Prognosis and risk factors for early postoperative wound leaks after trabeculectomy with and without 5-fluorouracil.

PURPOSE: To evaluate the prognosis of patients who develop early postoperative wound leaks after trabeculectomy, to determine risk factors for these leaks, and to document adverse outcomes. DESIGN: Multicenter randomized clinical trial. METHODS: Two-hundred thirteen patients with previous cataract surgery or failed filtering surgery were randomized to either trabeculectomy (standard group) or trabeculectomy with postoperative subconjunctival 5-fluorouracil injections (5-FU group). Masked measurements of intraocular pressure were performed throughout 5 years of follow-up. Failure was defined as a reoperation to control intraocular pressure or an intraocular pressure greater than 21 mm Hg with or without medication at or after the 1-year examination. An early postoperative wound leak was defined as one that developed within 2 weeks postoperatively, determined by daily topical fluorescein testing. RESULTS: At 1 year (5 years), the success rate for the 5-FU group was 80% (54%) in eyes without a leak, and 60% (28%) in those with a leak. The 1-year (5-year) success rate in the standard group was 50% (24%) in those without a leak and 44% (15%) with a leak. (P =.018, log-rank test, adjusted for treatment). Leaks were more common in the 5-FU group, 34/105 (32%), than in the standard treatment group, 22/108 (20%), (P =.066, chi(2)). More eyes with one-layer conjunctiva-Tenon capsule closure developed leaks 40/115 (35%) than those with two-layer closure 16/95 (17%) (P =.006, chi(2)). More eyes with a trabeculectomy located inferiorly 29/76 (38%) developed leaks than those done superiorly 27/137 (20%) (P =.006, chi(2)). Patients with leaks were older (66 years) than those without leaks (60 years) (P =.011, t test). CONCLUSION: An early postoperative wound leak was a risk factor for trabeculectomy failure. We recommend that trabeculectomy be performed in a superior location with a two-layer closure.

Preschool vision screening using the MTI-Photoscreener.

Amblyopia is a condition that, if detected and treated early, can improve vision for most children. Thus, both pediatric and ophthalmologic groups have acknowledged the need for preschool vision screening. However, vision screening is the exception rather than the rule for preschoolers, since traditional methods of vision screening are often inappropriate for the preschool population and almost impossible for those children who are preverbal or nonverbal, developmentally delayed, and/or have chronic illnesses or disabilities. This study evaluated the use of a photoscreener to detect vision problems in a preschool population. Fifty-one children ages 3 to 5 years were evaluated using the MTI Photoscreener. Results were compared with a complete ophthalmologic examination, including cycloplegia. The sensitivity and specificity calculated for this study was 83% and 68%, respectively. Findings conclude that the MTI Photoscreener detected a broad range of vision problems, seemed to require less time, and seemed more acceptable to preschoolers when compared with the traditional vision screening methods performed by registered nurses. Although the sensitivity and specificity rates for this study were less than desired, it is likely that both could be improved with additional photo interpretation training.

Outcomes and complications associated with perfluoro-n-octane and perfluoroperhydrophenanthrene in complex retinal detachment repair.

