[Primary phacoemulsification following acute primary angle closure glaucoma]. / Primäre Phakoemulsifikation nach akutem Winkelblock.

Recent developments and clinical studies indicate that primary phacoemulsification and intraocular lens implantation are safe and effective for the surgical treatment of primary angle closure glaucoma (ACG) compared to conventional iridectomy or laser-iridotomy. When compared to control eyes treated using standard peripheral iridectomy, the outcome in terms of intraocular pressure control, adjunct anti-glaucoma medication, visual acuity, and the necessity for successive surgical interventions favored primary phacoemulsification and intraocular lens implantation. Earlier biometric data underline the importance of the "lens factor" in the pathogenesis of relative pupillary block in ACG obtained by Scheimflug image processing and ultrasound biomicroscopy. The vast improvements in modern cataract surgery combined with our current understanding of the pathogenesis of relative pupillary block in ACG indicate that lens extraction is a better procedure in uncontrolled angle closure glaucoma than conventional iridectomy.

[Patient characteristics in a tertiary glaucoma center. Circumstances of treatment and attitudes of patients]. / Profil einer universitären Glaukomsprechstunde. Objektive Behandlungsumstände und subjektive Einstellungen der Patienten.

BACKGROUND: In order to look for conceptual improvements in the practical management of patients sent to our glaucoma department, we analyzed the structures, behaviour, and knowledge about the disease in this patient group. METHODS: Glaucoma patients who were sent for the first time to our department were included prospectively. Before being examined 129 patients were asked to answer a questionnaire concerning their individual characteristics, their behaviour, and patterns of treatment. RESULTS: Of the patients 74% had open-angle glaucoma (including normal tension, exfoliative, and pigment glaucoma), 22% had secondary glaucoma (including neovascular, congenital, and chronic closed-angle glaucoma), and 4% had suspected glaucoma. Written documentation of previously performed intraocular pressure measurements was not available for 84% of the patients. Younger patients had significantly more knowledge about glaucoma and used more possibilities to get information about the disease than elder patients. CONCLUSION: Education about glaucoma disease should be optimized especially for elder glaucoma patients. Documentation of intraocular pressure measurements is insufficient in our patient group.

[Implant exposure after viscocanalostomy with reticulated hyaluronic acid (SK-GEL)]. / Implantatexposition nach Viskokanalostomie mit hochvernetzter Hyaluronsäure (SK-GEL).

BACKGROUND: Lately, the application of intrascleral implants has been increasingly discussed to improve success rates of nonpenetrating surgery for the treatment of open-angle glaucoma. PATIENTS AND METHODS: A 36-year-old male patient with medically uncontrolled pigmentary glaucoma underwent viscocanalostomy with intrascleral implantation of reticulated hyaluronic acid (SK-GEL) in his right eye. RESULTS: The immediate postoperative course was unremarkable with control of intraocular pressure without additional glaucoma medications. At first follow-up, 2 weeks post surgery, conjunctival dehiscence with partial extrusion and exposure of the reticulated hyaluronic acid implant was observed. Under topical tobramycin ointment a gradual limbal readaptation of the conjunctiva over the surface of the exposed parts of the implant with formation of a filtration bleb was noted. Therefore, surgical revision remained unnecessary. CONCLUSIONS: Implant exposure following nonpenetrating antiglaucomatous surgery is a specific complication, which can appear whenever intrascleral implants are used. Depending on the local situation nonsurgical treatment may be successful.

UBM-guided chamber angle surgery for glaucoma management: an experimental study.

PURPOSE: The aim of this experimental study was to investigate the potential of ultrasound bimicroscopy (UBM)-guided chamber angle surgery as an alternative or supplement to gonioscopy and intraocular microendoscopy for intraoperative control. METHODS: In 15 porcine cadaver eyes, mechanical goniopuncture or punctual Er:YAG laser trabecular ablation was performed without operating microscope or gonioscopy, but with real-life ultrasound biomicroscopy monitoring with a 50 MHz transducer. Intraoperative localization of the microsurgical instruments and tissue-instrument contact were qualitatively evaluated. RESULTS: The instruments could be clearly visualized within the chamber angle and disturbing artefacts were only minimal when using mechanically fixed instruments in slow motion. Topographic localization, tissue contact, and penetration depth of the instruments entering the scleral were well illustrated as far as the technical resolution limits of UBM would allow. CONCLUSIONS: UBM can be used intraoperatively to monitor the correct manoeuvring of microsurgical instruments in selected ab interno procedures. Some adaptations and further modifications of the technique presented here will be necessary before UBM-guided surgery can be considered for clinical use in humans.

