Diaphragm and Lung Ultrasound Indices in Prediction of Outcome of Weaning from Mechanical Ventilation in Pediatric Intensive Care Unit.

OBJECTIVE: To predict the added value of diaphragmatic and lung ultrasound indices (US) in anticipation of the outcome of mechanical ventilation of pediatric patients in the intensive care unit. METHODS: This prospective study was conducted in Zagazig University, Pediatric Hospitals, PICU; Egypt. One hundred six mechanically ventilated children aged between 1 mo to 170 mo were included in the study. All patients were candidates for weaning and have been given a chance for spontaneous breathing trial (SBT), during which diaphragmatic and lung US was performed for them. The diaphragm thickening fraction (DTF), the diaphragmatic excursion and the lung US score (LUS), that included 4 US aeration forms, were assessed. RESULTS: There were statistically significant differences between patients with failed weaning and those with successful weaning regarding DTF, diaphragmatic excursion and LUS (p < 0.001). The best cut-off value of DTF, diaphragmatic excursion, and LUS for predicting weaning failure was ≥23.175%, ≥ 6.2 mm, and ≥ 12 with an AUC (area under curve) of 0.932, 0.876, and 0.934, respectively. CONCLUSIONS: Diaphragmatic and lung US add a quick, accurate and non-invasive indices to the weaning readiness parameters compared to the other standard parameters alone. So, it is recommended to be added to the predictive parameters of weaning outcome.

Change in intraocular pressure in myopic eyes measured with contact and non-contact tonometers after laser in situ keratomileusis.

PURPOSE: To study the change in the intraocular pressure (IOP) after laser in situ keratomileusis (LASIK) for correction of myopia. METHODS: One hundred twenty consecutive myopic eyes (60 patients) were included in a prospective study. All eyes received LASIK with the Nidek EC-5000 excimer laser and the Chiron Automated Corneal Shaper. Baseline refraction, keratometry, pachymetry, ablation depth, and IOP measured by Goldmann applanation tonometry and non-contact air puff tonometry were correlated with the IOP change after surgery. Sixty healthy eyes of 30 subjects served as controls. RESULTS: At 6 months, 108 eyes (90%) were examined. Compared to preoperative values, IOP decreased in 103 eyes (95.4%) when measured with applanation tonometry; it decreased in all eyes when measured with air puff tonometry. Mean change in IOP was -4.3 +/- 2.1 mmHg (range, -10.0 to +1.0 mmHg) with the applanation and -6.1 +/- 2.3 mmHg (range, -12.0 to -1.0 mmHg) with air puff tonometry. The IOP change measured with either instrument correlated significantly with the baseline IOP (P < .001) and the ablation depth (air puff, P < .001, applanation; P = .006). CONCLUSION: Intraocular pressure decreased significantly after LASIK when measured with either Goldmann (mean 4.3 mmHg) or air puff (mean 6.1 mmHg) tonometers. This decrease may delay the diagnosis or affect the management of future glaucoma that may develop in a myopic eye that received LASIK.

Nonpenetrating deep sclerectomy versus trabeculectomy in bilateral primary open-angle glaucoma.

OBJECTIVE: To establish the efficacy and safety of nonpenetrating deep sclerectomy versus trabeculectomy in primary open-angle glaucoma. DESIGN: Prospective randomized trial. PARTICIPANTS: Thirty-nine patients (78 eyes) with bilateral primary open angle glaucoma were included in the study. INTERVENTION: Eyes were randomly assigned to receive deep sclerectomy in one eye and trabeculectomy in the other eye. MAIN OUTCOME MEASURES: Mean intraocular pressure (IOP), postoperative medications, visual acuity, success rate, and complications. RESULTS: At 12 months, mean IOP reduction was 12.3 +/- 4.2 (sclerectomy) versus 14.1 +/- 6.4 mmHg (trabeculectomy) (P = 0.15), and an IOP

Fornix-based versus limbal-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil: four-year follow-up findings.

