Bradford J. Shingleton

The Spectrum and Burden of Ocular Injury

The authors conducted a hospital-based study to ascertain basic, descriptive epidemiologic information about ocular trauma in an urban setting. Over a 6-month period, 3184 patients presenting to our emergency ward with ocular trauma were studied. Severe injuries totaled 5.1% (ruptured globe, intraocular foreign body, hyphema, orbital/facial fracture) and 94.9% were superficial injuries and contusions. A disproportionate burden of severe ocular injury was borne by those less than 15 years of age. The work place accounted for 48% of all injuries and 50% of ruptured globes. Automobile repair-related tasks were specifically associated with injury. Sports injuries, although accounting for 3.4% of all injuries, were responsible for 60% of hyphemas and 10% of ruptured globes. Annual direct and indirect costs for these ocular injuries are estimated conservatively at

Canaloplasty: Circumferential viscodilation and tensioning of Schlemm canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults : Two-year interim clinical study results

5 million and a loss of 60 work years. A large burden of preventable eye trauma is borne by both patients and society.

Long-term changes in intraocular pressure after clear corneal phacoemulsification: Normal patients versus glaucoma suspect and glaucoma patients

PURPOSE: To evaluate the safety and efficacy of circumferential viscodilation and tensioning of the inner wall of Schlemms canal in a new surgical procedure for the treatment of open‐angle glaucoma (OAG). SETTING: Fourteen clinical sites in the United States and Germany. METHODS: In this international multicenter prospective study of adult patients with OAG having glaucoma surgery, patients with qualifying preoperative intraocular pressure (IOP) of at least 16 mm Hg or higher and open angles were eligible. Evaluation was performed at baseline and 1 day, 1 week, and 1, 3, 6, and 12 months preoperatively. After a nonpenetrating dissection technique to expose Schlemms canal was performed, a flexible microcatheter (iTrack 250A, iScience Interventional) was used to dilate the full circumference of the canal by injecting sodium hyaluronate 1.4% (Healon GV) during catheterization. A suture loop was placed in the canal to apply tension to the trabecular meshwork. High‐resolution ultrasound imaging was used to assess Schlemms canal and anterior segment angle morphology, including distension of the trabecular meshwork caused by the tensioning suture. Data analysis was performed in 2 groups: Group 1, in which patients met all inclusion criteria, and Group 2, made up of Group 1 patients who had successful suture placement. RESULTS: Group 1 comprised 94 patients and Group 2, 74 patients. The mean baseline IOP in Group 1 was 24.7 mm Hg ± 4.8 (SD) on a mean of 1.9 ± 1.0 medications per patient. In Group 2 (patients with sutures), the mean IOP was 16.1 ± 4.7 mm Hg 3 months postoperatively, 15.6 ± 4.0 mm Hg at 6 months, and 15.3 ± 3.8 mm Hg at 1 year. Medication use dropped to a mean of 0.6 ± 0.9 per patient at 12 months. Suture tensioning was an apparent contributing factor in achieving surgical success. Patients with measurable trabecular meshwork distension from suture tension had a mean IOP of 15.9 ± 5.2 mm Hg at 6 months and 14.5 ± 3.0 mm Hg at 12 months. Surgical and postsurgical adverse events were reported in 15 of 94 patients (16%) and included hyphema (3), elevated IOP greater than 30 mm Hg (3), Descemets tear (1), hypotony (1), choroidal effusion (1), and exposed closure suture with eyelid edema and erythema epiphora (1); 4 patients were subsequently converted to trabeculectomy. CONCLUSION: Circumferential viscodilation and tensioning of Schlemms canal was a safe and effective surgical procedure to reduce IOP in adult patients with OAG.

Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients.

PURPOSE To compare the effects of clear corneal phacoemulsification on intraocular pressure (IOP) in patients without glaucoma, glaucoma suspects, and patients with glaucoma. SETTING Urban, multisubspecialty private practice. METHODS A retrospective analysis of patients who had clear corneal phacoemulsification with a minimum of 12 months follow-up was performed. The patients were divided into 3 groups: no glaucoma (NG), glaucoma suspects (GS), and glaucoma (GG). None had a history of prior surgery. Glaucoma suspects included patients with elevated IOPs, abnormal discs, pseudoexfoliation syndrome, or pigment dispersion syndrome on no medications and with no field defects. Glaucoma patients had received only medical treatment. Two-tailed, homoscedastic t tests were used for statistical analysis. RESULTS There were 143 patients (164 eyes) in the NG group, 65 (75) in the GS group, and 61 (71) in the GG group. The mean preoperative IOP was 16.42 mm Hg +/- 2.77 (SD), 17.59 +/- 4.15 mm Hg, and 16.97 +/- 4.86 mm Hg in the 3 groups, respectively. At 1 year, the mean IOP was lower in all groups: 14.37 +/- 2.97 mm Hg, 15.68 +/- 3.38 mm Hg, and 15.86 +/- 4.00 mm Hg, respectively. The change was statistically significant in the NG and GS groups. Glaucoma patients showed a statistically significant reduction in the number of glaucoma medications postoperatively. CONCLUSION Clear corneal phacoemulsification was associated with a statistically significant long-term reduction in IOP.