A prospective randomised trial of viscocanalostomy with and without implantation of a reticulated hyaluronic acid implant (SKGEL) in open angle glaucoma.

AIM: To prospectively assess the efficacy and complications of viscocanalostomy with a reticulated hyaluronic acid implant (VSRHAI) versus standard viscocanalostomy in patients with medically uncontrolled open angle glaucoma. METHODS: A consecutive series of 40 patients (40 eyes) with uncontrolled open angle glaucoma underwent non-penetrating antiglaucomatous surgery. After the excision of the deep scleral flap they were randomly assigned to either a standard viscocanalostomy or additional implantation of a reticulated hyaluronic acid implant. Follow up visits were over a period of 12 months after surgery. RESULTS: The mean preoperative intraocular pressure (IOP) was 26.5 (SD 6.1) mm Hg for all patients enrolled. The mean IOP was 8.1 (SD 5.6) mm Hg 1 day after surgery for the viscocanalostomy group (p<0.001) and 12.0 (SD 5.2) mm Hg for the VSRHAI group (p<0.001). The postoperative IOP difference between the two groups was statistically significant (p = 0.03). The success rate, defined as an IOP lower than 22 mm Hg without medication, was 40% in both groups at 12 months postoperatively (p = 0.90). The number of postoperative complications was equally low for both groups. CONCLUSIONS: Both surgical procedures, viscocanalostomy and VSRHAI, provide comparable success rates over a 1 year follow up period. The specific intraoperative and postoperative complications of non-penetrating surgery were seen in our series, although the overall rate of postoperative complications proved equally low for both techniques.

[Combined deep sclerectomy and trabeculotomy in congenital glaucoma with complications]. / Kombinierte tiefe Sklerektomie und Trabekulotomie beim komplizierten kongenitalen Glaukom.

BACKGROUND: Lately there has been growing interest in deep sclerectomy as a therapeutic approach for the management of congenital glaucoma.In theory, its pressure-lowering effect is independent of external filtration, which minimizes the risk of failure due to conjunctival or episcleral scarring. In patients who have failed to benefit from previous filtering procedures and have refractory congenital glaucoma,deep sclerectomy could become an alternative. PATIENTS AND METHODS: A 3-year-old girl with refractory congenital glaucoma underwent deep sclerectomy in her left eye. Intraoperatively, percolation through the trabeculodescemetic window was weak, so that the procedure was supplemented by a trabeculotomy. RESULTS: By now, throughout a follow-up period of 20 months, stabilisation of disc cupping and ocular axial length has been achieved without additional glaucoma surgery or medications. CONCLUSIONS: In patients with congenital glaucoma,the combination of deep sclerectomy with trabeculotomy may provide an additional therapeutic approach whenever the prospect of success appears to be limited with deep sclerectomy alone.

Ultrasound biomicroscopy and its value in predicting the long term outcome of viscocanalostomy.