PURPOSE: To evaluate the safety and efficacy of fornix-based conjunctival flap versus limbal-based flap in initial trabeculectomy with postoperative 5-fluorouracil. METHODS: 29 patients (58 eyes) with bilateral primary open-angle glaucoma (POAG) were included in the study. Patients were randomly assigned to have a fornix-based conjunctival flap in one eye and a limbal-based flap in the other, followed by subconjunctival injection of 5-fluorouracil. RESULTS: Mean intraocular pressure (IOP) 2 years after treatment was 12.9 +/- 12.25 mmHg in eyes with fornix-based conjunctival flaps and 13.1 +/- 16.81 mmHg in eyes with limbal-based conjunctival flaps. At 4 years, mean IOP was 14.7 +/- 9.61 mmHg in eyes with fornix-based conjunctival flaps and 15.1 +/- 7.29 mmHg in eyes with limbal-based conjunctival flaps. Cumulative success at 4 years (IOP < 21 mmHg) was 89.6% in eyes with fornix-based conjunctival flaps versus 86.2% in eyes with limbal-based conjunctival flaps with medications. Cystic leaking blebs occurred in two cases, both with limbal-based flaps. CONCLUSION: The efficacy of limbal- and fornix-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil was not significantly different; however, in this study cystic leaking blebs were encountered only in eyes with limbal-based conjunctival flaps.

Randomized bilateral comparison of excimer laser in situ keratomileusis and photorefractive keratectomy for 2.50 to 8.00 diopters of myopia.

OBJECTIVE: To compare effectiveness, safety, and stability of excimer laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) for low-to-moderate myopia. DESIGN: Prospective, randomized, bilateral study. PARTICIPANTS: Thirty-three patients with a manifest refraction of -2.50 to -8.00 diopters (D) participated. INTERVENTION: For each patient, one eye received LASIK and the other received PRK. The first eye treated, and surgical method in the first eye, were randomized. Both eyes were treated by the same surgeon during the same operative session with a Summit Omnimed I laser (6-mm-diameter ablation) and a Chiron Automated Corneal Shaper. Follow-up was 90% at 1 and 2 years. RESULTS: At baseline, mean (+/-standard deviation) spherical equivalent manifest refraction was -4.80 +/- 1.60 D in LASIK-treated eyes and -4.70 +/- 1.50 D in PRK-treated eyes. At 1 day after surgery, 81% of patients (21 eyes) reported no pain in the LASIK-treated eye, whereas no patient (0%) reported being pain-free in the PRK-treated eye. At 3 to 4 days after surgery, 18 (80%) LASIK-treated eyes either improved or remained within 1 line of baseline spectacle-corrected visual acuity; only 10 (45%) PRK-treated eyes achieved this result. At 2 years after surgery, 18 (61%) LASIK- and 10 (36%) PRK-treated eyes achieved an uncorrected visual acuity of 20/20 or better, with no statistically significant difference in refractive outcome between the two techniques. Quantitative videokeratography showed more regularity after LASIK. Complications were similar in the two groups. Patients preferred LASIK by a margin of 2 to 1 at 1 year but showed no preference at 2 years. CONCLUSIONS: Using a 6-mm-diameter single-pass, large area ablation and an automated microkeratome to treat myopia of -2.50 to -8.00 D with 1.00 D or less astigmatism in 1994, the authors used LASIK to produce a higher percentage of eyes with an uncorrected visual acuity of 20/20 or better, more regular postoperative corneal topography, less postoperative pain, and more rapid recovery of baseline spectacle-corrected visual acuity than PRK. Both LASIK and PRK achieved successful correction of low-to-moderate myopia at 1 and 2 years after surgery.

Comparison of photorefractive keratectomy with excimer laser in situ keratomileusis in correcting low myopia (from -2.00 to -5.50 diopters). A randomized study.

