Comparison of limbus-based and fornix-based trabeculectomy: success, bleb-related complications, and bleb morphology.

PURPOSE: To compare the success and complications of trabeculectomy performed with limbus-based and fornix-based conjunctival approaches. DESIGN: Retrospective case series with some prospective data collection. PARTICIPANTS: Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008. INTERVENTION: We performed limbus-based operations during the first 4 years and fornix-based operations during the last 4 years. We collected data by chart review and by examination at the most recent visit. For each follow-up visit, we defined success as undergoing no further glaucoma procedure and achieving one of our intraocular pressure (IOP) criteria. We used Kaplan-Meier survival analysis, Cox proportional hazards models, and generalized estimating equation (GEE) analysis. During 2009, 439 trabeculectomy sites of 347 patients were quantitatively assessed by the Indiana bleb grading system. MAIN OUTCOME MEASURES: (1) Success rate of trabeculectomy, as determined by the achievement of each of our different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications. RESULTS: During the 4 years after surgery, the success rates of limbus-based and fornix-based trabeculectomy were not statistically different for any of our IOP criteria. Blebs after limbus-based surgery were more likely to be graded as higher and to be avascular (GEE model, both P < 0.0001). Four percent of eyes experienced late-onset bleb leaks within 4 years after both limbus- and fornix-based operations; however, limbus-based cases developed bleb leaks significantly later than did fornix-based cases (2.1 vs. 1.0 years; P=0.002, GEE model). Late bleb-associated infection during the first 4 years after surgery occurred more often in limbus-based operations, although statistical significance was borderline (P=0.054, Cox model). Symptomatic hypotony during all available follow-up was more common with fornix-based operations (P=0.01, GEE model). Eyes undergoing the fornix-based operation had a greater risk of cataract surgery in the 4-year period after surgery (P=0.02, Cox model), and fornix-based cases requiring cataract surgery had the operation earlier than limbus-based cases (P=0.002, GEE model). CONCLUSIONS: Success rates are similar between limbus-based and fornix-based trabeculectomy. Limbus-based procedures produce higher, more avascular blebs, with a greater risk of infection. Fornix-based procedures have more symptomatic hypotony and more and earlier cataract development.

Outcomes and bleb-related complications of trabeculectomy.

PURPOSE: To determine rates of success and complications of trabeculectomy surgery. DESIGN: Case series. PARTICIPANTS: Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008. INTERVENTION: By using the Wilmer Institute's billing database, we identified all patients at least 12 years of age coded as having undergone trabeculectomy between May 2000 and October 2008 by 1 of 2 glaucoma surgeons and whose surgery was not combined with another operation. From the chart, we abstracted demographic information on the patients and clinical characteristics of the eyes. The Kaplan-Meier product-limit method and Cox proportional hazard models were used to look at success rates and characteristics associated with inadequate intraocular pressure (IOP) reduction. Complications were tabulated. MAIN OUTCOME MEASURES: (1) Success rate of trabeculectomy, as determined by the achievement of each of 4 different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications. RESULTS: During the study period, 797 eyes of 634 persons underwent trabeculectomy without concurrent surgery. The success rates 4 years after surgery, with or without the use of IOP-lowering eye drops, were 70%, 72%, 60%, and 44%, for achievement of target IOP, ≤18 mmHg and ≥20% IOP reduction, ≤15 mmHg and ≥25% reduction, and ≤12 mmHg and ≥30% reduction, respectively. Increased chance of success was associated with European-derived race; use of mitomycin C (MMC); higher concentrations of MMC, when used; and higher preoperative IOP. Age and previous intraocular surgery were not associated with surgical success. Complications included worsening lens opacity in 242 of 443 phakic eyes (55%), loss of ≥3 lines of acuity (Snellen) in 161 eyes (21%), surgery for bleb-related problems in 70 eyes (8.8%), and infection occurring >6 weeks after surgery in 27 eyes (3.4%). A total of 101 eyes of 94 patients had at least 1 subsequent operation for inadequate IOP control. CONCLUSIONS: Trabeculectomy surgery performed by 2 experienced glaucoma specialists achieved target IOP at 4 years in 70% of those operated and was associated with progressive cataract and small risks of bleb-related complications. These results are comparable to those reported in smaller series.

