Baerveldt Aqueous Shunt with or without Mitomycin C Augmentation: A Retrospective Comparison Study.

OBJECTIVE: To evaluate if intraoperative mitomycin C (MMC) influences the success of Baerveldt aqueous shunts. DESIGN: Retrospective comparative case series. PARTICIPANTS: The study population consisted of 88 patients. Fifty-five received intraoperative MMC and 33 did not (controls). METHODS: The medical records of consecutive patients who underwent standalone Baerveldt aqueous shunts at Birmingham Midland Eye Centre, United Kingdom, were retrospectively reviewed. Patients in the MMC group received 0.2 to 0.4 mg/mL of MMC intraoperatively whereas controls did not. MAIN OUTCOME MEASURES: Primary outcome was survival, which was defined as an intraocular pressure (IOP) > 6 mmHg and ≤ 21 mmHg or ≤ 18 mmHg and > 20% IOP reduction from baseline. Further analysis of patients who required medications (qualified) or no medications (complete) was undertaken. Secondary outcomes were IOP, number of glaucoma medications, complications, intraluminal ripcord removal (IRR), and interventions. RESULTS: Average follow-up was 4.7 ± 1.4 years. At year 5, complete success with the ≤ 21 mmHg threshold was significantly higher in MMC vs controls (39.3% vs 17.8%; log rank P = 0.016). Final complete success with the ≤ 18 mmHg threshold was higher in patients with MMC shunts vs controls (38% vs 15.6%; log rank P = 0.0042). Qualified success was not different between patients with MMC shunts and controls with ≤ 21 mmHg (82% vs 93%; log rank P = 0.29) and ≤ 18 mmHg thresholds (70.3% vs 79.3%; log rank P = 0.44). Uveitic patients were also more likely to achieve complete success at both 21 and 18 mmHg thresholds among the patients receiving MMC compared with controls. Mitomycin C was correlated with lower number of medications between month 3 and year 2 post operatively (P < 0.001) and with a lower rate of IRR at all timepoints (P < 0.001). There were no significant differences in the incidence of prolonged hypotony, although MMC cases had higher transient hypotony at year 1 (P = 0.049). CONCLUSIONS: Mitomycin C provides a significant advantage in Baerveldt aqueous shunt survival when considering medication-free success but not in qualified success. Control patients required more medications to control IOP. This study suggests that intraoperative MMC augmentation of Baerveldt aqueous shunt surgery may be advantageous in achieving IOP control without the need for medication but that it may be associated with more transient hypotony episodes. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Comparison of 1-year surgical outcomes of combined cataract surgery and gonioscopy-assisted transluminal trabeculotomy (GATT) versus cataract surgery and iStent Inject.

PURPOSE: Evaluate the efficacy, safety, and complication rates of phacoemulsification cataract surgery when combined with either gonioscopy-assisted transluminal trabeculotomy (GATT) or iStent Inject. METHODS: This is a retrospective case-control study to compare the surgical outcomes of combined phacoemulsification cataract surgery with either GATT (phaco-GATT) or iStent Inject (phaco-iStent). Both groups had at least 1-year follow-up. The primary outcome measures were IOP and number of glaucoma medications (NGMs) at 1 year. Secondary outcomes measures were best corrected visual acuity (BCVA) and intra- or postoperative complications within the first year of follow-up. Success was defined as intraocular pressure (IOP) < 21 mmHg and ≥ 20% reduction in IOP at 1 year regardless of the NGM. RESULTS: Each group included 37 patients. The median baseline IOP (24 vs 17) and NGM (3 vs 2) were higher in the phaco-GATT group (p < 0.001). Phaco-GATT achieved a 38% (p < 0.0001) reduction in IOP compared to 13.2% (p < 0.001) in the phaco-iStent group at 1-year follow-up. The reduction in IOP and NGM was significantly higher in the phaco-GATT group (p < 0.01). After adjusting for baseline IOP, the reduction in IOP at 12 months was still significantly higher in the phaco-GATT group (p = 0.042). At 1 year, 86.4% of patients in the phaco-GATT group met the success criteria compared to 35.1% in the phaco-iStent group. Safety outcomes were slightly favourable in the phaco-iStent group. CONCLUSION: Phaco-GATT and phaco-iStent showed a significant reduction in IOP and NGM, with phaco-GATT having a significantly higher reduction. Phaco-iStent appears to have a higher safety profile and is probably preferable in monocular patients and those with a high risk of bleeding.

Endoscopic Goniosynechialysis for Acute Angle Closure Glaucoma Following Descemet's Stripping Automated Endothelial Keratoplasty.

