrected distance visual acuity of > or = 0.9 (20/22). With distance correction only, mean near visual acuity was 0.72 +/- 0.17 (20/25). Best corrected near acuity reached 0.89 +/- 0.11 (20/22), requiring an additional near add of +1.0 to +2.0 diopters (D). We observed an age-dependent difference in the depth of focus. In younger patients (46 +/- 6 years), the pseudoaccommodation range was 6.25 D; acuity attained was > or = 0.4 (20/50). In older patients (71 +/- 7 years), visual acuity at the near focus was substantially reduced (two lines). Regan contrast sensitivity was lower for MIOL patients at all contrast levels, but the difference was statistically significant only at very low contrast (11%). Contrast sensitivity and glare were dependent on the patient's age but did not change with the amount of postoperative astigmatism. Younger patients were very satisfied with the results of MIOL implantation, and the small loss of contrast sensitivity was counterbalanced by the advantage of improved depth of focus and uncorrected near visual acuity.

Effect of trabecular aspiration on early intraocular pressure rise after cataract surgery.

PURPOSE: To evaluate the efficacy of a new trabecular aspiration technique on intraocular pressure (IOP) immediately after cataract surgery. SETTING: University Eye Hospital of Cologne, Germany. METHODS: This prospective, double-masked study comprised 48 of 100 patients having extracapsular cataract extraction (ECCE) who were randomly assigned to a study group. In these patients, 180 degrees of the inferior circumference of the chamber angle was treated with negative suction pressure ranging between 100 and 200 mm Hg. The other 52 patients served as a control group. Intraocular pressure was measured preoperatively and early (5 to 7 hours) and late (12 to 48 hours) postoperatively. RESULTS: There was a significant mean increase in IOP from the preoperative to early postoperative period in both the control group (20.8 mm Hg) and the treatment group (7.4 mm Hg). There was no significant difference between preoperative and late postoperative pressures in either group. A one-way analysis of covariance of the changes in pressure from the preoperative to early postoperative period showed significantly less increase (P = .0041) in the aspiration than in the control group. CONCLUSION: Trabecular aspiration was effective in reducing the amount of IOP increase in the immediate period after ECCE.

Complications of endocapsular tension ring implantation in a child with Marfan's syndrome.

A 4-year-old boy with Marfan's syndrome had severe visual impairment after subluxation of the crystalline lens with bisection of the pupil. In the first eye, a capsular tension ring and an intraocular lens (IOL) were uneventfully placed in the capsular bag after phacoemulsification. During implantation of the endocapsular tension ring in the second eye, an inadvertent tear of the anterior capsule occurred, and the posterior chamber IOL was placed in the sulcus. In both eyes, severe lens epithelial proliferation with secondary IOL decentration developed postoperatively. Several surgical revisions were necessary to keep the IOL within the optical axis. In the eye with the sulcus-implanted IOL, the endocapsular tension ring was markedly decentered.

Cataract surgery under topical anesthesia in patients with coexisting glaucoma.

PURPOSE: To evaluate and compare levels of patient discomfort and complications during phacoemulsification with implantation of a foldable intraocular lens (IOL) under topical lidocaine hydrochloride in patients with and without various forms of chronic open-angle and chronic angle-closure glaucoma. SETTING: Two university eye centers in Germany. METHODS: This prospective nonrandomized comparative study comprised 176 eyes of 176 patients with various forms of chronic open-angle glaucoma and chronic angle-closure glaucoma. Eyes with cataract and without a glaucoma diagnosis or history of intraocular surgery served as a control group (n = 212). All patients received a minimum of 5 doses (2 drops per dose) of topical lidocaine hydrochloride 2% before standard temporal clear corneal phacoemulsification and foldable IOL implantation. No intracameral anesthetic injection was given, and no systemic sedatives were used. The main outcome measures were the number of complications and adverse events. RESULTS: The intraoperative complication rate in all patients (n = 388) was capsule tear, 1.3%; zonule tear, 1.8%; vitreous loss, 1.0%; iris prolapse, 0.8%. No statistically significant differences in intraoperative or early postoperative complications were found between the glaucoma and control groups. The mean pain scores of patients were 0.38 +/- 1.1 (SD) in the glaucoma group and 0.36 +/- 0.8 in the control group (P =.21) Patient preference for cataract surgery under topical anesthesia was similar in both groups. CONCLUSIONS: Surgery-related complications and patient discomfort were similar in patients with and without glaucoma who had phacoemulsification and IOL implantation under topical anesthesia. These results indicate that topical anesthesia is safe for routine phacoemulsification with foldable IOL implantation in patients with glaucoma and does not compromise patient comfort.

Massive anterior capsule shrinkage after plate-haptic silicone lens implantation in uveitis.

Two patients, both with bilateral uveitis, had synechiolysis, continuous curvilinear capsulorhexis (CCC), phacoemulsification, and in-the-bag implantation of a foldable single-piece plate-haptic silicone intraocular lens (IOL) in 1 eye. Several weeks postoperatively, massive anterior capsule shrinkage with obstruction of the visual axis occurred in both patients. Surgical revision was performed in both eyes. Both patients had CCC and phacoemulsification and confirmed in-the-bag acrylic IOL implantation in the second eye months after surgery in the first eye. Follow-up examinations showed no significant shrinkage of the anterior capsule opening in any eye. In patients with uveitis, intraoperative lens epithelial cell removal, creation of a large CCC, and careful selection of IOL style and material may prevent occlusion of the anterior capsule opening.