AIMS: To examine whether the early postoperative morphology at the site of sclerectomy, as visualised by ultrasound biomicroscopy (UBM), is an indicator of the mechanisms that lower intraocular pressure (IOP) and/or predictors of the long term outcome of viscocanalostomy. METHODS: 15 eyes of 14 patients with medically uncontrolled open angle glaucoma and no history of surgery underwent viscocanalostomy according to Stegmann's technique. Ultrasound biomicroscopy was performed during the first month after surgery. The following parameters were assessed: dimensions of the intrascleral "lake," presence of a filtering bleb, presence of a subconjunctival cavity or a suprachoroidal hypoechoic area, and the thickness of the residual trabeculocorneal membrane. A complete ophthalmological examination was performed the day before and the day after surgery. Follow up visits were scheduled 1 week, 4 weeks, 6 months, and 12 months after surgery. RESULTS: At 1 year successful control of IOP (<20 mm Hg) was achieved without further manipulation or medication in six of 15 eyes. The size of the intrascleral "lake" (average 0.62 mm(3)) did not correlate with later IOP; however, a visible route under the scleral flap and accidental perforation of the trabeculocorneal membrane were associated with long term lowering of IOP. Normal thickness of the trabeculocorneal membrane (0.10-0.15 mm) was indicative of IOP control with and without medication. When UBM showed an early collapse of the intrascleral cavity, control of IOP was not achieved. Other UBM findings did not predict long term function. CONCLUSION: In accordance with previous studies, the authors found that UBM examination is a useful method to evaluate outflow mechanisms after glaucoma surgery. This study shows that UBM imaging of external filtration during the early postoperative period can be used to predict the success of viscocanalostomy. However, to establish conclusively what parameters of UBM predict successful viscocanalostomy a larger number of patients must be studied.

Morphology of the trabecular meshwork three years after Erbium:YAG laser trabecular ablation.

Laser trabecular ablation (LTA) is an abinterno approach with the purpose to improve outflow facility by removing trabecular tissue and open Schlemm's canal. In a blind eye with secondary glaucoma following silicone oil surgery, Erbium:YAG LTA had been performed applying 12 neighboring single laser pulses (5-7 mJ pulse energy, 200 micros pulse duration) to the trabecular meshwork. Enucleation was performed three years after the procedure that did not achieve pressure control. Light-microscopy revealed neither marked scarring nor endothelial proliferation in the treated trabecular meshwork. However, most of the recognizable ablation craters failed to open Schlemm's canal. Although limited scar formation within the trabecular meshwork after LTA is a promising aspect, the present technique of Er:YAG LTA still needs technical and surgical improvements to guarantee reliable and reproducible openings of Schlemm's canal.

Specific features of apoptosis in human lens epithelial cells induced by mitomycin C in vitro.

BACKGROUND: Posterior capsule opacification (PCO) is still one of the major complications following modern cataract surgery. Several attempts have been made to find an appropriate therapeutic concept to significantly lower the rate of PCO. Here, we wanted to focus on the antimetabolic strategy, reducing PCO by using mitomycin C, further characterizing the pathway of apoptosis in human lens epithelial cells (hLECs). METHODS: Human lens epithelial cells were obtained from anterior lens capsules during cataract surgery. The expression of Fas, TRAMP, TRAIL-R1-R4, Apo-3L and TRAIL mRNA was investigated by means of RT-PCR using specific primers. For investigations on bcl-2, bax, p53 and the active form of caspase 3, cell cultures of hLECs were pretreated with mitomycin C and processed for immunocytochemistry thereafter. RESULTS: We detected the expression of the receptors Fas, TRAMP, TRAIL-R2 and TRAIL-R3 in hLECs. We further obtained evidence of the upregulation of the intracellular apoptotic signalling cascade, represented by bcl-2 and bax, the transcription factor p53 and the active form of caspase 3, after pretreatment with mitomycin C. CONCLUSION: We demonstrated the presence of the apoptosis-receptor system in hLECs. Furthermore, we demonstrated the possibility of the induction of key proteins of the apoptotic signalling cascade in these cells by the antimetabolic drug mitomycin C. This could have important implications on the strategies regarding both the prevention and the treatment of PCO after cataract surgery.

Cataract surgery under topical anesthesia in patients with coexisting glaucoma.

