Effect of primary Phacoviscocanalostomy/ Viscocanalostomy on intraocular pressure of normal tension glaucoma patients: 3-year results.

BACKGROUND: The objective of this study was to evaluate the efficacy of Viscocanalostomy/Phacoviscocanalostomy (VC/PVC) in lowering intraocular pressure (IOP) in Normal Tension Glaucoma (NTG) patients. METHODS: Retrospective electronic database review of patients who underwent VC/PVC for NTG between December 2009 and November 2011 at Stanley eye unit in Abergele Hospital. Goldmann applanation tonometry (GAT) was used for all IOP measurements which were taken at the time of listing for surgery and at 1 day, 1 week, 1 month, then 3-monthly up to 1 year, then half-yearly up to 3 years post operatively. Statistical analysis was performed using unpaired t-test. A P value of <0.05 was accepted as the level of significance. RESULTS: Operations were performed on 94 eyes from 67 patients over the study period. The mean age at the time of surgery was 76.4 years. Pre-operative IOP was 17.75 ± 2.19 mmHg (range 12-21 mmHg). 3 year follow-up showed a mean IOP of 13.41 ± 2.22 mmHg (range 8-18 mmHg). By year 3, 17 patients needed laser goniopuncture and 25 patients needed antiglaucoma drops. IOP was reduced by 24.4% at 3 years post-surgery, which was statistically significant (p < 0.0001). CONCLUSIONS: From our results, which show a 24.5% reduction in IOP at 3 years with 12% complication rate, we propose that a logical surgical management for NTG patients would be viscocanalostomy, thereby keeping trabeculectomy as an alternative.

Outcomes of Nd: YAG Goniopuncture After Viscocanalostomy/Phacoviscocanalostomy.

PURPOSE: The aim of this study is to evaluate the safety and efficacy of laser goniopuncture (LGP) to lower intraocular pressure (IOP) post-viscocanalostomy (VC)/phacoviscocanalostomy (PVC). Outcomes include: IOP reduction from pre-LGP levels and the need for further topical antiglaucomatous medication or surgery. PATIENTS AND METHODS: A total of 541 eyes that underwent VC/PVC between 2009 and 2012, at the Stanley eye unit in Abergele were included in the study. INCLUSION CRITERIA: All patients who had LGP at any timepoint after VC/PVC when target IOP was not achieved +/- progression in visual field with at least 6 months of follow-up data.Statistical analysis was performed on IOP values pre- and post-LGP, involving χ, Fischer exact, Mann-Whitney U, and Wilcoxon tests. A P-value of <0.05 was accepted as the level of significance. RESULTS: Of the 515 included eyes, 136 (26%) required LGP after a mean of 15.11±9.73 months after surgery (95% confidence interval, 13.46-16.76 mo), ranging from 1 to 42 months. LGP reduced IOP significantly from a mean of 22.92±5.80 to 17.08±5.30 mm Hg immediately for all eyes, a reduction of 5.84 mm Hg (or a 25% reduction) (P<0.0001). IOP significantly reduced in the VC group with a mean reduction of 7.60 mm Hg compared with 4.85 mm Hg in the PVC group immediately after the procedure (P=0.0038). LGP was required sooner in the VC group compared with PVC, 11.35 and 14.57 months, respectively (P=0.0393). A total of 69 (62%) eyes were commenced on topical IOP-lowering medications, mean 7.26±6.41 months after LGP. CONCLUSIONS: This study supports previous evidence that LGP enhances the IOP-lowering success of VC/PVC. The advantages of LGP are that it is a minimally invasive clinic-based procedure with a low complication rate.

Contralateral superior oblique posterior tenotomy (SOPT): a primary treatment for diplopia in downgaze following blowout orbital fracture.

PURPOSE: Superior oblique posterior tenotomy (SOPT) is a recognized surgical treatment to weaken the depressor effect of the superior oblique muscle without causing excyclotropia. We analyzed its use in the management of diplopia in downgaze due to contralateral blowout orbital fracture. METHODS: We performed a retrospective case note review of patients that had undergone an SOPT as a primary surgical option in the management of diplopia in down gaze caused by contralateral blowout orbital fracture. The study covered a 17-year period from 1993 and 2010. These cases had diplopia maximal to the side of the orbital blowout. Pre- and postoperative orthoptic measurements were compared. Surgical complications were noted. RESULTS: Five patients who fulfilled the entry criteria were identified. The mean follow-up period was 15.2 months (range 6-20 months). Preoperatively, the median |dev| was 2 prism diopters (PD) in primary position (range, 0-2) and 8 PD in downgaze (range, 2-18). At the final follow-up, the median |dev| in primary position was 0 PD (range, 0-2) and 2 PD in downgaze (range, 0-12). There were no significant differences pre- and postoperatively in both the primary position (p=0.19) or in downgaze (p=0.25) despite the large reduction in deviation size. Two patients needed a second procedure following SOPT. No patients complained of torsion, not in the primary position or in downgaze following the surgery. CONCLUSION: Contralateral SOPT can be a useful and simple primary treatment option for patients with moderate vertical deviations in downgaze to the same side of the orbital fracture. Larger deviations may require second surgeries. SOPT does not cause iatrogenic excyclotorsion and avoids surgery to a potentially much scarred inferior rectus area.