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.

Long-term outcomes after acute primary angle closure in a White Caucasian population.

INTRODUCTION: Very limited data is available on the morbidity and progression to primary angle closure glaucoma (PACG) in White Caucasian individuals following acute primary angle closure (APAC). Our aim is to identify the number of eyes who developed PACG following an APAC attack and to determine the risk factors for PACG development in a White Caucasian population in the United Kingdom (UK). We assessed the rate of blindness and visual impairment in the affected eye as defined by the World Health Organisation. METHODS: Retrospective observational study including 48 consecutive eyes of 46 White Caucasian subjects who presented with APAC to a tertiary referral unit in the United Kingdom. Eyes affected by glaucomatous optic neuropathy at presentation were excluded. We included in our analysis socio-demographic variables, ophthalmic findings, investigations and treatment. RESULTS: The mean final follow up period was 27 months ± 14 standard deviation (SD). Seven (15 %) eyes developed PACG. Statistical analysis showed that the following factors were linked to a higher risk of progression: length of symptoms before presentation and time taken to break the attack. The intraocular pressure (IOP) was significantly higher in the group who developed PACG at the one- and six-month visit compared to the group which did not develop the disease. At the final visit 3 (6 %) eyes were blind while 5 (10 %) were visually impaired. PACG was responsible for visual impairment in 2 (4 %) eyes but not for any case of blindness. CONCLUSIONS: Delayed presentation, length of time taken to break the attack and poor IOP control can result in PACG development and visual impairment. APAC causes a low long-term visual morbidity in White Caucasians.

ReGAE 10: long-term visual acuity outcomes after acute primary angle closure.

PURPOSE: The aim of this study was to identify the long-term visual acuity (VA) outcomes of eyes following an attack of acute primary angle closure in an urban UK population. PATIENTS AND METHODS: This was a retrospective observational case series of 134 consecutive eyes of 123 subjects presenting with acute primary angle closure to a supraregional tertiary referral unit in the United Kingdom over a period of 60 months. The VA in the affected eye was recorded at presentation 6 months after the acute event and at the final follow-up. In addition, causes of poor vision were documented as sociodemographic variables and surgical interventions. The main outcome measure was severe visual impairment (SVI). SVI was classified as VA<6/60 in the affected eye. RESULTS: A total of 134 eyes of 123 subjects were assessed, 89 (72%) female and 34 (28%) male patients. The majority of the individuals were White Caucasians (78%), followed by Indian and Pakistani (14%), African Caribbean (4%), and Chinese (2.4%). The mean age was 67.3±11.9 years.During the period of follow-up, 44 (33%) eyes needed a cataract surgery, whereas 13 (10%) eyes underwent filtration surgery. Eight (6%) eyes had combined cataract and filtration surgery. The mean final follow-up period was 31.4±18.1 months. At this stage, 16 (12%) of the affected eyes had SVI. Glaucomatous optic neuropathy was responsible for SVI in 5/16 eyes, 1 eye had corneal decompensation, whereas 2/16 eyes were affected by central retinal vein occlusion. Other SVI causes were age-related macular degeneration (5/16) and cataract (3/16). CONCLUSIONS: Sixteen (12%) eyes had SVI at the final follow-up. One third of SVI was secondary to GON.

The relationship between measurement method and corneal structure on apparent intraocular pressure in glaucoma and ocular hypertension.

