Electron microscopic evaluation of a gold glaucoma micro shunt after explantation.

UNLABELLED: We present a case of an explanted gold glaucoma micro shunt (GMS Plus) and the subsequent light and electron microscopic analyses. The shunt was implanted in a patient with medically refractive glaucoma. The intraocular pressure (IOP) was stable at 12 mm Hg 6 months postoperatively but spiked to 26 mm Hg 6 months later; membranous growth was visible on the implant gonioscopically. A second gold micro shunt was placed 2 years after the first. The IOP was 7 mm Hg 1 week postoperatively but increased to 23 mm Hg 3 weeks later; similar membranous growth was visible on this implant. One of the shunts was explanted, and light and scanning electron microscopic analyses revealed encapsulation around the shunt exterior and connective tissue invasion of the microstructure. This represents the first electron microscopic analysis of an explanted gold glaucoma micro shunt and the first unequivocal images of the fibrotic pseudo-capsule traversing its microchannels and fenestrations. FINANCIAL DISCLOSURE: Dr. Ahmed is a consultant to and has received research grants from Solx, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Malignant glaucoma after cataract surgery.

PURPOSE: To report a series of eyes that developed malignant glaucoma after cataract surgery. SETTING: Private academic practice, Toronto, Ontario, Canada. DESIGN: Retrospective case series. METHODS: Eyes that developed malignant glaucoma after cataract surgery were treated with medical therapy. This was followed by laser iridozonulohyaloidotomy, anterior chamber reformation and intraocular lens (IOL) pushback, and finally with surgical iridozonulohyaloidovitrectomy if all other measures were unsuccessful. Refraction, intraocular pressure (IOP), gonioscopy, and anterior chamber depth (ACD) by anterior segment optical coherence tomography were analyzed before treatment and after treatment. RESULTS: The study evaluated 20 eyes of 18 female patients aged 44 to 86 years. Preoperatively, the mean refraction was +3.11 diopters (D) ± 2.89 (SD), the mean axial length was 21.30 ± 1.40 mm, and all eyes had narrow or closed angles. Malignant glaucoma was diagnosed a mean of 5.8 ± 7.1 weeks postoperatively. At diagnosis, the mean refraction was -2.15 ± 2.95 D; the mean ACD, 2.49 ± 0.72 mm; and the mean IOP, 28.3 ± 10.8 mm Hg on a mean of 1.3 ± 1.6 medications. Two eyes responded to cycloplegia, 7 to laser iridozonulohyaloidotomy, and 6 to anterior chamber reformation-IOL pushback; 5 eyes required vitrectomy. Posttreatment, the mean refraction was -0.56 ± 1.07 D; the mean ACD, 3.30 ± 0.50 mm; and the mean IOP, 14.4 ± 4.60 mm Hg on a mean of 1.2 ± 1.4 medications. Cycloplegia was discontinued in 17 eyes. CONCLUSION: Malignant glaucoma can occur after phacoemulsification and presents with myopic surprise, anterior chamber shallowing and, possibly, elevated IOP. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Nd: YAG laser goniopuncture: indications and procedure.

Laser goniopuncture is a complementary adjunct to nonfiltering glaucoma surgery such as deep sclerectomy, viscocanalostomy, and canaloplasty, contributing to intraocular pressure control and the avoidance of additional incisional surgery. Goniopuncture is associated with a low complication rate and demonstrates minimal inflammation, hemorrhage, and hypotony when performed correctly. This article provides a detailed description of how to perform this procedure and methods of preventing and addressing complications.

The phaco hemi-flip: a method of lens removal in nuclei of soft to moderate density.

Although endocapsular nuclear fragmentation chopping techniques have allowed surgeons to decrease the amount of dissipated phaco energy in the anterior chamber and improve lens removal efficiency when compared with previous techniques, chopping maneuvers carry a small risk of capsular and zonular injury. Furthermore, in softer lenses, chopping techniques may be limited in providing sufficient nuclear cracking. Additionally, with torsional phaco technologies, adequate lens purchase may be suboptimal and lead to inefficient chopping. Supracapsular phaco techniques improve capsular safety, but may be challenging in small pupil/capsulorrhexis cases and place the corneal endothelium and anterior chamber tissues at greater risk to trauma from ultrasound energy. The phaco hemi-flip technique combines the advantages of these two approaches with a single endocapsular quick chop, followed by phacoaspiration removal of each heminucleus in the iris plane without further chopping or segmentation.

Late bleb leak management with trabeculectomy shutdown, Baerveldt glaucoma device implantation, and titratable tube lumen size.

PURPOSE: To report a case of late subconjunctival bleb leak, and its management to preserve vision and achieve optimal pressure control in a patient with advanced glaucoma, a 3+ Seidel positive bleb leak, and hypotony maculopathy in the better-seeing eye. DESIGN: Case Report. METHODS: Shutdown of the earlier trabeculectomy site with a scleral graft was achieved before insertion of a 250-mm Baerveldt glaucoma device. An absorbable ligature was used around the tube to prevent early postoperative hypotony. Additional pressure control was obtained by using a permanent polypropylene ligature to decrease the effective lumen size after the resorbence of the vicryl ligature. This suture was left in a location that would be accessible to laser suture-lysis, or manual removal if necessary. RESULTS: Intraocular pressure at 1 year postoperatively was 13 mm Hg on no medications with resolution of the macular folds and 3 lines of improvement of Snellen corrected distance visual acuity. The leak was completely resolved. CONCLUSION: Excellent pressure control was achieved in the surgical management of a late onset bleb leak by shutting down the old trabeculectomy, and inserting a new Baerveldt tube shunt with an adjustable lumen size.

The clear corneal tongue: a mechanism for wound incompetence after phacoemulsification.

PURPOSE: To describe a mechanism for wound incompetence after phacoemulsification with corneal incisions resulting in early postoperative wound leakage. DESIGN: Observational case series. METHODS: Three patients who had uneventful phacoemulsification through a clear corneal incision were identified because of a postoperative wound leak. A corneal tongue, consisting of an everted triangular flap of posterior corneal stroma, the Descemet membrane, and endothelium, was observed in the wounds of all cases. RESULTS: One wound leak resolved after pressure patching. The other two necessitated wound revisions. None of the patients developed endophthalmitis. CONCLUSIONS: In phacoemulsification with corneal incisions, an everted flap of posterior corneal tissue, a corneal tongue, may prevent normal anatomical apposition of the surgical wound edges leading to potential wound incompetence. This event may increase the risk of endophthalmitis after clear corneal phacoemulsification.