OBJECTIVE: To compare laser in situ keratomileusis (LASIK) with photorefractive keratectomy (PRK) in the correction of myopia from -2.00 to -5.50 diopters. DESIGN: Prospective, randomized, paired clinical trial. PARTICIPANTS: Fifty-two eyes of 26 myopic patients were enrolled in the study. INTERVENTION: Each patient received PRK on one eye (PRK eye) and LASIK on the other (LASIK eye); the procedure assigned to each eye, and the sequence of surgeries for each patient was randomized. MAIN OUTCOME MEASURES: Slit-lamp microscopy, manifest refraction, uncorrected and spectacle-corrected visual acuity, and videokeratography were done before operation, and 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after operation. Patient satisfaction and preference were assessed by a subjective questionnaire. RESULTS: All LASIK eyes had fast, painless recovery. At 1 year, 24 patients (92.3%) were examined, the mean spherical equivalent refraction was -0.08 +/- 0.38 diopter in the PRK eyes and -0.14 +/- 0.31 diopter in the LASIK eyes, and the uncorrected visual acuity was 20/20 or better in 15 PRK eyes (62.5%) and 19 LASIK eyes (79.2%); no eye lost 2 or more Snellen lines of spectacle-corrected visual acuity. Both procedures were stable throughout the first year. One PRK eye developed dense subepithelial corneal haze. The strongest correlate to spectacle-corrected visual acuity after the two procedures was the coefficient of variation of corneal power over the pupil. Nineteen patients (79.2%) preferred the LASIK procedure because of the fast, painless recovery. CONCLUSIONS: In the current study, PRK and LASIK were found to be similarly effective, predictable, stable, and reasonably safe for the correction of myopia between -2.00 and -5.50 diopters. Laser in situ keratomileusis has the advantage of fast, painless recovery. Patients prefer LASIK.

One-site versus 2-site phacotrabeculectomy: a randomized study.

PURPOSE: To compare 1-site and 2-site combined phacoemulsification with foldable intraocular lens (IOL) implantation and trabeculectomy. SETTING: El-Maghraby Eye Hospital, Jeddah, Saudi Arabia. METHODS: Seventy-six eyes with coexisting cataract and glaucoma were randomly assigned to have a mitomycin-C trabeculectomy in a superior quadrant combined with phacoemulsification and foldable IOL implantation through the same incision (1-site group) or a separate, temporal, clear corneal incision (2-site group). Postoperative evaluation included visual acuity, intraocular pressure (IOP), bleb assessment, and number of antiglaucoma medications. Follow-up ranged from 12 to 18 months. RESULTS: Mean preoperative IOP was 28.1 mm Hg +/- 7.1 (SD) in the 2-site group and 26.2 +/- 6.5 mm Hg in the 1-site group. At 6 months postoperatively, mean IOP was 16.9 +/- 4.3 and 16.8 +/- 3.8 mm Hg, respectively (P = .9) and at 12 months, 17.6 +/- 3.3 and 19.1 +/- 3.1 mm Hg, respectively (P = .044). Twenty-three of 39 eyes (59%) in the 2-site group and 14 of 37 (38%) in the 1-site group had clinically apparent filtering blebs at 12 months (P = .065). Postoperative astigmatic change and complications were comparable. CONCLUSION: Mitomycin-C trabeculectomy superiorly combined with separate temporal clear corneal phacoemulsification provided 1 year IOP control comparable to that with single-incision (1-site) combined cataract and glaucoma surgery.

The contribution of phacoemulsification to combined cataract and glaucoma surgery.

The refinements of small incision cataract surgery by phacoemulsification with foldable intraocular lens implantation and the pharmacologic modulation of wound healing have brought new options for the combined procedure. Phacoemulsification combined with filtering surgery has the potential advantage of requiring a smaller conjunctival and scleral incision, which may reduce inflammation and bleb scarring with the possibility of enhanced bleb formation and long-term intraocular pressure control. The smaller phacoemulsification incision also helps to reduce postoperative astigmatism and improve visual results. Following combined phacoemulsification and filtering surgery, a larger area of undisturbed or virginal tissue in the conjunctiva and at the limbus is spared for further glaucoma surgeries or revision if the initial procedure fails. The risk of suprachoroidal hemorrhage during phacoemulsification in this susceptible group of patients is minimized by maintaining a closed chamber during the procedure.

Excimer laser in situ keratomileusis to correct compound myopic astigmatism.

