Nylon Hang Back Sutures in the Repair of Secondary Ptosis Following Overcorrected Dysthyroid Upper Eyelid Retraction.

PURPOSE: Repair of blepharoptosis secondary to surgical overcorrection of thyroid related primary upper eyelid retraction (secondary ptosis) can be unpredictable. This study describes the long-term results of "hang-back" nylon sutures, for an anterior approach surgical repair of secondary ptosis. METHODS: This was a retrospective consecutive case note review of patients referred with secondary ptosis (after prior upper eyelid lowering for thyroid eye disease), under the care of a single surgeon at Moorfields Eye Hospital & subsequently at Barking Havering Redbridge University Hospitals NHS Trust (SSD). In accordance with hospital trust policy, this audit was registered and all patient data was anonymized, ethical approval was not required. Patients with secondary ptosis underwent surgery under local anesthesia through an upper eyelid skin-crease incision. The anterior portion of the levator muscle was freed from all scar tissues and its action re-established on the superior part of the upper tarsal plate, using two 6-0 nylon hang-back sutures placed centrally and medially. The margin reflex distance 1 (MRD1), skin crease height, eyelid contour, symmetry of eyelid position (difference in margin reflex distance 1 <1 mm in both eyes) and degree of lagophthalmos were assessed from clinical notes preoperative and postoperatively at 1, 3, and 12 months. RESULTS: Surgery was undertaken in 14 eyelids in 13 patients (3 males; 23%), with 9/14 (65%) eyelids having undergone attempted repair of ptosis prior to referral; in 7 of the 8 (88%) eyelids with previous failed ptosis repair, the referring surgeon had used soluble hang-back sutures. As compared with an average preoperative margin reflex distance 1 of 0.9 mm (median 1, range: -1 to 2 mm), the average margin reflex distance 1 at 3 months was 3.0 mm (median 3, range: 2.5-4 mm; p < 0.0001) and 2.8 mm at 12-month follow up (median 3, range: 2-4mm; p < 0.0001). The upper eyelid central skin crease height changed from a preoperative mean of 9.8 mm (median 9, range: 5-15 mm) to 8.7 mm at 3 months (median 8, range: 7-12 mm; p = 0.1412) and 8.9 mm at 12-month follow up (median 9, range: 7-11 mm; p = 0.2930). Only 3 patients had postoperative lagophthalmos (one patient 3 mm and two patients 1 mm) at 3 months after surgery, this resolving by the 12-month postoperative visit. Thirteen cases (93%) had a good functional, symmetrical, and aesthetic result at 12 month follow up, with a late recurrence of ptosis in 1 patient (7%). CONCLUSION: The "hang-back" semi-permanent suture technique for repair of over-corrected upper eyelid lowering in thyroid eye disease appears to provide an excellent and predictable long-term result with a low incidence of late recurrence of ptosis.

Trabeculectomy Can Improve Long-Term Visual Function in Glaucoma.

PURPOSE: To measure the magnitude and direction of visual field (VF) rates of change in glaucoma patients after intraocular pressure (IOP) reduction with trabeculectomy. DESIGN: Retrospective, comparative, longitudinal cohort study. PARTICIPANTS: Patients with open-angle glaucoma. METHODS: Patients who underwent trabeculectomy (Trab) with mitomycin-C (74 eyes of 64 patients) with ≥4 reliable VF measurements before and after trabeculectomy and at least 4 years of follow-up before and after surgery were included. Decay or improvement exponential models were used to calculate pointwise rates of perimetric change before and after surgery. A separate comparison (Comp) group with unoperated glaucoma (71 eyes of 65 patients) with similar baseline damage, number of VF tests, and follow-up was used to address possible regression to the mean. Proportions of VF locations decaying or improving before and after surgery in the Trab group, and during the first and second halves of follow-up in the Comp group, were calculated. A multivariate analysis was used to explore variables associated with VF improvement. MAIN OUTCOME MEASURES: The rate of pointwise VF change before and after surgery in the Trab group and Comp group. RESULTS: Patients in the Trab group were followed for 5.1±2.1 years (mean ± standard deviation) before and 5.4±2.3 years after surgery, with 8.9±4.7 VF tests before and 9.0±4.4 VF tests after surgery. The mean rate of change for all VF locations slowed from -2.5±9.3%/year before surgery to -0.10±13.1%/year after surgery (P < 0.001). In the Trab group, 70% of locations decayed and 30% improved preoperatively; postoperatively, 56% decayed and 44% improved. The differences between the Trab and Comp groups were significant (P < 0.0001, chi-square test). The magnitude of IOP reduction correlated with the excess number of VF locations that exhibited long-term improvement postoperatively (P = 0.009). In the Trab group, 57% of eyes had ≥10 improving VF locations postoperatively. CONCLUSIONS: The results show that trabeculectomy slows the rate of perimetric decay and provide evidence of sustained, long-term improvement of visual function in glaucoma. These findings suggest the possibility of reversal of glaucomatous dysfunction of retinal ganglion cells and their central projections.

