Pars plana Baerveldt tube insertion with pars plana vitrectomy for refractory glaucoma.

BACKGROUND: Glaucoma drainage implants (GDIs) are used for managing recalcitrant glaucoma and are usually placed in the anterior chamber. This approach may lead to complications such as corneal decompensation, and so a pars plana approach is used in at risk eyes. AIMS: To compare functional outcomes and complications of 250 mm(2) and 350 mm(2) pars plana Baerveldt tube insertion with pars plana vitrectomy (PPV) (both 20- and 23-gauge) for managing refractory glaucoma. SETTINGS AND DESIGN: A retrospective chart review of 38 patients (39 eyes) undergoing combined PPV-Baerveldt procedure for glaucoma recalcitrant to maximal medical treatment or previous filtering procedures with >6 weeks of follow-up. MATERIALS AND METHODS: Main outcome measures were visual acuity, intraocular pressure (IOP), number of glaucoma medications, and postoperative complications. STATISTICAL ANALYSIS USED: A paired 't' test was used to evaluate changes in IOP and glaucoma medications, Fisher's exact test was used to compare complication rates, and Kaplan-Meier survival curves were constructed for comparison of overall outcomes. RESULTS: Mean patient age was 62.2 years. Mean follow-up period was 33.7 months, with 36 (92%) eyes followed for ≥6 months. Mean±SD preoperative IOP and number of glaucoma medications were significantly reduced by the combined procedure (P<0.05). Thirty-five (90%) eyes maintained final IOP between 6 and 21 mmHg. Vision improved by ≥2 lines in 10 (26%) eyes, remained stable in 15 (38%) eyes, and decreased in 14 (36%) eyes. Two (5.1%) eyes developed no light perception vision, with one (2.6%) eye becoming phthisical. Twenty-four (62%) eyes developed complications managed with conservative measures. Five (13%) eyes required ≥1 surgeries within a year of the combined procedure. CONCLUSIONS: Pars plana Baerveldt tube implantation with PPV can preserve vision, reduce IOP, and decrease the number of glaucoma medications necessary to achieve target IOP in patients with recalcitrant glaucoma.

Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School.

AIM: To describe the complications related to cataract surgery performed by phacoemulsification technique by third-year ophthalmology residents at New Jersey Medical School, who are trained to perform phacoemulsification without any prior experience with extracapsular extraction. DESIGN: Retrospective, observational case series. METHODS: A retrospective chart review of 755 patients who underwent cataract surgery by third-year residents between July 2000 and June 2005 at the Institute of Ophthalmology and Visual Science was performed. Details of intraoperative complications (posterior capsular rupture, vitreous loss, subluxation of lens fragments into the vitreous, extracapsular cases converted to phacoemulsification, retinal detachment, vitreous haemorrhage and haemorrhagic choroidals) of the cases done by phacoemulsification technique were recorded. Results were analysed and compared with complication rates reported from other residency programmes and from experienced ophthalmologists. RESULTS: Of 755 cataract surgeries, 719 were performed using phacoemulsification technique. Posterior capsule disruption occurred in 48 (6.7%), vitreous loss in 39 (5.4%) and dislocated lenticular fragments in 7 (1.0%) of 719 cases that underwent phacoemulsification technique. Subsequent pars plana lensectomy was required in 5 (0.7%) cases; 1 case (0.1%) experienced retinal detachment and haemorrhagic choroidal detachment. CONCLUSION: The residents can perform phacoemulsification well with a very low complication rate, without prior training with extracapsular cataract extraction technique.

Systemic reactions associated with ophthalmic medications.

Although most medications for ophthalmic disease are administered locally, systemic absorption occurs as the drug passes into the nasopharynx by way of the nasolacrimal duct and may lead to a significant exposure. Knowledge of the mechanism of action of the drug, extent of systemic exposure, and its corresponding risks are important factors that must be considered before prescription of any ophthalmic agent. The relative risk in turn depends on the agent prescribed, plasma levels achieved, and individual susceptibility factors. Judicious use of pharmacotherapy in the management of ophthalmic disease should minimize the risk-benefit ratio.

The Proview phosphene tonometer fails to measure ocular pressure accurately in clinical practice.