PURPOSE: We studied the efficacy, predictability, stability, and safety of excimer laser in situ keratomileusis (LASIK) to correct myopia and astigmatism. METHODS: We prospectively studied 87 consecutive eyes of 56 patients who received LASIK, divided into two groups: the myopic group included eyes with myopia more than -2.00 diopters (D) and astigmatism less than 0.50 D and the astigmatism group included eyes with myopia of more than -2.00 D and astigmatism of 0.50 D or more. The Chiron automated corneal shaper and the Nidek EC-5000 excimer laser were used in all eyes. A modified personal nomogram was used in all eyes. The changes in refractive sphere and cylinder, and complications were studied at 2 and 6 weeks, 3, 6, and 12 months after surgery. Preoperatively, the mean spherical equivalent refraction was -4.41 D (range, -2.25 to -7.25; SD, 1.74) in the myopia group and -5.79 D (range, -2.25 to -15.50 D; SD, 2.45) in the astigmatism group. The mean spherical component of the refraction was -4.39 D (range, -2.25 to -7.25; SD, 1.74) in the myopia group and -5.19 D (range, -2.00 to -14.00; SD, 2.32) in the astigmatism group. The mean refractive cylinder was 1.19 D (range, 0.5 to 3.00 D; SD, 0.62) in the astigmatism group. RESULTS: At 12 months, 81 eyes (93.6%) of 51 patients were examined; the mean spherical equivalent refraction was -0.43 D (range, +0.50 to -1.25 D; SD, 0.35) in the myopia group and -0.33 D (range, +1.25 to -2.13 D; SD, 0.52) in the astigmatism group. The mean spherical component of the refraction at 12 months was -0.33 D (range, +0.50 to -1.25 D; SD, 0.33) in the myopia group and -0.17 D (range, +1.50 to -1.50; SD, 0.48) in the astigmatism group. The mean refractive cylinder was 0.19 D (range, 0 to 0.75 D; SD, 0.25) in the myopia group and 0.32 D (range, 0 to 1.25 D; SD, 0.30) in the astigmatism group. The mean change in spherical equivalent refraction between 6 weeks and 12 months after surgery was -0.08 D toward myopia (range, -0.50 to -0.75 D; SD, 0.23) in both groups. No eyes lost two or more lines of spectacle-corrected visual acuity. Patient satisfaction was high in both groups. Complications included undercorrection that necessitated reoperation (three eyes), overcorrection (two eyes), and small disc diameter (one eye). No vision threatening complications were observed. CONCLUSION: LASIK with the Nidek EC5000 laser is effective, reasonably predictable, stable, and safe for correction of compound myopic astigmatism with a spherical component between -2.00 and -14.00 D, and a cylindrical component between 0.50 and 3.00 D using the techniques in this study. Astigmatism is undercorrected with the current algorithm. Correction of higher amounts of astigmatism requires further study.

Lens capsule inclusion in trabeculectomy with cataract extraction.

PURPOSE: To deliberately include a flap of anterior lens capsule in the trabeculectomy site to determine whether it aids filtration in a glaucoma bleb. SETTING: El-Maghraby Eye Hospital, Jeddah, Saudi Arabia. METHODS: The study comprised 23 consecutive patients (25 eyes) with dense cataract and uncontrolled glaucoma despite maximum medical therapy. Combined trabeculectomy, planned extracapsular cataract extraction, posterior chamber intraocular lens implantation, and inclusion of the anterior lens capsule under the trabeculectomy scleral flap were performed. Follow-up ranged from 6 to 72 months. RESULTS: All eyes had improved visual acuity mainly because of cataract removal. Best spectacle-corrected visual acuity in 20 eyes ranged from 20/40 to 20/20. A diffuse filtration bleb was achieved in most cases. Postoperative intraocular pressure (IOP) was 20 mm Hg or less in 80% of eyes. Five eyes required additional topical timolol therapy. None required additional carbonic anhydrase inhibitor therapy. CONCLUSION: The combined procedure appeared to be a sound method of providing visual rehabilitation and adequate IOP control. The use of the capsular wick seemed to help maintain glaucoma filtration.