Location of Initial Visual Field Defects in Glaucoma and Their Modes of Deterioration.

PURPOSE: To describe the location of initial visual field defects (VFD) in glaucoma, their modes of deterioration, and those factors associated with different modes of deterioration. METHODS: Patients with POAG were categorized into four groups based on three consecutive initial VFD: (1) superior paracentral defects (PD), (2) inferior PD, (3) superior nasal defects (ND), and (4) inferior ND. According to the worsening of the VF, four further subgroups were identified: (1) superior central worsening (CW), (2) inferior CW, (3) superior peripheral or nasal worsening (NW), and (4) inferior NW. Systemic and ocular factors were analyzed for each of the subgroups to identify possible associations. RESULTS: One hundred sixty-two eyes of 162 subjects were analyzed. Superior PD (n = 40) were more frequent in females and associated with disc hemorrhage (DH), and were less frequent in patients with systemic hypertension (HT). Inferior PD (n = 35) showed a significant association with cup shape measure and axial length. Superior ND (n = 37) were more highly associated with HT and diabetes. Inferior ND (n = 50) showed a lower incidence of DH. With binary logistic regression analysis, superior PD showed a significant association with both HT and DH. With respect to VF worsening, superior CW showed a significant association with HT and diabetes, whereas superior NW was associated with a high minimum IOP during follow-up, and inferior NW was associated with a high maximum IOP during follow-up. CONCLUSIONS: The initial location and subsequent direction of worsening of VFD were associated with different systemic and ocular factors.

Disc haemorrhage is associated with the fast component, but not the slow component, of visual field decay rate in glaucoma.

BACKGROUND/AIMS: To investigate the association of disc haemorrhage (DH) with regional visual field (VF) decay in glaucoma. METHODS: Retrospective longitudinal study was performed. Patients from the University of California, Los Angeles, glaucoma database were assigned to two groups based on the presence or absence of a DH. Pointwise exponential regression was used to identify the fast and slow rate components of VF decay. Associations between patient demographics, ocular and systemic factors, and visual field rates were analysed. RESULTS: A total of 185 patients were included, 54 of whom were documented to have a DH at some point during their course. DH group had a higher female preponderance (p=0.017, OR 2.23), a higher incidence of peripapillary atrophy (p=0.002, OR 4.46), more advanced disease (p=0.016) and a higher fast rate component of VF decay (p<0.001) than non-DH group. With multivariate logistic regression analysis, only the fast rate component showed a statistically significant relationship with DH. CONCLUSIONS: The presence of DH is associated with a greater fast component rate of VF decay. The identification and monitoring of the fast component of VF decay may prove useful in the identification and management of glaucoma patients at high risk of progression.

Measurement of the optic disc vertical tilt angle with spectral-domain optical coherence tomography and influencing factors.