PURPOSE: To analyse the relationship between measured intraocular pressure (IOP) and central corneal thickness (CCT), corneal hysteresis (CH) and corneal resistance factor (CRF) in ocular hypertension (OHT), primary open-angle (POAG) and normal tension glaucoma (NTG) eyes using multiple tonometry devices. METHODS: Right eyes of patients diagnosed with OHT (n=47), normal tension glaucoma (n=17) and POAG (n=50) were assessed. IOP was measured in random order with four devices: Goldmann applanation tonometry (GAT); Pascal dynamic contour tonometer (DCT); Reichert ocular response analyser (ORA); and Tono-Pen XL. CCT was then measured using a hand-held ultrasonic pachymeter. CH and CRF were derived from the air pressure to corneal reflectance relationship of the ORA data. RESULTS: Compared to the GAT, the Tonopen and ORA Goldmann equivalent (IOPg) and corneal compensated (IOPcc) measured higher IOP readings (F=19.351, p<0.001), particularly in NTG (F=12.604, p<0.001). DCT was closest to Goldmann IOP and had the lowest variance. CCT was significantly different (F=8.305, p<0.001) between the 3 conditions as was CH (F=6.854, p=0.002) and CRF (F=19.653, p<0.001). IOPcc measures were not affected by CCT. The DCT was generally not affected by corneal biomechanical factors. CONCLUSION: This study suggests that as the true pressure of the eye cannot be determined non-invasively, measurements from any tonometer should be interpreted with care, particularly when alterations in the corneal tissue are suspected.

Research into Glaucoma and Ethnicity (ReGAE) 8: is there a relationship between social deprivation and acute primary angle closure?

OBJECTIVES: Social deprivation as measured by the Index of Multiple Deprivation (IMD) and Townsend scores has been shown to be associated with advanced presentation of primary open angle glaucoma. The aim of this study was to investigate the putative association of social deprivation as a risk factor for acute primary angle closure (APAC) in a UK urban population. METHODS: Case notes of 139 consecutive patients presenting with APAC at the Birmingham and Midland Eye Centre, Birmingham, UK, were examined. Deprivation was scored using the IMD 2004 and Townsend scores. These score were compared with the West Midlands reference population. RESULTS: The level of deprivation in patients with APAC was graded according to the IMD quintiles, in which quintile 1 represents the highest level of deprivation and quintile 5 represents the lowest level of deprivation. Of the patients studied, 66.1% (n=90) were from quintiles 1 or 2 (most deprived) whereas 9% (n=12) came from quintile 5 (least deprived), compared with predicted frequencies of 40% and 20%, respectively. Deprivation levels measured by frequency within each IMD quintile were significantly higher in the APAC group compared with the reference population (χ(2), p<0.001). CONCLUSIONS: In this population patients presenting with APAC were more likely to come from areas with a high level of social deprivation.

Metabolomic analysis of human vitreous humor differentiates ocular inflammatory disease.

PURPOSE: Vitreoretinal disorders lack specific biomarkers that define either disease type or response to treatment. We have used NMR-based metabolomic analysis of human vitreous humor to assess the applicability of this approach to the study of ocular disease. METHODS: Vitreous samples from patients with a range of vitreoretinal disorders were subjected to high-resolution (1)H-nuclear magnetic resonance spectroscopy (NMR). Good quality spectra were derived from the vitreous samples, and the profiles were analyzed by three different methods. RESULTS: Principal component analysis (PCA) showed a wide dispersal of the different clinical conditions. Partial least squares discriminant analysis (PLS-DA) was used to define differences between lens-induced uveitis (LIU) and chronic uveitis (CU) and could distinguish between these conditions with a sensitivity of 78% and specificity of 85%. A genetic algorithm coupled with multivariate classification identified a small number of spectral components that showed clear discrimination between LIU and CU samples with sensitivity and specificity >90%. Assignment of specific resonances indicated that some metabolites involved in the arginase pathway were significantly more abundant in LIU than CU. CONCLUSION: The discrimination we observed based on PCA, PLS-DA, and multivariate variable selection analysis of the NMR spectra suggests that a complex mix of metabolites are present in vitreous fluid of different uveitic conditions as a result of the disease process. Collectively the data demonstrates the efficacy of metabolomic analysis to distinguish between ocular inflammatory diseases.

Vitreous loss during phacoemulsification in glaucoma patients: long-term intraocular pressure control.