PURPOSE: To evaluate the Proview Eye Pressure Monitor as a medical instrument and as a technique for enabling a patient to obtain an accurate measure of his or her intraocular pressure (IOP). DESIGN: An experimental laboratory evaluation and an independent prospective clinical study to test the reproducibility and accuracy of the Proview technique relative to Goldmann applanation tonometry. PARTICIPANTS: For the laboratory study, we analyzed 3 tonometers, each packaged as a Proview Eye Pressure Monitor by Bausch & Lomb. In the independent prospective experimental study, 137 subjects participated, consisting of healthy volunteers and glaucoma patients. METHODS: For laboratory testing, we held each tonometer with a micrometer to assure controlled positioning and pressed its sensing tip against a force meter that produced a calibrated, digital force reading. For clinical testing, we taught subjects (n = 137) to use the Proview technique in accordance with the manufacturer's instructions. Each subject obtained 5 measurements with each of the 5 different Proview devices. A clinician measured the IOP using Goldmann applanation tonometry. MAIN OUTCOME MEASURES: We measured the absolute value, linearity, and repeatability of the force meter readings on the tonometers during the instrument laboratory evaluation. The accuracy was evaluated by comparing the Proview measurements to the Goldmann applanation measurements. Reproducibility of clinical Proview measurements was also measured. All measurements were in mmHg during the clinical evaluation. RESULTS: Laboratory: There was a linear relationship between the pressures read by the Proview tonometers and known forces. The Proview tonometers read the maximum pressure applied. Clinical: The Proview technique is simple to use because it was comfortable and reproducible, with an average variance of the measurements by the same patient of 3.4 mmHg(2). Other variables besides IOP seem to affect the Proview pressure measurements, as seen in the large scatter in our data, measured by our correlation coefficient of r = 0.41. The sensitivity of the Proview technique to detect patients with high IOP (which we defined as a Goldmann pressure of >/=22 mmHg) is low; the Proview pressure identified only 18% (4/22) of these patients. CONCLUSIONS: The Proview instrument and technique were reproducible. However, the Proview tonometer seems not to be reliable as an indicator of IOP. The sensitivity for detecting high IOP was low in this cohort, and the agreement with Goldmann applanation was poor for some individuals. This brings into question the underlying assumption that a force proportional to the IOP generates phosphenes.

Antifibrotics and wound healing in glaucoma surgery.

When medical and laser therapy fail to control intraocular pressure, glaucoma filtration surgery needs to be performed. Glaucoma surgery is unique in that its success is linked to interruption of the wound-healing response in order to maintain patency of the new filtration pathway. In this article we will review the wound-healing pathway and the pharmacologic interventions that have been employed clinically and experimentally to interrupt wound healing, particularly steroids and the antifibrotic agents 5-fluorouracil and mitomycin C. A review of the published literature looking at use of these agents to enhance success as well as the associated complications are presented, critiqued, and interpreted in order to put the studies in proper perspective. Future directions and recommendations regarding use of these agents are available and an introduction to newer wound modulating agents such as anti-transforming growth factor beta 2 is presented.

Systemic adverse effects of beta-adrenergic blockers: an evidence-based assessment.

PURPOSE: To present an evidence-based review of the systemic adverse effects of beta-adrenergic blockers and recommend safety guidelines for use of ophthalmic beta-adrenergic blockers. DESIGN: Literature review of published articles in peer-reviewed journals and medical texts. METHODS: Pre-MEDLINE and MEDLINE search of relevant English language articles from 1966 to the present. Cardiovascular, pulmonary, endocrine/metabolic, central nervous system, sexual, exercise, and neuromuscular effects of systemic or ophthalmic beta-adrenergic blockers were reviewed. RESULTS: Systemic beta-adrenergic antagonists unequivocally reduce mortality in patients with mild, moderate, and even severe congestive heart failure. Development of symptomatic bradycardia on systemic or ophthalmic beta-adrenergic blockers alone likely indicates underlying cardiac conduction disturbances. Beta 2-adrenergic blockade, regardless of route of administration, may exacerbate or trigger bronchospasm in patients with asthma or pulmonary disease associated with hyper-reactive airways. This review identifies no scientific studies supporting the development of worsening claudication, depression, hypoglycemic unawareness, or prolonged hypoglycemia in non-insulin-dependent diabetes, sexual dysfunction, or impaired neuromuscular transmission with systemic or ophthalmic beta-adrenergic blockers. CONCLUSIONS: Many commonly presumed adverse beta-adrenergic blocker effects observed via systemic or ocular administration are not supported by published randomized clinical trials. Wide acceptance of such traditionally purported side effects has been largely due to propagation of isolated case reports and short series as well as personal communication felt to reflect expert opinion. Many more patients may be eligible to use these drugs. Obtaining a careful medical history and checking pulse rate and rhythm in the office should identify the vast majority of patients with potential cardiopulmonary contraindications.