OBJECTIVE: To compare rates of perfluorocarbon liquid (PFCL) intraocular retention, anatomic and visual acuity outcomes, and complications associated with intraoperative perfluoro-n-octane (Perfluoron) versus perfluoroperhydrophenanthrene (Vitreon) in retinal detachment repair. DESIGN: Retrospective noncomparative consecutive case series. PARTICIPANTS AND METHODS: Records of consecutive patients who underwent retinal detachment repair with intraoperative Perfluoron (n = 78) or Vitreon (n = 84) at the Bascom Palmer Eye Institute between November 1, 1991, and October 31, 1994, were retrospectively reviewed. MAIN OUTCOME MEASURES: Comparison of PFCL intraocular retention rates, retinal reattachment rates, visual acuity outcomes, and postoperative complication rates between the Perfluoron and Vitreon groups at postoperative day 1, week 1, month 1, month 3, and month 6. To assess the study's generalizability, the Perfluoron data obtained in the current study were compared with results of the Perfluoron Multicenter Clinical Study. RESULTS: Retained Perfluoron was noted less frequently (P < 0.03) than retained Vitreon at each postoperative visit assessed. At 6 months postoperatively, the cumulative rate of retained PFCL (noted at any of the study postoperative visits) was 7.8% of patients in the Perfluoron group and 38.3% in the Vitreon group (P < 0.001). No significant difference was found between the groups in retinal reattachment rates; at 6 months postoperatively, the retina was attached in 45 of 61 (74%) patients in the Perfluoron group and 36 of 57 (63%) patients in the Vitreon group (P = 0.2). There was a trend (P = 0.055) toward better 6-month visual acuity in the Perfluoron group compared with the Vitreon group. The incidence of corneal abnormality at any study visit was 46.7% in the Perfluoron group and 77.4% in the Vitreon group (P < 0.001). At 6 months postoperatively, the cumulative rate of elevated intraocular pressure (>25 mmHg) was 13 +/- 4% and 37 +/- 5%, respectively (P = 0.004). No significant difference was found between the groups in rates of postoperative hypotony. Results of this study are comparable with those observed in the Perfluoron Multicenter Clinical Study. CONCLUSIONS: In this study, Perfluoron was retained intraocularly less frequently than Vitreon. Although no significant difference was found between groups in retinal reattachment rates, Perfluoron is associated with slightly better 6-month visual acuity and lower rates of corneal abnormality and elevated intraocular pressure compared with Vitreon.

Surgical technique, visual outcome, and complications of pediatric intraocular lens implantation.

PURPOSE: To evaluate retrospectively the surgical technique, visual outcome, and complications of pediatric cataract extraction (CE) and intraocular lens (IOL) implantation. METHODS: Forty-three patients ages 2 to 12 underwent CE with IOL implantation with a minimum follow up of 1 month. RESULTS: All IOLs were implanted in the posterior chamber with 17 (40%) in the bag, 25 (58%) sulcus fixated, and one (2%) partially in the bag (one haptic in the bag, one in the sulcus). Primary posterior capsulectomy was performed in 12 (28%) cases. A final visual acuity of at least 20/40 was achieved in 26 (60%) and at least 20/80 in 32 (74%). Posterior capsule opacification developed in 18 (42%) and pupillary capture in 7 (16%). Seventeen (40%) patients had postoperative visual acuity worse than 20/40. Of these, nine (53%) had this visual outcome as a result of presumed amblyopia. CONCLUSIONS: Posterior chamber IOL implantation affords a safe and effective method of visual rehabilitation for cataractous children 2 years of age and older. Amblyopia and antecedent posterior segment trauma, rather than IOL-related or surgical complications, are the limiting factors in final visual outcome.

Pediatric photoscreening for strabismus and refractive errors in a high-risk population.

OBJECTIVE: To determine the accuracy of the MTI Photoscreener in detecting strabismus and refractive errors in children. PARTICIPANTS: One hundred children underwent MTI photoscreening followed by complete ophthalmologic examination. Six observers graded the photographs for strabismus, according to the location of the corneal light reflexes, and for refractive error, according to the size and location of the light crescent. RESULTS: The sensitivity of the MTI Photoscreener in detecting any amblyogenic factor was 80% to 91%, with a specificity of 20% to 67%. The sensitivity and specificity for particular amblyogenic factors varied widely among observers. The ranges were as follows: strabismus, sensitivity = 23% to 50%, specificity = 76% to 96%; myopia, sensitivity = 89%, specificity = 48% to 76%; hyperopia, sensitivity = 20% to 80%, specificity = 88% to 96%; and astigmatism, sensitivity = 46% to 77%, specificity = 79% to 89%. CONCLUSIONS: These results suggest caution in relying on photoscreening to detect strabismus and refractive errors in children.

Elevated intraocular pressure and hypotony following silicone oil retinal tamponade for complex retinal detachment: incidence and risk factors.