PURPOSE: To assess the long-term effect of vitreous loss during phacoemulsification on intraocular pressure (IOP) control in glaucoma patients. SETTING: Birmingham and Midland Eye Centre, City Hospital, Birmingham, United Kingdom. METHODS: In this study, 26 glaucoma cases with vitreous loss during phacoemulsification were identified from operative room records. The cases were performed from January 1999 to December 2001. Minimum follow-up was 12 months. Postoperative IOP control in eyes with vitreous loss (Group 1) was assessed and compared with that in stable fellow eyes (Group 2), which served as controls. Another control group (Group 3) comprised patients with primary open-angle glaucoma who had successful phacoemulsification. Case notes of 22 patients from the same period fulfilled these criteria. RESULTS: The 3 groups were comparable in age, sex, laterality, ethnicity, mean IOP, and mean number of medications preoperatively. Twelve months after surgery, 43.2% in Group 1, 23.1% in Group 2 (P<.05) and 4.5% in Group 3 had significantly worse IOP; the differences between Group 1 and Groups 2 and 3 were statistically significant (P<.05). Intraocular pressure control was significantly better in Group 3 than in Group 2 (P<.05). CONCLUSIONS: Vitreous loss during cataract surgery in glaucoma patients adversely affected IOP control in the long term. Results suggest that uneventful cataract surgery in glaucoma patients improves IOP control.

Histochemical analysis of bandage contact lens precipitates.

Contact lens deposits have been reported previously with extended wear of soft contact lenses, with proteins, lipids, mucous, and various salts such as chloride, potassium and calcium being deposited on the lens surface [1]. We report an unusual case of precipitates on the surface of a bandage contact lens (BCL) following intensive treatment with topical preservative free artificial tears. Evaluation included microscopic and histochemical analysis of the BCL. We have also reviewed the literature for previous reports of contact lens precipitates.

Long-term results of trabeculectomy with mitomycin C applied under the scleral flap.

PURPOSE: The objective of this study was to look at the long-term safety, and the effectiveness on intraocular pressure, of trabeculectomy and mitomycin C (MMC) applied under the scleral flap. METHODS: All patients undergoing trabeculectomy and MMC application during the period June 1992-August 1995 were included. Data on 30 eyes of 25 patients were reviewed. We looked at sociodemographic variables, intraocular pressure (IOP) control, visual acuities and bleb morphology. Bleb-related and other complications were also noted. Statistical analysis was performed with Student's paired t-test, and Kaplan-Meier life table analysis was utilised for IOP control. RESULTS: The mean age of patients (12 male and 13 female) was 56 years (range 7-79 years), with a mean follow-up period of 8.7 years (range 5-11 years). There was one eye with blebitis/endophthalmitis at 4 years, and one eye developed hypotonous maculopathy. Ten eyes were noted to have poor bleb morphology due to long-standing fibrosis, and the majority of these underwent further surgical intervention with 5-fluorouracil (5FU) needling. The IOP control showed good results, with mean IOP falling from a preoperative level of 24.8-15.2 mmHg at the last visit, with good probability of maintenance in the longer term. The main reason for reduced vision was pre-existing co-morbidity and development of lenticular opacities. CONCLUSION: In the series with the longest follow-up period our study showed that trabeculectomy augmented with MMC under the scleral flap in these difficult cases can achieve good long-term IOP control and is associated with minimal long-term complications.

Reversible visual loss in a patient with rheumatoid arthritis and the role of vascular imaging.

Spontaneous vertebral artery dissection is a condition that can have lethal consequences. The condition should be considered in young male patients who present with a stroke. At presentation, headaches, cerebral ischaemic episodes and oculosympathetic paresis are the most commonly encountered manifestations. The diagnosis is confirmed with angiography. Here, we present a middle-aged male gardener with rheumatoid arthritis and signs of vertebral artery dissection to highlight the importance of diagnosis and discuss the controversies in management.

Anterior scleritis, scleral thinning, and intraocular pressure measurement.

We report a case of unilateral glaucoma with falsely low intraocular pressure reading as a result of scleral thinning from anterior scleritis.