Canaloplasty: Circumferential viscodilation and tensioning of Schlemm canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults

PurposeThis study evaluates the change in intraocular pressure (IOP) and glaucoma medication requirements after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients at 3 years and last follow-up (mean 5 y). Patients and MethodsThis study represents a retrospective analysis of patients who had clear corneal phacoemulsification and at least 3 years of follow-up. The patients were classified into 3 groups: glaucoma (G), glaucoma suspects (GS), and no glaucoma (NG). No patient had a history of previous intraocular surgery. Single factor analysis of variance, Fisher exact tests, 2-tailed paired Student t tests and Kaplan-Meier analysis were applied. ResultsForty-eight patients (55 eyes) in the glaucoma group, 41 patients (44 eyes) in the GS group, and 59 patients (59 eyes) in the NG group met the above criteria. At 3 years follow-up IOP was significantly decreased in all groups; (G) group decreased 1.4±3.3 mm Hg (P=0.0025), GS 1.4±4.2 mm Hg (P=0.004), and NG 1.7±3.1 mm Hg (P=0.0005). At the final follow-up visit (mean near 5 y for all groups) the IOP was significantly decreased in all groups, (G) group 1.8±3.5 mm Hg (P=0.005), GS 1.3±3.7 mm Hg (P=0.025), and NG 1.5±2.5 mm Hg (P<0.0001). The number of preoperative and postoperative glaucoma medications in the (G) group did not show any significant change at 3 and 5 years (P=0.36, P=0.87). Kaplan-Meier analysis shows that at 3 years, 85% of the (G) group, 81% of GS, and 90% of the NG had IOPs less than or equal to their preoperative IOP, with the same number of glaucoma medications or less. At 5 years the percentages were 76%, 79%, and 85%, respectively. ConclusionsThis study demonstrates that cataract removal by clear cornea phacoemulsification in glaucoma patients, glaucoma suspects, and normal patients results in a small but significant decrease in IOP that is sustained at 3 years and a mean of 5 years in all groups. This study does not imply that cataract removal by phacoemulsification is a substitute for a combined procedure but may be an appropriate procedure for certain patients based on medication requirements and extent of optic nerve damage.

Evaluation of intraocular pressure in the immediate period after phacoemulsification.

PURPOSE: To evaluate 2‐year postsurgical safety and efficacy of canaloplasty (circumferential viscodilation and tensioning of the inner wall of Schlemm canal) to treat open‐angle glaucoma (OAG). SETTING: Multicenter surgical sites. METHODS: This international prospective study comprised adult OAG patients having glaucoma surgery or combined glaucoma–cataract surgery. Qualifying preoperative intraocular pressure (IOP) was at least 16 mm Hg and historical IOP, at least 21 mm Hg. The full circumference of the canal was viscodilated and a trabecular tensioning suture placed with a microcatheter. Primary outcome measures included IOP and glaucoma medication use. RESULTS: At 24 months, all 127 eyes (127 patients) had a mean IOP of 16.0 mm Hg ± 4.2 (SD) and mean glaucoma medication use of 0.5 ± 0.8 (baseline values 23.6 ± 4.8 mm Hg and 1.9 ± 0.8 medications). Eyes with canaloplasty alone had a mean IOP of 16.3 ± 3.7 mm Hg and 0.6 ± 0.8 medications (baseline values 23.2 ± 4.0 mm Hg and 2.0 ± 0.8 medications). Eyes with combined glaucoma–cataract surgery had a mean IOP of 13.4 ± 4.0 mm Hg and 0.2 ± 0.4 medications (baseline values 23.1 ± 5.5 mm Hg and 1.7 ± 1.0 medications). The IOP and medication use results at all time points were statistically significant versus baseline (P <.001). The late postoperative follow‐up identified 3 patients with elevated IOP. No other serious ocular or nonocular complications were reported. CONCLUSION: Canaloplasty was safe and effective in reducing IOP in adult patients with OAG.