OBJECTIVE: To evaluate the incidence of and risk factors for persistently elevated intraocular pressure (IOP) and hypotony in patients who have undergone pars plana vitrectomy with silicone oil injection for the management of complex retinal detachment. SUBJECTS AND METHODS: The medical records of 532 patients who underwent silicone oil injection for the management of complex retinal detachments between January 1, 1991, and December 31, 1996, at the Bascom Palmer Eye Institute, Miami, Fla, were reviewed. Elevated IOP was defined as elevated IOP requiring an operation at any time postoperatively or a persistently elevated IOP of greater than 25 mm Hg at or after the 6-month visit. Hypotony was defined as a persistent IOP of 5 mm Hg or less at or after the 6-month visit. Patients with transient perioperative IOP fluctuations were not counted. RESULTS: Survival analysis for patients without cytomegalovirus retinitis (n = 383) revealed that 12.9% had an elevated IOP and 14.1% had hypotony by 6 months, 21% had an elevated IOP and 20.3% had hypotony by 1 year, and 29.5% had an elevated IOP and 27.3% had hypotony by 2 years. Among patients with cytomegalovirus retinitis (n = 149), none had a persistently elevated IOP, 10% had hypotony by 6 months, and 5.9% had persistently elevated IOP and 10% developed chronic hypotony by 1 year. A history of glaucoma before silicone oil retinal tamponade (P = .03), diabetes mellitus (P = .02), and a high IOP on the first postoperative day (P = .006) were risk factors for elevated postoperative IOP in patients without cytomegalovirus retinitis. Risk factors for postoperative hypotony in patients without cytomegalovirus retinitis included preoperative hypotony (P<.001) and aphakia (P = .03). CONCLUSIONS: An elevated or low IOP often develops postoperatively in patients without cytomegalovirus retinitis who undergo silicone oil injection for the management of complex retinal detachment. Risk factors for an elevated postoperative IOP include a history of glaucoma, diabetes mellitus, and a high IOP on the first postoperative day. Risk factors for hypotony include preoperative hypotony and aphakia.

Visual function and quality of life among patients with glaucoma.

This study determines the relation between visual field impairment, visual functioning, and global quality of life in patients with glaucoma. Binocular visual field impairment was calculated from simultaneous Esterman visual field testing using the Humphrey automated perimeter. Visual acuity impairment, defined with the American Medical Association's Guides to the Evaluation of Permanent Impairment; visual functioning, measured with the VF-14 and the field test version of the National Eye Institute-Visual Functioning Questionnaire; and global quality of life, assessed with the Medical Outcomes Study 36-Item Short Form Health Survey, were determined in 147 consecutive patients with glaucoma. None of the Medical Outcomes Study 36-Item Short Form Health Survey domains demonstrated more than a weak correlation with visual field impairment. The VF-14 scores were moderately correlated (r = -0.58). Of the National Eye Institute-Visual Functioning Questionnaire scales, peripheral vision (r = -0.60), distance activities (r = -0.56), and vision-specific dependency (r = -0.56) were moderately correlated with visual field impairment; vision-specific social functioning, near activities, vision-specific role difficulties, general vision, vision-specific mental health, color vision, and driving were modestly correlated with visual field impairment (r value between -0.32 and -0.55); visual pain was weakly correlated with visual field impairment; and general health and vision-specific expectations were not notably correlated with visual field impairment. Statistically adjusting for visual acuity weakened the correlations. The Medical Outcomes Study 36-Item Short Form Health Survey indicated that our patients with glaucoma were comparable with previously studied patients without severe systemic medical problems. However, the Medical Outcomes Study 36-Item Short Form Health Survey scores did not correlate with visual field impairment in our study. Based on the moderate correlation between binocular visual field impairment with the VF-14 and the National Eye Institute-Visual Functioning Questionnaire, these questionnaires may be useful among patients with glaucoma.

Some factors related to coronary heart disease incidence in Honolulu Japanese men: the Honolulu Heart Study.

Eight thousand and six Japanese men born in the years 1900-1919 participated in the baseline examination of the Honolulu Heart Study. Of the survivors, 94.6 per cent participated in a second examination two years later. All but 23 of the second exam refusers were contacted about their health. These procedures identified 101 men who had developed coronary heart disease (CHD) for the first time during this two-year interval. This incidence was associated with elevated levels of serum cholesterol, blood pressure, relative weight, uric acid, and cigarette smoking. Considered by itself, non-fasting serum triglyceride was related to CHD incidence, but in the context of other (non-lipid) characteristics this apparent association was not significant. Cigarette smoking was related to CHD other than angina pectoris (AP) but not to AP alone, while the reverse was true for glucose intolerance. In this cohort, the association between relative weight and CHD was as strong as that between serum cholesterol and CHD.