Excimer laser phototherapeutic keratectomy before cataract extraction and intraocular lens implantation.

PURPOSE: To determine whether sequential excimer laser phototherapeutic keratectomy (PTK) followed by cataract extraction and intraocular lens (IOL) implantation with power calculation based on the new corneal curvature is effective in managing superficial corneal disease. METHODS: Of a consecutive series of 18 eyes of 16 patients who received PTK, extracapsular cataract extraction, and posterior chamber IOL insertion, twelve eyes had spheroidal degeneration and six eyes, calcific band keratopathy. The PTK was done with either a Summit ExciMed laser or a Visx 20/20 laser using a 5.0 to 6.0 mm diameter ablation zone. Intraocular lens calculations were done a mean of 3.3 months after PTK. Cataract surgery was by extracapsular cataract extraction with posterior chamber IOL implantation. Patients were followed up for a mean of 14 months. RESULTS: Eighteen eyes completed follow-up examinations. Mean time between PTK and cataract surgery was 3.3 months. Phototherapeutic keratectomy was completed in one surgery session using one ablation treatment (ablation and slitlamp microscopy) in five eyes, two treatments in seven eyes, and three to seven treatments in six eyes. Eleven (61%) of 18 eyes had a final spherical equivalent refraction within +/- 1.00 diopter. Two eyes developed moderate to marked subepithelial reticular corneal haze from PTK. No vision-threatening complications occurred. CONCLUSION: Excimer laser PTK followed by cataract extraction and posterior chamber IOL implantation can safely and effectively treat eyes with superficial corneal disease and age-related cataract. Calculation of the IOL power after the cornea has healed from the PTK compensates for changes in corneal curvature.

Intraoperative mitomycin-C versus postoperative topical mitomycin-C drops for the treatment of pterygium.

BACKGROUND AND OBJECTIVE: To evaluate the safety and efficacy of two different regimens of mitomycin-C (MMC) application as adjunctive chemotherapy in the treatment of pterygia. PATIENTS AND METHODS: One hundred fifty-six patients underwent pterygium excision using the bare sclera technique. They were randomly assigned to have either 0.1 mg/ml of MMC applied to the bare sclera for 3 minutes intraoperatively, or 0.05-mg/ml drops applied topically for 2 weeks postoperatively. The mean follow-up period was 11 months (range 7 to 17). RESULTS: Complications with the intraoperative MMC included 5 cases of recurrence (5.75%), 2 cases of superficial punctate keratitis (SPK), and 3 cases of delayed conjunctival wound healing. Topical MMC led to 6 cases of recurrence (6.9%), 5 cases of SPK, 4 cases of delayed conjunctival wound healing, and 2 cases of mild iritis. CONCLUSION: A single, intraoperative application of MMC is a simple, effective alternative adjunctive treatment for pterygium.

Transscleral fixation of posterior chamber intraocular lenses in the absence of capsular support.

PURPOSE: To evaluate the safety and efficacy of a modified technique of transscleral fixation of posterior chamber intraocular lenses (IOLs) in the management of unilateral aphakia and in cases of IOL exchange. SETTING: El-Maghraby Eye Hospital, Jeddah, Saudi Arabia. METHODS: This prospective study comprised 41 eyes of 41 patients who had transscleral fixation of a posterior chamber IOL using a modified technique. Of these patients, 36 had unilateral aphakia and 5 had pseudophakia requiring lens exchange. Patient age ranged from 40 to 80 years. Follow-up was 12 months. RESULTS: Uncorrected visual acuity improved in all patients. Best corrected visual acuity was unchanged in 87.8% of patients, improved by two to four Snellen lines in 9.8%, and decreased by one or two Snellen lines in 2.4%. Most complications were minor and managed medically; only two patients required further surgical intervention. CONCLUSION: Our modified technique is safe and effective. We recommend evaluation of longer term results.

Excimer laser in situ keratomileusis under a corneal flap for myopia of 2 to 20 diopters.