PURPOSE: To evaluate and compare levels of patient discomfort and complications during phacoemulsification with implantation of a foldable intraocular lens (IOL) under topical lidocaine hydrochloride in patients with and without various forms of chronic open-angle and chronic angle-closure glaucoma. SETTING: Two university eye centers in Germany. METHODS: This prospective nonrandomized comparative study comprised 176 eyes of 176 patients with various forms of chronic open-angle glaucoma and chronic angle-closure glaucoma. Eyes with cataract and without a glaucoma diagnosis or history of intraocular surgery served as a control group (n = 212). All patients received a minimum of 5 doses (2 drops per dose) of topical lidocaine hydrochloride 2% before standard temporal clear corneal phacoemulsification and foldable IOL implantation. No intracameral anesthetic injection was given, and no systemic sedatives were used. The main outcome measures were the number of complications and adverse events. RESULTS: The intraoperative complication rate in all patients (n = 388) was capsule tear, 1.3%; zonule tear, 1.8%; vitreous loss, 1.0%; iris prolapse, 0.8%. No statistically significant differences in intraoperative or early postoperative complications were found between the glaucoma and control groups. The mean pain scores of patients were 0.38 +/- 1.1 (SD) in the glaucoma group and 0.36 +/- 0.8 in the control group (P =.21) Patient preference for cataract surgery under topical anesthesia was similar in both groups. CONCLUSIONS: Surgery-related complications and patient discomfort were similar in patients with and without glaucoma who had phacoemulsification and IOL implantation under topical anesthesia. These results indicate that topical anesthesia is safe for routine phacoemulsification with foldable IOL implantation in patients with glaucoma and does not compromise patient comfort.

Multifocal intraocular lens implantation in pediatric cataract surgery.

OBJECTIVE: To evaluate implantation of a zonal-progressive multifocal intraocular lens (IOL) in children. STUDY DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Thirty-five eyes of 26 pediatric patients aged 2 to 14 years with multifocal IOL implantation at one institution with more than 1 year of follow-up. INTERVENTIONS: Standard surgical procedure comprised an anterior capsulorrhexis, lens material aspiration via two side-port incisions, temporal tunnel incision, and multifocal IOL (SA40-N; Allergan, Irvine, CA) implantation in all eyes. In 24 eyes (68%), a 5-mm posterior capsulorrhexis was created with forceps, followed by an anterior vitrectomy in 19 of those eyes (54%). RESULTS: Twenty-six patients (35 eyes) had an average follow-up of 27.4 +/- 12.7 months (range, 12-58 months). At last follow-up, best-corrected distance visual acuity improved significantly (P = 0.001), 71% of eyes with a visual acuity of 20/40 or better and 31% of eyes with a visual acuity of 20/25 or better. In the 9 bilateral cases, spectacle dependency was moderate, with only 2 children (22%) reporting the permanent use of an additional near correction. The remaining children were either using distance-correction only (4 patients; 44%) or no glasses at all (3 patients; 33%). Stereopsis also improved significantly after multifocal IOL implantation (P = 0.01). Sixteen eyes (46%) experienced obscuration of the entrance pupil that required intervention, with 10 requiring a second intraocular surgery. Four eyes required an anterior membranectomy for persistent fibrinous membrane. Intraocular lens decentration requiring surgical intervention developed in six eyes. CONCLUSIONS: Multifocal IOL implantation is a viable alternative to monofocal pseudophakia in this age group.

[Does the dissection depth and thickness of the deep scleral flap affect intraocular pressure after viscocanalostomy? A clinico-pathologic correlation]. / Hat die genaue Präparationstiefe und -dicke der tiefen Skleralamelle Einfluss auf den Augeninnendruck nach Viskokanalostomie?--eine klinisch-pathologische Korrelation.

BACKGROUND: Non-perforating glaucoma surgery preserves the integrity of the trabecular meshwork in order to avoid postoperative hypotony. The purpose of our study was to investigate whether the morphologic variability of the excised deep scleral flap influences the postoperative intraocular pressure (IOP) after viscocanalostomy. METHODS: Light-microscopy of the deep scleral flap was performed in 17 patients who had undergone viscocanalstomy. Morphologic parameters (thickness and dissection level of the deep scleral flap) were correlated with the postoperative IOP. RESULTS: The mean thickness of the deep scleral flap was 309 +/- 95 microns; the dissection level was too deep in 5 cases (trabecular tissue excised) and too high in 6 cases (no signs of Schlemm's canal). The max. preop. IOP was 36.2 +/- 8.5 mmHg and came down to 10.6 +/- 5.7 mmHg at day 1 postop. and 12.4 +/- 4.9 mmHg at day 3/4 postop. At a median follow-up of 6 months IOP was 21.7 +/- 5.5 mmHg. A significant correlation between postop. IOP and the morphology of the deep scleral flap could not be demonstrated. CONCLUSIONS: Variations of the thickness and depth of the deep scleral flap showed little influence on the initial IOP level following viscocanalostomy. Other factors, f.e. the suturing of the external flap or invisible microruptures of the trabecular meshwork, could be of importance for the early postoperative IOP.

