Asher Weiner

Clinical Patterns and Associated Conditions in Chronic Uveitis

We determined the relative frequencies of the different types of chronic uveitis, and the possible associated conditions, among 400 consecutive patients with chronic uveitis examined during the years 1982 through 1988. Of the 400 patients, 183 (45.75%) had anterior uveitis, 98 (24.5%) ahd panuveitis, 61 (15.3%) had intermediate uveitis, and 58 (14.5%) had isolated posterior uveitis. Only four of the 98 patients with panuveitis (4.1%) were considered idiopathic after a comprehensive examination, whereas 94 of the 183 patients with anterior uveitis (51.4%) were similarly classified. We found an associated condition in 242 of the 400 patients of the study group (60.5%). Of these 242 patients, 61 had Behçets disease, which constituted the most frequently encountered associated condition in this study. Of the 61 patients with Behçets disease, 58 had panuveitis and constituted 59.2% of the panuveitis group. Of the 61 patients with intermediate uveitis, 17 (27.9%) had a concurrent disease. An associated condition was found in 95% and 96.2% of patients with unilateral and bilateral panuveitis, respectively, but in none of the patients with unilateral intermediate uveitis. Environmental, cultural, or genetic factors may be accountable for the differences discovered between our findings and those of previously published studies from the United States and England with respect to relative frequencies of some of the associated diseases in patients with chronic uveitis.

High-risk characteristics of fellow eyes of patients with unilateral neovascular age-related macular degeneration

OBJECTIVE This study aimed to determine whether clinical tests of ocular function and macular appearance independently can help to predict which patients with unilateral neovascular age-related macular degeneration (AMD) will have a choroidal neovascular membrane (CNVM) develop in their fellow eye. DESIGN The study design was a prospective cohort study. PARTICIPANTS One hundred twenty-seven patients with unilateral neovascular AMD observed for up to 4.5 years participated. INTERVENTION Functional measurements included visual acuity, macular visual field, glare recovery time, and foveal electroretinogram amplitude and implicit time. MAIN OUTCOME MEASURE The age-adjusted proportion of patients having a CNVM develop over follow-up assessed by the Cox proportional hazards model with stepwise selection was measured. RESULTS On average, 8.8% of patients had a CNVM develop each year. Independent risk factors for the fellow eye were its glare recovery time in minutes (relative risk = 1.30, confidence interval = 1.10-1.54, P = 0.003) and its extent of visible macular abnormalities on a four-point scale (relative risk = 1.62, confidence interval = 1.06-2.59, P = 0.03). Of the fellow eyes that converted, the interval to have a CNVM develop was inversely related to the foveal electroretinogram implicit time. CONCLUSIONS A slower recovery from glare and more extensive funduscopic changes appear to be independent risk factors for the development of a CNVM in the fellow eyes of patients with unilateral neovascular AMD. A slower foveal electroretinogram implicit time may be a sign of early stage CNVM development, perhaps because of outer retinal ischemia. These results have clinical management implications, particularly for those patients at high risk of having a potentially treatable form of AMD develop.

Glaucoma tube shunt implantation through the ciliary sulcus in pseudophakic eyes with high risk of corneal decompensation.

PurposeTo summarize our clinical experience with implanting Baerveldt glaucoma tube shunts through the ciliary sulcus in eyes with a posterior chamber intraocular lens and shallow anterior chambers, corneal transplants, guttata or edema. Patients and MethodsA retrospective interventional nonrandomized noncomparative case series. Main outcome measure was postoperative corneal status. Secondary outcome measures included postoperative intraocular pressure (IOP), visual acuity and complications. ResultsThirty-six eyes of 32 patients were identified through chart review. Follow-up period was 21.8±16.6 months (mean±standard deviation, range: 4.0 to 58.5 mo). At final visit, all 23 preoperative clear native corneas and 6 of 7 corneal transplants remained clear. Thus, of the 30 preoperative clear corneas, only 1 decompensated. Preoperative IOP was 27.9±11.8 mm Hg (range: 12 to 59 mm Hg), reduced postoperatively to 10.1±3.9 mm Hg (range: 2 to 21 mm Hg, P=0.0001), a reduction of 58.2%±19.3% (range: 5.0% to 95.4%). Final IOP was ≥5 and ≤21 mm Hg in 33 of 36 eyes (91.7%). It was lowered by 30% or more in 34 of 36 eyes (94.4%). ConclusionsAlthough previously published studies demonstrated a significant risk of corneal decompensation after angle or pars plana tube implantation, our clinical experience suggests that ciliary sulcus tube implantation in eyes with a posterior chamber intraocular lens is a safe and effective procedure even in eyes with high risk of corneal decompensation.