PURPOSE: We studied the efficacy and safety of a recent technique of keratomileusis for myopia, excimer laser in situ keratomileusis. METHODS: We studied retrospectively 88 eyes of 63 patients who received excimer laser in situ keratomileusis with the Chiron Automated Corneal Shaper and the Summit OmniMed laser under a hinged corneal flap without sutures. RESULTS: Mean follow-up was 5.2 months. Mean spherical equivalent of the manifest refraction before surgery was -8.24 diopters (range, -2.00 to -20.00 diopters). Mean spherical equivalent refraction after surgery was +0.22 +/- 1.42 diopters. Of 40 eyes with a baseline refraction from -2.00 to -6.00 diopters, 25 eyes (63%) had refraction within +/- 0.50 diopter of emmetropia, and 37 eyes (93%) had refraction within +/- 1.00 diopter. In eyes with baseline refraction of -6.12 to -12.00 diopters, postoperative refraction was within +/- 1.00 diopter in 19 (65%) of 29 eyes. In eyes with baseline refraction of -12.10 to -20.00 diopters, postoperative refraction was +/- 1.00 diopter in eight (43%) of 19 eyes. Overall, 64 (72.8%) of 88 eyes had a refraction within +/- 1.00 diopter after surgery. Between three weeks and five months after surgery the change in the mean spherical equivalent refraction was -0.61 diopter in the myopic direction. Uncorrected visual acuity after surgery was 20/20 or better in 31 eyes (36%) and 20/40 or better in 61 eyes (71%). Three eyes (3.6%) lost two lines or more of spectacle-corrected visual acuity, two from progressive myopic maculopathy and one from irregular astigmatism. No eyes had vision-threatening complications. CONCLUSION: Excimer laser in situ keratomileusis under a corneal flap can be an effective method of reducing myopia between -2.00 and -20.00 diopters, with minimal complications. Current surgical algorithms need modification to improve predictability of outcome. Stability of refraction after surgery requires further study.

Efficacy and safety of excimer laser photorefractive keratectomy and radial keratotomy for bilateral myopia.

PURPOSE: To compare the safety and efficacy of radial keratotomy (RK) and photorefractive keratectomy (PRK) to correct myopia. METHODS: In this randomized, prospective, parallel-group study, 33 patients with bilateral myopia of 1.00 to 5.00 diopters (D) had PRK in one eye and RK in the other. The order of surgeries and treatment assignments were randomized, and the bilateral surgeries were within 1 week for each patient. Data were collected using standardized procedures. Clinical measurements and satisfaction surveys were taken in masked fashion. RESULTS: Eyes that had PRK had statistically significantly more residual myopia than RK-treated eyes at 3, 6, and 12 months postoperatively. This result was attributed to the use of an older excimer laser PRK algorithm that was used at the initiation of the study. No eye that had PRK was overcorrected by 0.50 D or more at 1 year postoperatively, while seven eyes that had RK were overcorrected by at least 0.50 D and six were overcorrected by 1.00 D. Eyes that had PRK had a statistically significant mean shift in the myopic direction between 6 and 12 months postoperatively; two RK eyes had hyperopic shifts of 1.00 D. Three RK eyes and two PRK eyes failed to achieve an uncorrected visual acuity of 20/40 or better by 12 months postoperatively. No eye lost any best corrected visual acuity. CONCLUSION: The two procedures were comparably safe and effective in treating mild to moderate myopia under this protocol. Eyes that had PRK were somewhat more myopic at 1 year after surgery, attributable to the older PRK ablation algorithm. Adoption of newer (current) laser algorithms has improved the predictability of PRK. There was also evidence of reduced variability of outcome in the PRK group. The PRK eyes did not exhibit hyperopic shifts during the 1 year follow-up.

Automated in situ keratomileusis for myopia.