Massive anterior capsule shrinkage after plate-haptic silicone lens implantation in uveitis.

Two patients, both with bilateral uveitis, had synechiolysis, continuous curvilinear capsulorhexis (CCC), phacoemulsification, and in-the-bag implantation of a foldable single-piece plate-haptic silicone intraocular lens (IOL) in 1 eye. Several weeks postoperatively, massive anterior capsule shrinkage with obstruction of the visual axis occurred in both patients. Surgical revision was performed in both eyes. Both patients had CCC and phacoemulsification and confirmed in-the-bag acrylic IOL implantation in the second eye months after surgery in the first eye. Follow-up examinations showed no significant shrinkage of the anterior capsule opening in any eye. In patients with uveitis, intraoperative lens epithelial cell removal, creation of a large CCC, and careful selection of IOL style and material may prevent occlusion of the anterior capsule opening.

Morphological variability of the trabecular meshwork in glaucoma patients: implications for non-perforating glaucoma surgery.

BACKGROUND/AIMS: Morphological variability of the trabecular meshwork could be of considerable importance for the proper intraoperative outcome of non-perforating antiglaucomatous surgery, such as deep sclerectomy and viscocanalostomy. The aim of this study was therefore to assess qualitative and quantitative characteristics of the trabecular meshwork in glaucoma patients undergoing trabeculectomy. METHODS: Trabeculectomy specimens from 177 glaucoma patients were prepared for light microscopy; 100 specimens were found to be suitable for qualitative assessment and quantitative computerised image analysis; measurements were taken of the meridional diameter of Schlemm's canal as well as the thickness of the trabecular meshwork at different positions. RESULTS: The mean meridional diameter of Schlemm's canal was 290 microm with the smallest values in the young patients with infantile and secondary glaucomas. the thickness of the trabecular meshwork ranged between 50-70 microm in the anterior region and between 100-130 microm for the posterior portion. The thickness of the anterior meshwork significantly decreased with age. The pigmentation of excised trabecular meshwork was found to be weak or even lacking in 68 patients. In 20 glaucoma patients the uveal meshwork was covered by an endothelial layer. CONCLUSIONS: From the morphological point of view the risk of inadvertent perforation during deep sclerectomy in older, white glaucoma patients should be taken into account even by an experienced surgeon, because the anterior meshwork in these cases is very thin and trabecular pigmentation that can be used as a topographic landmark is often lacking. The functional success of non-perforating glaucoma surgery in many patients may be limited by endothelial covering of the trabecular meshwork.

Perspectives in trabecular surgery.

The aim of trabecular surgery is to selectively combat the diseased structure central to the pathogenesis of chronic open-angle glaucoma, thereby reducing potential hazards during and after conventional filtering procedures. This overview considers new techniques in ab interno trabecular surgery. Special emphasis is placed on the description of each novel technique, its instrumentation, presumed mechanism of action and clinical results. Trabecular aspiration is evaluated as a method of clearing intertrabecular spaces of extracellular debris in pseudoexfoliation glaucoma with or without simultaneous cataract surgery or goniocurettage, while laser trabecular ablation is discussed for the treatment of absolute glaucomas. Where corneal haze has formed visualisation of the anterior chamber angle structures and trabecular surgery is performed with the aid of a microendoscope. Although the results are very promising it should be understood that some of these procedures are still in the experimental phase and are undergoing careful clinical evaluation, leaving plenty of room for refinements and further developments.

Postoperative application of mitomycin for trabeculectomies.