Faculty beliefs, perceptions, and level of community involvement in their research: a survey at one urban academic institution.

Health researchers are increasingly interested in how best to engage communities in their health-related research studies. To help determine how researchers have interacted with community members in their research, we conducted a survey of full-time faculty from the Johns Hopkins Medical Institutions regarding researchers' beliefs and experiences with community-based research. Approximately 41% of respondents who conducted human subject studies had enrolled local residents in their research. Researchers whose studies were based in the surrounding community were significantly more likely to involve community members in all stages of their research (e.g., selection of the problem, project planning, data collection, interpretation and dissemination of results, or developing an intervention) than were faculty whose studies enrolled community members as research participants but whose studies were not set in the community. Over 90% of all faculty respondents agree that community involvement improves the relevance of their research, although almost 60% had not done so. Most faculty value community involvement, but they want more institutional support for such activities and they seek better skills to involve community. Few studies have surveyed researchers who enroll community members as research participants to document practices regarding community involvement in the research process. Given that the majority (73.6%) of faculty responded that they intend to include local residents in their upcoming studies, future research to evaluate interventions designed to facilitate community involvement, especially in the inner city, would help stakeholders identify best practices for involving and engaging communities in health research.

"You've got to understand community": community perceptions on "breaking the disconnect" between researchers and communities.

BACKGROUND: Community-based participatory research (CBPR) is a growing approach to research yet its implementation does not come without challenges. Incorporating CBPR may be especially difficult for large academic medical institutions where research is conducted by different stakeholders operating under different paradigms. The Environmental Justice Partnership (EJP) is a community-academic partnership that sought to understand and address these challenges. OBJECTIVES: To know how to effectively foster collaboration between a large academic medical center and its surrounding urban community, the EJP sought to understand community stakeholders' views on research, the research process, and how to improve researcher-community collaborations. METHODS: This study used a qualitative approach to gather information from residents and representatives from community-based organizations (CBOs) and city agencies. The data are from 17 semistructured interviews and 8 focus groups (n = 80) conducted from October 2003 to May 2004. RESULTS: Respondents emphasized the importance of disseminating research findings, working closely with the community before research starts and throughout the study, and listening to community members' priorities and needs. Those with personal research experience had more positive attitudes about research than respondents who had not been in research. CONCLUSIONS: Academic institutions need to make greater effort to involve communities regularly in their community-based research to identify community priorities and concerns. Institutions may want to develop strategies for their affiliated researchers to facilitate partnership building. Especially for large academic institutions in urban settings, such efforts may help to bridge distance between researchers and community to promote the shared goal of improved public health.

Community screening for eye disease by laypersons: the Hoffberger program.

PURPOSE: To describe the results of a community-based eye screening program in Baltimore. DESIGN: Cross-sectional study. METHODS: This was a retrospective study of the results of screening both eyes of 5352 persons who presented at multiple community sites. The screening examination had eight risk factor questions, visual acuity measurement, and a screening field test and was carried out by technicians and lay volunteers. Screened persons (screenees) received a definitive eye examination at no out-of-pocket cost, transportation was offered, and inexpensive eyeglasses were provided if needed. The main outcome measures were the rate of appointment keeping and the eye diseases identified. Telephone interviews were used to assess reasons for missing appointments and satisfaction with visits. RESULTS: Screenees had a median age of 45 years, were 71% black, 59% female, and had estimated median annual family income of 24,000 dollars. Among 1331 screenees who scheduled a definitive examination appointment, 552 (41%) completed the visit. Data on definitive diagnosis was available in 480 out of 552 persons (87%). Reasons given for failing to come for definitive examination were: no appointment given (26%), forgot (20%), lack of transportation (9%), and lack of insurance coverage (6%). Of those who accepted a second visit date after defaulting, only 25% (41/167) appeared. Of 17 persons identified with glaucoma at screening, 4 had previously been diagnosed, but had ceased active care. CONCLUSION: After community screening for eye disease, efforts to provide definitive ophthalmic examination were only modestly effective. Failure of screenees to come for examination and loss to follow up were identified as serious problems.