BACKGROUND: In situ keratomileusis is a rapidly changing refractive corneal surgical procedure for the correction of myopia. We report here the results of a retrospective study of in situ keratomileusis with the refractive cut made with a microkeratome. The technique represents an intermediate stage of development that used a sutured corneal disc, an early automated microkeratome, and no reoperations for residual refractive error. METHODS: We carried out a retrospective chart review of the first 107 consecutive eyes (73 patients) that received in situ keratomileusis with an automated microkeratome (Ruiz corneal shaper) at the El Maghraby Hospital in Jeddah, Saudi Arabia between November, 1991 and February, 1993. Sixty-three eyes (59%) were followed for a mean of 1 year. Manifest refraction measured by an ophthalmologist or optometrist was the major response variable. Surgery followed the Ruiz nomogram, which specified an anterior corneal disc approximately 7.2 mm in diameter and 160 microns in thickness and a plano in situ refractive cut a mean of 4.2 mm in diameter and 93 microns in thickness. RESULTS: The mean baseline spherical equivalent of the manifest refraction was -11.97 +/- 5.30 diopters (D) (range, -3.75 to -28.00 D). At a mean of 1 year after surgery, the mean refraction was -1.86 +/- 3.13 D (range, -13.25 to +4.63 D); 13 eyes (21%) had a refraction within +/- 0.50 D and 22 (35%) within +/- 1.00 D. Undercorrection of more than -1.00 D was present in 36 eyes (57%). At baseline, 48 of 63 eyes (75%) could see 20/40 or better with spectacle correction. At 1 year, 13 of 63 eyes (21%) could see 20/40 or better uncorrected. To measure the stability of refraction in 61 eyes, the mean refraction at 1 month of +0.62 +/- 2.43 D was compared to that at 1 year after surgery (mean, -1.41 +/- 3.10 D), indicating a loss of effect in the direction of increasing myopia. Nine eyes (14%) lost two to five lines of spectacle-corrected visual acuity. Two eyes had central epithelial implantation plaques in the lamellar bed that required removal. CONCLUSION: In situ keratomileusis using an automated corneal shaper and sutured corneal discs at an intermediate stage of development produced less than desirable refractive and visual acuity results.

Excimer laser in-situ keratomileusis (LASIK) under a corneal flap for myopia of 2 to 20 D.

BACKGROUND: We report the results of a recent technique of keratomileusis for myopia: excimer laser in-situ keratomileusis (LASIK). METHODS: We studied retrospectively 88 eyes of 63 patients that received LASIK with the Chiron Automated Corneal Shaper and the Summit OmniMed excimer laser under a hinged corneal flap without sutures. RESULTS: Mean follow-up was 5.2 months. Mean spherical equivalent of the manifest refraction before surgery was -8.24 diopters (D)(range -2.00 to -20.00 D). Mean spherical equivalent refraction after surgery was +0.22 D (SD, 1.42 D). Of 40 eyes with a baseline refraction from -2.00 to -6.00 D, 25 (63%) had a refraction within +/- 0.50 D and 37 eyes (93%) within +/-1.00 D. In 29 eyes with baseline refraction of -6.12 to -12.00 D, postoperative refraction was within +/-1.00 D in 19 (65%). In 19 eyes with baseline refraction of -12.10 to -20.00 D postoperative refraction was +/-1.00 D in 8 (43%). Overall, 64 of 88 eyes (72.8%) had a refraction within +/-1.00 D after surgery. Between three weeks and five months after surgery the change in the mean spherical equivalent refraction was -0.61 D in the myopic direction. Uncorrected visual acuity after surgery was 20/20 or better in 31 eyes (36%) and 20/40 or better in 61 eyes (71%). Three eyes (3.6%) lost two lines or more of spectacle corrected visual acuity, two from progressive myopic maculopathy and one from irregular astigmatism. No eyes had vision threatening complications. CONCLUSION: Excimer laser in-situ keratomileusis (LASIK) under a corneal flap can be an effective method of reducing myopia between -2.00 to -20.00 D, with minimal complications. Current surgical algorithms need modification to improve predictability. Stability of refraction after surgery requires further study.

Molteno implant versus trabeculectomy with adjunctive intreoperative mitomycin-C in high-risk glaucoma patients.