BACKGROUND: Persistent hypotony is a severe complication following trabeculectomy with intraoperative application of mitomycin. OBJECTIVE: To reduce this rate of hypotony by using a lower concentration of mitomycin and applying the mitomycin only topically to the filtering bleb following surgery. METHODS: Patients were enrolled on a consecutive basis and prospectively followed up. Standard trabeculectomies were performed and mitomycin applied postoperatively on the 3 days following surgery (group 1). For comparison, data from previous studies were used for control eyes with intraoperative mitomycin application (group 2) and no mitomycin application (group 3). Preoperative and postoperative data, complications, and the need for further surgical procedures were evaluated. RESULTS: The study group (group 1) consisted of 22 cases. The mean follow-up was 13.4 and 13.5 months for groups 1 and 2, respectively. Average intraocular pressure values decreased from 33. 6 and 31.0 mm Hg (P =.32; t test) to 16.0 and 12.5 mm Hg in the 2 groups (P =.03; t test). The average number of medications decreased from 2.5 and 2.5 to 0.6 and 0.4 (P =.35; t test) in groups 1 and 2, respectively, at the last visit. Hypotony lasting for more than 3 months occurred only in eyes with intraoperative mitomycin application (14/22). Choroidal detachment (3/22) and hypotony maculopathy (2/22) also were only noted in eyes from group 2. In group 3, success rates were much lower. CONCLUSIONS: This is the first clinical study, to our knowledge, to evaluate the efficacy of this new technique of mitomycin application. From the results, it appears that the postoperative application of mitomycin following trabeculectomy is associated with a lower risk of severe and long-standing hypotony. This technique may be promising in eyes at low risk for failure.

Photoablative laser-grid trabeculectomy in glaucoma filtering surgery: histology and outflow facility measurements in porcine cadaver eyes.

BACKGROUND AND OBJECTIVE: Mid-infrared laser technology opens new perspectives in experimental glaucoma surgery. The aim of the study was to determine the efficacy of grid-laser trabeculectomy to reduce aqueous outflow resistance sufficiently in perfused porcine cadaver eyes. MATERIALS AND METHODS: Twenty-five freshly enucleated porcine cadaver eyes were randomly assigned to either laser-grid trabeculectomy (LGT), conventional trabeculectomy (CT), or control. In all surgical cases a scleral flap was prepared in a standardized manner. In order to penetrate into the anterior chamber a 1 x 2 mm sclerectomy was performed in CT, and 10 transscleral ablation craters were created in LGT. An erbium:YAG laser (2.96 microm) was used for transscleral photoablation. Radiation was delivered in a single 6 mJ-pulse of 200 micros duration by means of an articulated zirconium fluoride optical fiber and a 200 microm quartz fiber-tip. Outflow facility was measured at a constant perfusion pressure. RESULTS: Laser-grid trabeculectomy (LGT) yielded reproducible ablation areas varying between 210-300 microm in diameter, with 90% being full-thickness penetrations. Collateral thermal damage was less than 30 microm. Outflow facility measurements revealed a statistically significant increase (mean +/- SD) from 0.255 +/- 0.096 microL/min/mm Hg in control eyes (n = 9) to 0.772 +/- 0.157 microL/min/mm Hg in the LGT group (n = 9), and 2.957 +/- 0.602 microL/min/mm in the CT group (n = 7). Flattening of the anterior chamber, folding of Descemet's membrane, and iris prolapse were only observed in the CT eyes but not in the GLT group. CONCLUSION: Application of the laser-grid trabeculectomy produces patent transscleral perforation with minimal collateral tissue damage and effects a significant reduction (67%) in outflow resistance without any postoperative hypotony-related complications.

A comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery.

