Amar Alwitry

Frequency of bleb manipulations after trabeculectomy surgery

Aim: To quantify the type and frequency of postoperative bleb manipulations undertaken after modern glaucoma surgery. Methods: Bleb manipulations were recorded after trabeculectomy surgery on 119 consecutive patients with at least 1 year of follow-up. The type of intervention and time after surgery were recorded. Statistical analysis identified success rates at various intraocular pressure (IOP) cut-off definitions and identified factors that increased the risk for bleb manipulation. Results: In all, 78.2% of trabeculectomies were followed by some form of bleb manipulation. Almost 49% of blebs underwent massage and a similar number required at least one suture removal, 31.1% required at least one 5-fluorouracil (5-FU) injection and 25.2% required at least one needling and 5-FU injection. The median time to the first intervention for massage, suture removal, 5-FU injection, and needling and 5-FU injection were 1, 14, 14 and 43 days, respectively. IOP measurements were higher at all follow-up time points in the intervention group. Failure to achieve specific IOP target pressures was also generally poorer in the 5-FU, and needling and 5-FU intervention groups. Conclusions: Postoperative intervention is a frequent occurrence after modern glaucoma surgery. This requires intensive postoperative follow-up and is a labour-intensive undertaking. Despite interventions in our group of patients, IOP in the intervention group was always higher than in the group that required no intervention.

First day review after uncomplicated phacoemulsification: is it necessary?

Purpose To determine whether first day follow-up is necessary after routine uncomplicated phacoemulsification cataract surgery. Methods Data collected prospectively at day 1 postoperative review. Results In 510 consecutive cases, serious complications occurred in 8 (1.6%) (wound leak [4], corneal abrasion [2], iris prolapse [1], hyphema [1]). Intraocular ptessure (IOP) >30 mmHg was found in 26 (5.1%) and was strongly associated with a diagnosis of pre-existing glaucoma or ocular hypertension (odds ratio [OR] 7.7). Symptoms of headache or ocular discomfort occurred in 40 (7.8%), mostly in association with raised IOP, and were also associated with pre-existing glaucoma or ocular hypertension (OR 4.7). Central corneal edema was found in 61 (12.0%). In the absence of corneal edema, IOP was >30 mmHg in only two cases (0.39%). Conclusions Few sight-threatening complications were detected on the morning after an uncomplicated procedure. First day follow-up may be safely omitted if adequate patient counseling is undertaken and there is provision of adequate access to eye services. Review prior to discharge on the day of surgery would provide an opportunity to detect these few surgical complications and for counseling. A diagnosis of glaucoma or ocular hypertension is a risk factor for significantly raised next day IOP and these patients are more likely to experience postoperative discomfort. They may benefit from prophylactic treatment.

Role of intraocular pressure measurement on the day of phacoemulsification cataract surgery

Purpose: To determine whether measurement of intraocular pressure (IOP) preoperatively or in the early postoperative period is an accurate predictor of raised IOP 24 hours after cataract surgery. Setting: Department of Ophthalmology, Queens Medical Centre, Nottingham, United Kingdom. Methods: This prospective study comprised 101 eyes of 101 patients having phacoemulsification cataract surgery. The IOP was measured by Goldmann applanation tonometry preoperatively and 2 to 3 hours, 6 to 8 hours, and 22 to 24 hours postoperatively. The relationship between the same‐day and next‐day IOP readings was examined. Results: One hundred patients completed the study. The IOP at 22 to 24 hours was significantly correlated with the IOP preoperatively (correlation coefficient [r] 0.54; 95% confidence interval [CI], 0.38‐0.67) and at 6 to 8 hours (r = 0.56; 95% CI, 0.41‐0.68). In contrast, the IOP measurement at 2 to 3 hours correlated relatively poorly with the next‐day IOP (r = 0.33; 95% CI, 0.14‐0.49). Twelve patients had an IOP of 26 mm Hg or higher at 22 to 24 hours. The risk of this outcome increased significantly with higher IOP values preoperatively and, to a lesser extent, with a raised IOP at 6 to 8 hours. Glaucoma and ocular hypertension were associated with a 2.9‐fold increased risk (95% CI, 0.67‐12.8) of a next‐day IOP of 26 mm Hg or higher. Conclusions: Preoperative IOP or a diagnosis of glaucoma or ocular hypertension were significant risk factors for raised next‐day IOP after small‐incision phacoemulsification. It may be possible to select patients at greater risk of prolonged ocular hypertension before surgery for prophylactic IOP‐lowering treatment. This would minimize patient morbidity and reduce the number of patients requiring next‐day review, resulting in significant health economic savings.