PURPOSE: The Molteno implant is one of the most widely used drainage devices for the management of complicated glaucoma. Antiproliferative agents such as mitomycin-C (MMC) have markedly improved the outcome of glaucoma filtering surgery. This case control study compares the results of these two techniques in the management of high-risk glaucoma patients. METHODS: Forty-three consecutive patients with complicated glaucoma who underwent glaucoma filtration surgery with intraoperative application of 0.3 mg/ml of MMC were matched with a control group of 43 glaucoma patients who previously had tube surgery using a single-plate Molteno drainage implant in most of the cases. Control patients were matched based on diagnostic group of glaucoma, the number of prior filtration surgeries, and patient age. All patients had a minimum follow-up time of 12 months. RESULTS: Intraocular pressure (IOP) +/- 21 mm Hg was achieved 6 months postoperatively in 34 patients (79.1%) with Molteno implant and in 38 (88.4%) treated with MMC (p < 0.2), and 12 months postoperatively in 26 (60.5%) and 35 (81.4%) patients, respectively (p < 0.03). Complications after Molteno implant included hypotony (20.9%), flat anterior chamber (11.6%). tube-cornea touch (6.9%), and tube exposure (4.7%); after MMC, hypotony occurred in 6.9% and flat anterior chamber in 2.3% CONCLUSIONS: A significantly greater reduction in IOP was noticed in MMC-treated eyes 12 months postoperatively. Complications occurred more frequently in the Molteno-treated eyes. Filtration surgery with adjunctive MMC therapy seems to have a higher benefit/risk ratio in the management of highrisk glaucoma.

Posterior chamber lens implantation for primary repair of corneal lacerations and traumatic cataracts in children.

Children older than 3 years of age rarely tolerate contact lenses for unilateral surgical aphakia. This problem is even more pronounced following repair of corneal lacerations or perforations that are associated with traumatic cataracts. Even if surgery is successful, such eyes are functionally doomed because of deep anisometropic amblyopia. We evaluated prospectively in 15 children (3 to 8 years) the results of combined operation of corneal repair, aspiration of traumatic cataract, and primary posterior chamber lens implantation. Postoperative occlusion treatment was carefully monitored. Follow up ranged from 6 to 60 months, with an average of 39.2 months. The final best corrected visual acuity at the patient's last visit was 20/40 or better in 11 of 15 children (73.3%). The most frequent complication was a nonfunctional pupil due to traumatic iris damage or posterior synechiae in 13 cases. The most visually significant complication was posterior membrane formation and/or posterior capsule opacification, which required additional surgeries in six children.

Cryolathe keratomileusis for correction of myopia of 4.00 to 8.00 diopters.

BACKGROUND: During the last decade, new refractive surgery procedures have been introduced; older techniques have been modified or even abandoned. Cryolathe myopic keratomileusis has been in clinical use for approximately 30 years. In this retrospective study, we present our experience in applying this technique for the correction of 4.00 to 8.00 diopters of myopia. METHODS: Autoplastic cryolathe keratomileusis was performed on 61 eyes of 44 patients who were at least 18 years of age, with a preoperative myopia of 8.00 D or less, and 4.00 D or less of astigmatism. The surgical technique used the Barraquer microkeratome and cryolathe. The mean postoperative observation period was 28 months (range, 12 to 73 months). RESULTS: The mean preoperative spherical equivalent refraction was -5.95 +/- 1.14 D (range, -4.25 to -8.00 D). After a mean follow up of 28 months, the mean postoperative spherical equivalent refraction was -0.91 +/- 1.49 D (range, +2.00 to -7.75 D). At the end of follow up, 37 eyes (60.7%) were within +/- 1.00 D of emmetropia and 44 eyes (72.1%) achieved 20/40 or better uncorrected visual acuity. Complications included corneal ectasia in one eye (1.6%) and epithelial inclusions of the interface in another eye (1.6%). Irregular astigmatism was not a major problem, occurring in only two eyes (3.3%). CONCLUSIONS: Cryolathe keratomileusis is a proven and feasible technique for correcting moderate to high amounts of myopia in properly selected patients; there is a low incidence of vision-threatening complications.