OBJECTIVES: To evaluate and compare levels of patient discomfort and perioperative complications during phacoemulsification and implantation of a foldable intraocular lens under topical lidocaine hydrochloride and retrobulbar anesthesia in patients with cataract who also had exfoliation syndrome, uveitis, posterior synechia, phacodonesis, or previous intraocular surgery. DESIGN: A prospective, randomized, controlled trial was carried out at 2 institutions. PARTICIPANTS: A total of 476 eyes of 476 patients with various well-established risk factors fulfilled the inclusion criteria. In 238 eyes, phacoemulsification was performed under retrobulbar anesthesia, while the other 238 eyes received topical anesthesia. INTERVENTIONS: All patients underwent temporal clear corneal phacoemulsification and implantation of a foldable intraocular lens. Patients under retrobulbar anesthesia received a single injection (3. 5-5.5 mL) of a combination of 0.75% bupivacaine hydrochloride, 2% lidocaine, and hyaluronidase into the retrobulbar space. Patients in the topical anesthesia group received a minimum of 5 doses (approximately 40 microL per dose) of 2% topical lidocaine. No intracameral injection of any anesthetic was given. MAIN OUTCOME MEASURES: The number of complications and adverse events. The intraoperative conditions were judged by the surgeon (P.C.J. or F.K. J.), and a 10-point visual analog scale was used immediately after surgery to assess each patient's overall severity of intraoperative pain. RESULTS: The overall intraoperative complication rate was 1.9% for capsular tear, 3.8% for zonular tear, 1.5% for vitreous loss, and 1.0% for iris prolapse. Apart from the incidence of vitreous loss, which was significantly (P =.041) lower in the topical anesthesia group, no statistically significant differences in intraoperative and early postoperative complications were found between the groups. A supplemental posterior sub-Tenon space injection was required in 1.3% of the topical anesthesia group and in 0.8% of the retrobulbar anesthesia group. Chemosis (2.5%), subconjunctival hemorrhage (1.7%), and periorbital hematoma (0.8%) were seen only in the retrobulbar anesthesia group. The mean + SE pain scores estimated by the patients were 0.84 + 1.30 in the topical anesthesia group and 0.73 + 1.50 in the retrobulbar anesthesia group (P =.41). Patient preference for topical anesthesia (91%) appeared to be significantly (P =.01) higher than for retrobulbar anesthesia (62%). The surgeons found anesthesia-related intraoperative difficulty to be slightly lower in the retrobulbar anesthesia group (8%) than in the topical anesthesia group (14%). CONCLUSIONS: Surgery-related complications and patient discomfort were similar for the 2 methods of anesthesia. Topical anesthesia is justified as a means of improving safety without causing discomfort to the patient even in complicated cases of cataract surgery. Arch Ophthalmol. 2000;118:1037-1043

The risk profile of trabecular aspiration versus trabeculectomy in glaucoma triple procedure.

OBJECTIVE: This study was set up to establish the relative safety and effectiveness of trabecular aspiration in combination with phacoemulsification and intraocular lens (IOL) implantation (phacoaspiration) for decreasing intraocular pressure (IOP), and to compare the outcome of this method of treatment with that of standard filtering glaucoma triple procedure (phaco-trab). STUDY DESIGN: Prospective, randomized study. PARTICIPANTS: The study consisted of 40 eyes of 40 patients with uncontrolled exfoliation glaucoma without a history of previous intra- or extraocular surgery and in need of cataract surgery. INTERVENTION: Temporal clear corneal phacoemulsification and foldable IOL implantation was performed in all eyes. In the phaco-aspiration group, trabecular aspiration was performed with a suction force of 100-200 mmHg under light tissue-instrument contact using a modified intraocular aspiration probe. A modified Cairns-type trabeculectomy without adjunctive antimetabolites was performed superiorly in the phaco-trab eyes after IOL implantation. MAIN OUTCOME MEASURES: The surgical outcome was assessed in terms of IOP change, need for adjunctive glaucoma medication, visual acuity outcome, and incidence of complications. RESULTS: At 1 year after combined surgery, mean (+/-SD) IOP and number of glaucoma medi- cation were 19.5+/-2.7 mmHg and 0.6+/-0.5 in the phaco-aspiration group, compared with 17.5+/-2.4 mmHg and 0.3+/-0.4 in the phaco-trab group. Hyphema (38%) and ocular hypotony (14%) were observed in the phaco-trab group only, whereas blood reflux (52%) and descemetolyses (23%) were seen exclusively in the phaco-aspiration group. CONCLUSION: In exfoliative eyes, trabecular aspiration in combination with phacoemulsification and IOL implantation is less effective in reducing postoperative IOP and number of glaucoma medications than the standard filtering glaucoma triple procedure. The risk profile, however, appears to be more favorable in the phaco-aspiration-treated eyes than in the phaco-trab group. Trabecular aspiration in glaucoma triple procedure could serve as a possible treatment of choice for exfoliative eyes with coexisting cataract and glaucoma.