Baerveldt tube implantation following failed deep sclerectomy versus repeat deep sclerectomy.

PURPOSE: To compare the surgical outcomes of repeat deep sclerectomy (DS) and the Baerveldt glaucoma implant (BGI) in eyes with failed primary deep sclerectomy. DESIGN: A retrospective comparative case-control study. METHODS: Fifty-eight eyes of 56 glaucoma patients with previously failed DS underwent BGI (group BGI) and 58 eyes of 55 patients underwent repeat DS (group DS) at a tertiary referral centre. Visual acuity, intraocular pressure (IOP), number of glaucoma medications, surgical failure rates and complication rates were compared between groups. Surgical failure was defined as loss of IOP control, loss of light perception, or need for further glaucoma surgery. RESULTS: Baseline demographics were similar between groups. Preoperatively, median IOP was lower in the DS than the BGI group (19 mmHg versus 21 mmHg, p = 0.10). Postoperatively at year 1, median IOP was significantly higher in the DS than BGI group (14 mmHg versus 11 mmHg, p = 0.02). There were no differences between the DS and BGI groups in mean number of medications preoperatively (2.3 versus 2.6) or postoperatively (1.3 versus 1.1). Complication rates were significantly higher in the DS group [41 % (n = 24) versus 14 % (n = 8); p = 0.01]. The failure rate at 1 year was higher in eyes with repeat DS than in eyes with BGI (30 vs. 21 %, respectively; p = 0.07). CONCLUSIONS: Baerveldt implants were more effective in lowering IOP and resulted in significantly fewer complications than repeat deep sclerectomy in eyes with previously failed deep sclerectomy.

Predictive factors for intraocular pressure reduction after phacoemulsification in Swiss patients.

BACKGROUND: Phacoemulsification is known to induce postoperative intraocular pressure (IOP) reduction, the degree of which varies according to glaucoma subtype and race. The authors set out to investigate the effect of cataract surgery on IOP, in a Swiss Caucasian population, and identify ocular predictive factors. PATIENTS AND METHODS: 234 consecutive cases of 188 patients undergoing phacoemulsification between January 2011 and December 2012 were retrospectively reviewed and data collected. Exclusion criteria included acute angle closure, malignant glaucoma and pre-existing or subsequent glaucoma surgery. Pre- and post-operative visual acuity, IOP, gonioscopic findings, glaucoma medications, and laser treatments were recorded for eligible eyes. All eyes received the same postoperative regimen. Using multivariate analysis the predictive power of preoperative IOP, iridocorneal angle width, axial length on IOP reduction following phacoemulsification at months 3, 6 and 12 postoperatively were assessed. Eyes with narrow angles were compared against those with open angles. RESULTS: 172 eyes of 121 patients met the inclusion criteria; mean age was 70.3 years (SD±10.7 years), with 77 males. Preoperatively median IOP was 16 mmHg (range 9-32 mmHg), mean number of glaucoma medications was 1.2 (SD±1.1), median visual acuity was 0.28 LogMAR (range 0-2.3LogMar). At 3 months post-operatively mean IOP decreased to 14 mmHg (p<0.01) and remained statistically significantly reduced until 12 months, mean number of glaucoma medications was reduced to 1.0 and mean Snellen visual acuity increased to 0.8. Multivariate analysis revealed that pre-operative IOP and iridocorneal angle width (at 3 months) were significant predictive indicators of IOP reduction. At 12 months, IOP reduction was similar between open and narrow angle groups and total IOP reduction was no longer statistically significant. No intraoperative complications were recorded. CONCLUSIONS: Intraocular pressure reduction following phacoemulsification was greatest during the very early post-operative period, particularly in narrow angle patients. By one year, angle size was no longer predictive of IOP lowering, however pre-operative IOP and number of anti-glaucoma medications remained correlated with total IOP reduction.

Precision of the retinal tomograph as a screening device.

PURPOSE: To assess the diagnostic accuracy of the Heidelberg Retinal Tomograph 3 (HRT3) as a screening device in comparison with the reference standard of Octopus standard automated perimetry results (SAP) combined with clinical findings. METHODS: All patients underwent screening examinations and investigations within a single day. Abnormal screening results were classified as follows: The HRT3: Either "borderline" or "outside normal limits" using the global Moorfields classification (MFC); SAP and clinical exam: A mean defect>2.4 dB or "outside normal limits" clear text analysis of SAP; and one of the following i) IOP>21 mmHg, ii) Van Herrick<», iii) cup disc ratio>0.55, iv) optic nerve head abnormality, v) narrow iridocorneal angle or vi) evidence of peripheral anterior synechiae on gonioscopy. RESULTS: The mean age of the participants was 59.9 years (±14.8 [21, 91]). Twenty-three subjects (16%) were classified as abnormal on SAP and clinical exam. The HRT3 classification had a sensitivity of 30% (95% CI [16%, 51%]) with associated specificity of 58% (95% CI [49%, 66%]). Of the sixty subjects classified as borderline or outside normal limits with the HRT MFC global result, seven subjects were also abnormal according to SAP and clinical exam. CONCLUSION: The results suggest that the HRT3 may not be suitable as a sole screening device; however, further investigation is necessary.