We describe a new modified technique to release the peripheral iridocorneal adhesions that formed after Descemet stripping automated endothelial keratoplasty. The usual technique of goniosynechialysis was modified and performed using endoscopic fiber-optic light and camera probe to aid visualization of the adherent iris tissue and carry out uneventful 270 degrees release of adhesions. The iris tissue was gently pulled away using micro forceps. The modified technique was conceptualized, as the view from the cornea was very poor due to recent lamellar surgery and corneal oedema secondary to poorly controlled intraocular pressure. The blocked trabecular meshwork system was successfully recanalized, which allowed an adequate control of intraocular pressure. The graft survived the insult and cornea gained complete clarity giving the patient the desired vision and improved quality of life. How to cite this article: Rana M, Shah S, Pandey P, Masood I. Endoscopic Goniosynechialysis for Acute Angle Closure Glaucoma Following Descemet's Stripping Automated Endothelial Keratoplasty. J Curr Glaucoma Pract 2018;12(2):90-93.

Primary meningococcal conjunctivitis: an unusual case of transmission by saliva.

A 49-year-old diabetic man presented with a 2-day history of a painful right eye associated with a purulent discharge. Prior to becoming symptomatic, he reported that someone spat at him, resulting in direct contact between the saliva and his affected eye. Gram stain revealed numerous leucocytes with Gram-negative diplococci, and culture yielded Neisseria meningitidis (serogroup C). There was no evidence of any systemic infection, and blood cultures were negative for any growth. He was treated for primary meningococcal conjunctivitis (PMC) with intensive topical antibiotic eyedrops as well as systemic antibiotics. One week after commencing treatment he remained systemically well and his symptoms had fully resolved.

Cannula detachment during cataract surgery: results of a survey.

OBJECTIVE: To ascertain whether cannula displacement during cataract surgery with the use of the Luer lock is a common and recognized complication. METHODS: A questionnaire was sent to attending physicians on the Royal College of Ophthalmologists U.K. register inquiring about episodes of cannula displacement and complications. RESULTS: Despite the use of Luer locks, 60 cases of cannula detachment were reported; 196 respondents experienced this complication, and the most common cause of cannula detachment was stromal hydration (50%). Hydrodissection and viscoelastic were experienced by 18% and 17%, respectively. No severe damage resulted in most cases (76 cases), but some serious complications were reported: retinal damage (9%) and vitreous loss (17%). CONCLUSIONS: We recommend that surgeons test the union carefully themselves and then test the system by squirting outside the eye. Additionally, we recommend that a new cannula be used for each stage of the procedure. The viscoelastic cannula, in particular, should not be used for any other purpose.

Gonioaspiration for refractory glaucoma secondary to traumatic hyphema in patients with sickle cell trait.

The authors describe a new surgical method for treating disproportionately high intraocular pressures secondary to small traumatic hyphemas in three patients with the sickle cell trait. A novel technique was performed in all three cases to clear the hyphema from the anterior chamber angle. A Lewicky anterior chamber maintainer cannula was placed at the superior limbus to maintain infusion into the anterior chamber. Under direct visualization using a Koeppe goniotomy lens, a 23-gauge single-port cannula was used to aspirate the hyphema from the anterior chamber angle until it was free of blood. There were no intraoperative complications. Measurements of intraocular pressure were normal 2 hours after the procedure and at every subsequent visit. There was an improvement in visual acuity to 6/9 or better in all three of the cases. Therefore, gonioaspiration is an effective treatment of persistently raised intraocular pressures in patients with sickle cell trait.

Idiopathic intracranial hypertension: the association between weight loss and the requirement for systemic treatment.

BACKGROUND: To determine whether weight loss is significantly associated with a discontinuation of treatment for idiopathic intracranial hypertension METHODS: The notes of 36 patients with idiopathic intracranial hypertension under regular review for at least 12 months by a single neuro-ophthalmologist were retrospectively reviewed. Weight was recorded at each assessment and weight loss recommended. Treatment was adjusted according to symptoms, visual function including visual fields and optic disc appearance only. Patients were divided according to duration of continuous follow-up, and then sub-divided as to whether they were on or not on treatment at most recent review and whether weight loss had been achieved compared to presentation. Survival analysis was performed to assess the probability of remaining on treatment having lost weight. RESULTS: Considering the patients as 3 groups, those with at least 12 months follow-up (n = 36), those with at least 18 months follow-up (n = 24) and those with 24 months or more follow-up (n = 19), only the group with 24 months or more follow-up demonstrated a significant association between weight loss and stopping systemic treatment (Fisher's exact test, p = 0.04). Survival analysis demonstrated that the probability of being on treatment at 5 years having gained weight was 0.63 and having lost weight was 0.38 (log rank test, p = 0.04). The results suggest that final absolute body mass index is more important than the change in body mass index for patients who stop treatment (Mann Whitney U, p = 0.05). CONCLUSION: This is the first study to demonstrate that weight loss is associated with discontinuation of treatment. Unlike previous studies, our results suggest that final absolute body mass index is more important for stopping treatment than a proportional reduction in weight.