Intraocular pressure 3 to 4 hours and 20 hours after cataract surgery with and without ab interno trabeculectomy

Purpose To evaluate intraocular pressure (IOP) immediately after cataract surgery with or without ab interno trabeculectomy (Trabectome) and whether trabeculectomy‐related hyphema increases the risk for IOP spikes. Settings Private glaucoma practice. Design Retrospective interventional nonrandomized comparative chart review. Methods Intraocular pressure was measured 3 to 4 hours and 20 hours postoperatively. Results The combined group comprised 73 eyes of 73 patients and the cataract‐only group, 75 eyes of 75 patients. The mean preoperative IOP was 15.8 mm Hg ± 3.6 (SD) and 14.9 ± 3.0 mm Hg, respectively (P = .09). In the combined group, the IOP decrease was significant at 3 to 4 hours (P = .0003) and 20 hours (P = .0007). In the cataract‐only group, the IOP increased significantly (P < .0001 and P = .0035, respectively). The mean IOP was significantly lower in the combined group than in the cataract‐only group at 3 to 4 hours (12.8 ± 5.9 mm Hg versus 19.7 ± 7.5 mm Hg) and 20 hours (12.7 ± 7.0 mm Hg versus 17.2 ± 5.9 mm Hg) (both P < .0001). Significantly fewer eyes in the combined group than in the cataract‐only group had IOP spikes (overall, P = .0077; 3 to 4 hours, P = .001). Hyphema occurred in 35 eyes (47.9%) in the combined group; however, the IOP was similar with or without hyphema. Only 1 eye with an IOP spike in the combined group had hyphema. Conclusion Combining ab interno trabeculectomy and cataract surgery reduced short‐term postoperative IOP and the incidence of IOP spikes despite the common hyphema. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Clinical experience with sulcus-implanted Baerveldt glaucoma tube shunts fully concealed behind the iris in undilated pseudophakic eyes.

Purpose:To describe our clinical experience with ciliary sulcus-implanted Baerveldt glaucoma tube shunts entirely concealed behind the iris in undilated pseudophakic eyes (concealed tubes, CT group), compared with similarly implanted tubes whose openings remain fully exposed in the undilated pupillary area (nonconcealed tubes, NCT group). Methods:A retrospective interventional nonrandomized comparative chart review. The main outcome measures were postoperative tube incarceration by the iris, and postoperative intraocular pressure (IOP) and the number of IOP-lowering medications. Results:Fifteen eyes of 15 patients were identified in the CT group and 41 eyes of 41 patients in the NCT group. In the CT and NCT groups, the postoperative follow-up period was 14.4±10.2 months (mean±SD; range, 3 to 42 mo) and 22.9±18.1 months (mean±SD; range, 3 to 72 mo; P=0.08), respectively. Only 1 case of tube incarceration by the iris has occurred in the CT group (6.7%) and none in the NCT group. This eye was treated with laser iridotomy with no recurrence. Preoperative IOPs in the CT and the NCT groups were 27.2±9.6 mm Hg (mean±SD; range, 16 to 46 mm Hg) and 25.5±10.6 mm Hg (mean±SD; range, 12 to 59 mm Hg; P=0.6), respectively. The IOPs were significantly reduced to 13.3±4.1 mm Hg (mean±SD; range, 6 to 22 mm Hg; P=0.0001) and 10.8±4.4 mm Hg (mean±SD; range, 4 to 25 mm Hg; P=0.0001), respectively, at the final visit. The difference in the final visit IOP between the groups approached significance (P=0.056). The number of preoperative IOP-lowering medications was 3.9±0.7 (mean±SD; range, 2 to 5) and 4.0±1.0 (mean±SD; range, 1 to 6), respectively. It was significantly reduced to 1.9±1.2 (mean±SD; range, 0 to 4; P=0.0001) and 1.8±1.4 (mean±SD; range, 0 to 5; P=0.0001), respectively. There was no significant difference between the groups before (P=0.6) or after surgery (P=0.8). Conclusions:Although NCTs tend to have a lower final IOP compared with CTs, the latter are safe and effective and do not require surgical repositioning. Should a CT become occluded by the iris, an uncommon event in our study, it could be treated by laser iridotomy alone.

Clinical experience with urgent tube shunt implantation through the ciliary sulcus in phakic eyes

PurposeTo review the clinical course and outcomes of 3 phakic, ischemic, and inflamed eyes in which we performed urgent tube shunt implantation through the ciliary sulcus without lensectomy.MethodsThis is a retrospective interventional case series. Three eyes of 3 diabetic patients with uncontrolled severe neovascular glaucoma, shallow anterior chambers with closed angles and poor view to the posterior segment, where concomitant lensectomy was not recommended due to uncontrolled uveitis and ischemia, underwent tube shunt implantation through the ciliary sulcus. Main outcome measures were surgical complications, especially injury to the crystalline lens, and postoperative intraocular pressure (IOP).ResultsNo surgical complications, including injury to the crystalline lens, have occurred. We used surgical modifications to allow sufficient visualization of the sulcus area to avoid injury to the crystalline lens during scleral tunneling and tube insertion through the ciliary sulcus. Postoperatively, the uveitis, ischemia, and vision have improved and IOP was controlled throughout follow-up. Cataract surgery with pupilloplasty was performed in one eye a year later with no complications and no interruption to IOP control.ConclusionsBased on our small and limited retrospective study, and under unusual circumstances, urgent tube shunt implantation through the ciliary sulcus may be considered in phakic eyes with severely uncontrolled IOP, shallow anterior chambers and poor view to the posterior segment, and when concomitant lensectomy is not recommended. We advise the use of appropriate surgical modifications by experienced glaucoma surgeons to prevent intraoperative complications. Further and larger studies are needed to evaluate the safety of this surgical option.