Evaluating the trabecular micro-bypass stent combined with phacoemulsification compared to phacoemulsification alone.

AIM: The aim of this study was to assess the effect of iStent (trabecular micro-bypass stent) implantation in combination with phacoemulsification on IOP and glaucoma medications and to compare this to the outcome of phacoemulsification alone. PATIENTS AND METHODS: A retrospective consecutive comparative review was undertaken. 131 eyes with ocular hypertension and medically controlled glaucoma underwent phacoemulsification alone (n=78 group I) or combined with gonioscopic-guided implantation of one iStent (n=31, group II) or two iStents (n=22, group III). Patients were assessed at postoperative weeks 1, 3 and 6, and months 3 and 6. Pre- and post-operative measures included visual acuity, IOP and glaucoma medications. RESULTS: Post-operatively at 6 months, mean IOP decreased from 16.3 mmHg to 14.2 mmHg in group I (p<0.01), from 16.7 mmHg to 15.1 mmHg in group II (p<0.16) and from 17.0 to 13.8 in group III (p=0.05). Mean glaucoma medication decreased from 1.9 to 1.6 in group I (8%, p=0.12), from 2.5 to 0.8 in group II (27%, p=0.04), and from 2.1 to 1.0 in group III (45%, p<0.01). CONCLUSIONS: iStent implantation resulted in similar IOP reduction to phacoemulsification alone but achieved a significantly greater reduction in glaucoma medications. This may improve compliance and quality of life, and reduce health care costs in patients with early to moderate glaucoma.

Reattachment of Descemet's membrane using C3F8 gas in an eye with a Baerveldt aqueous shunt.

Descemetʼs membrane detachment (DMD) is a rare complication following cataract and glaucoma surgery as well as lamellar graft procedures. DMD can lead to blurry vision, halos and severe visual loss. Clinically, when there is a large central detachment, a double anterior chamber is seen to form. In this scenario, surgical repair may be needed. Repair of localised DMD may be achieved by injection of gases such as perfluoropropane (C3F8) and sulfurhexafluoride (SF6) or sterile air. The effect of a functioning Baerveldt tube in situ during these injections has not been reported. We report a case of DMD repair in an eye with a Baerveldt aqueous shunt.

Esophageal adenocarcinoma metastatic to the orbit.

A 75-year-old woman presented with orbital and ethmoidal metastases from an esophageal adenocarcinoma 6 months after diagnosis of the primary.

The Amsler chart is of doubtful value in retinal screening for early laser therapy of subretinal membranes. The West London Survey.

PURPOSE: Validating the current protocol of Amsler chart grid surveillance for the early detection of subretinal neovascular membrane(SRN) in age-related macular degeneration(AMD), and investigating its value in facilitating early laser therapy. METHODS: A retrospective pilot study. SETTING: Central London eye hospital with dedicated 24-h ophthalmic casualty serving West and West-central London. PARTICIPANTS: 100 consecutive AMD patients who attended casualty with vision loss fulfilling the following criteria: patients had received and been instructed in the use of Amsler charts according to the unit's dispensation protocol,fluorescein angiography which confirmed new SRN. Patients presented over 20 months. Outcome measures were detection of SRN by the Amsler chart, and laser treatment of SRN. RESULTS: The Amsler chart surveillance protocol had detected SRN in 29 of the 100 patients. The surveillance protocol detected less than 30% of the specific patients who subsequently underwent laser treatment. A statistically significant difference was seen on comparing the ages of patients in whom the screening protocol was successful versus those in whom it was unsuccessful (student's t-test,P<3.2 x 103). Younger patients were more likely to be detected using the Amsler chart. A one-tailed Z2 test approached, but did not achieve, statistical significance (Z2 = 1.057,P <0.3) suggesting that patients who have already lost vision to SRN in one eye might not be more likely to be detected using the surveillance protocol than patients in whom SRN was affecting their first eye. In all, 38% of surveillance responders went on to receive laser therapy, compared with 37% of surveillance nonresponders. CONCLUSIONS: The current Amsler chart surveillance protocol is suboptimal for detecting SRN in AMD, and a proportion of cases suitable for early laser therapy may be missing rapid detection. The results are especially important since recent advances in laser therapy for SRN require early detection for optimal effectiveness.