Effect of hyaluronidase on ocular motility in sub-Tenon's anesthesia: Randomized controlled trial

Purpose: To assess the effect of hyaluronidase additive on the onset and degree of ocular akinesia in sub‐Tenons anesthesia for cataract surgery. Setting: Routine cataract operating list. Method: This double‐blind randomized controlled study comprised 100 patients who had phacoemulsification cataract surgery. Patients were randomized to 1 of 2 groups. For sub‐Tenons anesthesia, Group A received 5 mL lignocaine 2% with sodium hyaluronidase 150 IU/mL and Group B, 5 mL plain lignocaine 2%. Akinesia was assessed by scoring movement in the 6 positions of gaze. Scores ranged from 0 (complete akinesia) to 3 (no akinesia). Movements were measured at 30 seconds and 1, 3, 5, and 10 minutes. Changes in motility scores were compared by the Mann‐Whitney U test. Results: There was no significant difference in akinesia between the 2 groups 30 seconds after the injection (P = .224); however, at 1 and 3 minutes, Group A achieved significantly better akinesia than Group B (P = .003 and P = .023, respectively). The median score after 3 minutes was 3.5 (interquartile range 0 to 7.5) in Group A and 7.0 (interquartile range 2.5 to 10.0) in Group B. There was no significant difference between the groups at 5 and 10 minutes (P = .225 and P = .831, respectively). Conclusions: The addition of hyaluronidase in sub‐Tenons anesthesia significantly improved the rapidity of the onset of akinesia. This benefit disappeared over time; after 5 minutes the akinesia observed in the group receiving hyaluronidase was similar to that in the group receiving lignocaine alone. Thus, there appears to be no benefit to adding hyaluronidase to the anesthetic solution in terms of final ocular akinesia.

Severe decompression retinopathy after medical treatment of acute primary angle closure

We describe a case of medically treated acute primary angle closure (APAC) resulting in severe visual loss owing to retinal haemorrhage. We are unaware of previous reports on this phenomenon in the world literature. A 65-year-old woman visited her optometrist for a routine check. Her pupils were dilated and no pathology was found. Her vision progressively deteriorated that evening. She attended the hospital and was noted to have unreactive mid-dilated pupils bilaterally. Visual acuity was 20/60 OU (pinhole). Intraocular pressure (IOP) was 60 mm Hg OD and 66 mm Hg OS. Gonioscopy showed occluded angles. The patient had moderate hypermetropia but otherwise had no other ocular risk factors for angle closure. A diagnosis of iatrogenic APAC was made and the patient was given intravenous acetazolamide, topical dexamethasone, iopidine 1% and pilocarpine 4%. Ninety min later, IOPs was found to …

Predictive value of early IOP in mitomycin-C augmented trabeculectomy.

PurposeTo determine whether early intraocular pressure (IOP) after mitomycin-C (MMC) augmented trabeculectomy has any predictive value for intermediate IOP outcome. MethodsRetrospective case note review. All cases of trabeculectomy using MMC augmentation and at least 1-year follow-up during the study period were included. Cases where a bleb leak occurred were excluded from the analysis. Only first eyes operated upon during the study period were included. Patient demographics and postoperative course were documented and analyzed. Early IOP measurements at day 1, day 7, and month 1 postoperatively were correlated to IOP at 1 year or final follow-up. ResultsOne hundred nineteen trabeculectomies were identified. Of these 27 (22.7%) had an early bleb leak and were excluded. Further analysis was carried out on the remaining 92 cases. Mean age of cases was 70.8 years. Nine cases (9.8%) were repeat trabeculectomies. Mean follow-up time was 18.5 months (range 12 to 60 mo). Patients with a final IOP of ≤16 mm Hg (without drops or further surgery) (unqualified successes) had a mean day 1 IOP of 12.5 mm Hg compared with 17.4 mm Hg in those with an IOP more than 16 mm Hg at final follow-up (P=0.02). Patients with a final IOP of ≤16 mm Hg (with or without drops) (qualified successes) had mean day 1 IOP of 13.3 mm Hg compared with 17.1 mm Hg in those with an IOP of >16 mm Hg at final follow-up (P=0.06). At 1 month the mean IOPs were 10.7 mm Hg and 19.5 mm Hg, respectively (P<0.001). By logistic regression analysis at final recorded visit those cases in the lowest IOP quartile at 1 month were 14 times more likely to have an IOP ≤16 mm Hg without treatment than those in the highest quartile at 1 month. ConclusionsOur data suggests that a low early postoperative IOP measurement is a predictive factor for IOP value and success after intermediate length follow-up in patients undergoing trabeculectomy surgery augmented with MMC.

Primary low-risk trabeculectomy augmented with low-dose mitomycin-C

Purpose To present outcome data on low risk primary trabeculectomy augmented with low dose peroperative (0.1 mg/mL for 1 minute) mitomycin-C (MMC). Methods Retrospective case note review. All cases of trabeculectomy utilizing MMC augmentation at a concentration of 0.1 mg/mL with an application time of 1 minute and at least 1 year follow-up during the study period were included. Only first eyes were included. Patient demographics and postoperative course including complications, interventions, and outcomes were documented and analyzed. Results Fifty-nine trabeculectomies that met the inclusion criteria were identified. Mean age of cases was 70.8 years. Mean follow-up time was 19.3 months. Bleb leaks occurred in 16 (27.1%) cases. Only one case required surgical intervention in the form of resuturing after 14 days. At 1 year, there was a reduction in mean number of topical medications from 2.70 to a mean of 0.07. Unqualified success (intraocular pressure [IOP] at 1 year of less than 16 mmHg without medication) was achieved in 49 cases (83.1%). Mean IOP was reduced from the preoperative value of 23.1 mmHg (SD 5.8) to 13.5 mmHg (SD 5.0) (p<0.001). Conclusions Our data suggest that a primary trabeculectomy augmented with a low dose of MMC is a safe and effective procedure for IOP reduction in patients with a low risk of trabeculectomy failure.