Descemet membrane endothelial keratoplasty for corneal decompensation due to iridoschisis.

PURPOSE: To report a case of bilateral iridoschisis with cataracts and corneal decompensation in a patient who underwent cataract extraction and superficial iridectomy followed by Descemet membrane endothelial keratoplasty (DMEK). OBSERVATIONS: A 58-year-old man with previously diagnosed iridoschisis, cataracts, and diabetes mellitus experienced progressive vision loss bilaterally due to corneal decompensation. Slit lamp examination revealed iridoschisis with iris fibrils contacting the corneal endothelium, stromal edema, and mild guttate changes bilaterally. Corneal findings were more severe in the right eye, including the presence of bullous keratopathy at the time of presentation. Cataract extraction with intraocular lens implantation and superficial iridectomy were performed in the right eye, followed by DMEK. These same procedures were performed subsequently in the left eye. Postoperatively, the patient had significant improvement in visual acuity and corneal edema. CONCLUSIONS AND IMPORTANCE: DMEK can be performed safely and successfully after staged cataract surgery with superficial iridectomy in eyes with endothelial decompensation caused by iridoschisis.

Oral mineralocorticoid antagonists for recalcitrant central serous chorioretinopathy.

PURPOSE: To evaluate the effect and tolerance of oral mineralocorticoid antagonists, eplerenone and/or spironolactone, in recalcitrant central serous chorioretinopathy. METHODS: Retrospective consecutive observational case series. Primary outcome measures included central macular thickness (CMT, µm), macular volume (MV, mm(3)), Snellen visual acuity, and prior treatment failures. Secondary outcomes included duration of treatment, treatment dosage, and systemic side effects. RESULTS: A total of 120 patients with central serous chorioretinopathy were reviewed, of which 29 patients were treated with one or more mineralocorticoid antagonists. The average age of patients was 58.4 years. Sixteen patients (69.6%) were recalcitrant to other interventions prior to treatment with oral mineralocorticoid antagonists, with an average washout period of 15.3 months. The average duration of mineralocorticoid antagonist treatment was 3.9±2.3 months. Twelve patients (52.2%) showed decreased CMT and MV, six patients (26.1%) had increase in both, and five patients (21.7%) had negligible changes. The mean decrease in CMT of all patients was 42.4 µm (range, -136 to 255 µm): 100.7 µm among treatment-naïve patients, and 16.9 µm among recalcitrant patients. The mean decrease in MV of all patients was 0.20 mm(3) (range, -2.33 to 2.90 mm(3)): 0.6 mm(3) among treatment-naïve patients, and 0.0 mm(3) among recalcitrant patients. Median visual acuity at the start of therapy was 20/30 (range, 20/20-20/250), and at final follow-up it was 20/40 (range, 20/20-20/125). Nine patients (39.1%) experienced systemic side effects, of which three patients (13.0%) were unable to continue therapy. CONCLUSION: Mineralocorticoid antagonist treatment had a positive treatment effect in half of our patients. The decrease in CMT and MV was much less in the recalcitrant group compared to the treatment-naïve group. An improvement in vision was seen only in the treatment-naïve group. Systemic side effects, even at low doses, may limit its usage in some patients.

The impact of surgical intraocular pressure reduction on visual function using various criteria to define visual field progression.

PURPOSE: To examine the impact of surgical intraocular pressure (IOP) reduction on visual function using various methods to define visual field (VF) progression. METHODS: A retrospective chart review was conducted on consecutive glaucoma patients who underwent surgical IOP reduction between January 1, 2002 and December 31, 2007. All subjects had glaucomatous optic neuropathy, a minimum of 5 preoperative and 5 postoperative VFs, and were followed for a minimum of 2 years both before and after surgery. VF progression was determined using guided progression analysis, linear regression analysis of the visual field index, and individual sensitivity values using Progressor software. RESULTS: Seventeen eyes of 17 patients (mean age 77.9±9.9 y) were enrolled. Subjects were followed for a mean 5.8±2.4 years before surgery and 4.5±1.5 years after surgery. The mean postoperative IOP (11.3±4.2 mm Hg) and medications (1.3±1.3) were significantly (P<0.001 and P=0.01) reduced compared with before surgery (18.0±3.9 mm Hg, 2.4±0.9, respectively). The number of eyes judged to have VF progression using any method during the postoperative period (3 of 17, 17.6%) was significantly (P=0.03) reduced compared with the preoperative period (9 of 17 eyes, 52.9%). Using visual field index criteria, 8 eyes were judged to have preoperative VF progression and 1 eye had persistent VF progression during the postoperative period. None of the eyes judged to have preoperative VF progression using Early Manifest Glaucoma Trial (n=4) and Progressor criteria (n=1) demonstrated persistent VF progression during the postoperative period. Among eyes with preoperative VF progression, the postoperative slope of mean deviation (-0.21±0.23 dB/y) was significantly (P=0.03) reduced compared with before surgery (-1.01±0.23 dB/y). CONCLUSIONS: Despite differences in the criteria used to define VF progression, glaucoma surgical IOP reduction significantly reduces the incidence and rate of VF progression.