PURPOSE: To report a novel method for measuring the vertical tilt angle of the optic nerve (ON) head and to investigate the associated factors. DESIGN: Cross-sectional diagnostic study. METHODS: One hundred and twelve normal, glaucomatous, and glaucoma suspect eyes (99 patients) were enrolled in this study. Subjects underwent a full eye examination, biometry, and spectral-domain optical coherence tomography (SDOCT). The vertical tilt angle was measured on high-resolution cross-sectional SDOCT images passing through the ON head and foveal centers using the inner edges of the Bruch membrane opening as the reference plane. The correlation between the vertical tilt angle with the ovality index and the potential associated factors was estimated with univariate and multivariate linear regression analyses. RESULTS: The median (interquartile range, [IQR]) axial length and visual field mean deviation were 24.5 (23.8-25.3) mm and -0.9 (-2.76 to 0.26) dB. The median (IQR) tilt angle was 3.5 (1.2-11.2) degrees. There was a moderate correlation between the ovality index and tilt angle (Spearman ρ = 0.351; P < .001). In univariate analyses, axial length, spherical equivalent, and mean deviation were correlated with the tilt angle (P = .002, P = .011, and P = .013, respectively). Axial length, mean deviation, and their interaction showed a statistically significant correlation with the tilt angle in multivariate analyses (P = .044 for axial length, P = .039 for mean deviation, and P = .028 for their interaction). CONCLUSIONS: We describe a new method for measuring the ON head vertical tilt angle with high-resolution SDOCT imaging. The ovality index demonstrated only a moderate correlation with the tilt angle measurements and hence is not a good proxy measure for the vertical ON head tilt angle. Axial length and visual field mean deviation are the main factors associated with the ON head vertical tilt angle. The underlying basis for the relationship of vertical tilt angle and glaucoma severity should be further explored.

Validation of point-wise exponential regression to measure the decay rates of glaucomatous visual fields.

PURPOSE: This study was conducted to validate a recently described technique for measuring the rates of visual field (VF) decay in glaucoma. METHODS: A pointwise exponential regression (PER) model was used to calculate average rates of faster and slower deteriorating VF components, and that of the entire VF. Rapid progressors had a faster component rate of >25%/year. Mean deviation (MD) and visual field index (VFI) forecasts were calculated by (1) extrapolation of linear regression of MD and VFI, and (2) calculation de novo from the PER-predicted final thresholds. RESULTS: The mean (± SD) years of follow-up and number of VFs were 9.2 (± 2.7) and 13.7 (± 5.8), respectively. The median rates of the decay were -0.1 and 3.6 (%/year) for the slower and the faster components, respectively. The "rapid progressors" (32% of eyes) had a mean decay rate of 52.2%/year. In comparison with actual values, the average absolute difference and the mean squared error for MD forecasts with linear extrapolation of indices were 3.58 dB and 31.91 dB(2), and with the de novo recalculation from PER predictions were 2.95 dB and 17.49 dB(2), respectively. Similar results were obtained for VFI forecasts. Comparisons of the prediction errors for both the MD and VFI favored the PER forecasts (P < 0.001). CONCLUSIONS: PER for measuring rates of VF decay is a robust indicator of rates across a wide range of disease severity and can predict future global indices accurately. The identification of "rapid progressors" identifies high-risk patients for appropriate treatment.

Arthroscopic excision of a painful bipartite patella fragment.

Bipartite patella, although usually asymptomatic, can become a source of persistent pain following injury. When nonoperative treatments such as physiotherapy and rest fail to produce any resolution in the symptoms, surgery is usually performed. This may include excision of the painful fragment, lateral retinacular release, or detachment of the vastus lateralis insertion, generally performed as open surgical procedures. In the case of vastus lateralis release, however, there has been recent report of statistically better results using an arthroscopic technique. Furthermore, open partial patellectomy has been criticized as being invasive and at times requiring long postoperative rehabilitation. We describe the case of a 26-year-old man who presented with a painful bipartite patella fragment that had not responded symptomatically to nonsurgical treatment. The painful fragment was removed arthroscopically as a day case under a general anesthetic. This was carried out through 3 portals and involved the use of a combination of probe, periosteal elevator, and arthroscopic shaver. Using this technique, we were able to minimize the surgical trauma associated with an open surgical procedure. The early result of this case encourages the use of an arthroscopic technique for partial patellectomy in the surgical treatment of a bipartite patella.