Canaloplasty: Three-year results of circumferential viscodilation and tensioning of Schlemm canal using a microcatheter to treat open-angle glaucoma

Purpose: To determine the incidence of hypotony or intraocular pressure (IOP) spikes in the early period after clear corneal phacoemulsification in normal and glaucomatous eyes. Setting: Ambulatory surgical center. Methods: This retrospective analysis comprised 112 eyes that had clear corneal phacoemulsification. Postoperative IOP measurements were collected 30 minutes, 1 day, and 1 month after surgery. Results: Twenty‐three eyes had an IOP of 5 mm Hg or below 30 minutes postoperatively. The IOP at 30 minutes was lower than at 1 day in both the normal and the glaucoma group. The mean IOP in the normal group was 10.0 mm Hg ± 4.3 (SD) at 30 minutes and 16.9 ± 4.4 mm Hg at 1 day (P ≤ .005). The means in the glaucoma group were 9.6 ± 3.9 mm Hg and 16.9 ± 5.7 mm Hg, respectively (P ≤ .0002). The IOPs at 30 minutes and 1 day were not significantly different between the 2 groups. Conclusion: A significant percentage of eyes having clear corneal phacoemulsification had an IOP of 5 mm Hg or less 30 minutes after surgery. Even though there were no postoperative complications from hypotony and there was a relative absence of significant IOP elevation 1 day postoperatively, the frequency of low IOP at 30 minutes suggests that consideration be given to leaving postoperative eyes with a higher IOP at the completion of phacoemulsification rather than with the estimated 10 mm Hg tactile IOP strived for in this study.

Contact Transscleral Nd:YAG Laser Cyclophotocoagulation: Midterm Results

PURPOSE: To report 3‐year results of the safety and efficacy of canaloplasty, a procedure involving circumferential viscodilation and tensioning of the inner wall of Schlemm canal to treat open‐angle glaucoma. SETTING: Multicenter surgical sites. DESIGN: Nonrandomized multicenter clinical trial. METHODS: This study comprised adult open‐angle glaucoma patients having canaloplasty or combined cataract–canaloplasty surgery. Qualifying preoperative intraocular pressures (IOPs) were at least 16 mm Hg with historical IOPs of at least 21 mm Hg. A flexible microcatheter was used to viscodilate the full circumference of the canal and to place a trabecular tensioning suture. Primary outcome measures included IOP, glaucoma medication use, and adverse events. RESULTS: Three years postoperatively, all study eyes (n = 157) had a mean IOP of 15.2 mm Hg ± 3.5 (SD) and mean glaucoma medication use of 0.8 ± 0.9 compared with a baseline IOP of 23.8 ± 5.0 mm Hg on 1.8 ± 0.9 medications. Eyes with combined cataract–canaloplasty surgery had a mean IOP of 13.6 ± 3.6 mm Hg on 0.3 ± 0.5 medications compared with a baseline IOP of 23.5 ± 5.2 mm Hg on 1.5 ± 1.0 medications. Intraocular pressure and medication use results in all eyes were significantly decreased from baseline at every time point (P<.001). Late postoperative complications included cataract (12.7%), transient IOP elevation (6.4%), and partial suture extrusion through the trabecular meshwork (0.6%). CONCLUSION: Canaloplasty led to a significant and sustained IOP reduction in adult patients with open‐angle glaucoma and had an excellent short‐ and long‐term postoperative safety profile. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

The Development Encapsulated Filtering Blebs

BACKGROUND Early reports of both contact and noncontact transscleral Nd:YAG laser cyclophotocoagulation have been encouraging; however, recent evidence indicates a significant incidence of hypotony, visual loss, and phthisis with the noncontact technique with more than 6 months of follow-up. The authors sought to determine the intermediate term effects of contact transscleral Nd:YAG laser cyclophotocoagulation (CYC). METHODS The authors followed 116 eyes of 114 patients for a minimum of 1 year after treatment of advanced glaucoma with CYC. RESULTS The mean preoperative intraocular pressure (IOP) of 35.0 +/- 1.0 mmHg decreased to 18.6 +/- 1.1 mmHg (P less than 0.0001) during the average follow-up of 19.0 +/- 0.6 months (range, 12 to 36 months). Intraocular pressure control of 3 to 25 mmHg was achieved in 72%, 3 to 22 mmHg in 65%, and 3 to 19 mmHg in 56% of eyes. Retreatment was required in 31 of the 116 eyes (27%). Intraocular pressure decreased to less than 3 mmHg in 9 eyes and to 0 mmHg in 6 of these 9 eyes. Nineteen eyes, all with initial visual acuity of counting fingers or worse, progressed to no light perception; 17 of 36 eyes (47%) with visual acuity of 20/200 or better lost 2 or more Snellen lines. CONCLUSION Midterm results of CYC continue to be encouraging but are tempered by a nearly 10% incidence of hypotony or phthisis and the progression of visual loss.

Pseudoexfoliation and the cataract surgeon: Preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses

The development of an encapsulated filtering bleb (Tenons cyst) complicated 56 of 409 consecutive filtering operations (13.7%) performed during a 40-month period after January 1983. Fifteen eyes (27.8% of encapsulated blebs) required surgical revision. The recognition of bleb encapsulation occurred 20.4 +/- 12.7 days (mean +/- standard deviation) postoperatively. Prolonged duration of beta-adrenergic antagonist therapy was associated with an increased frequency of bleb encapsulation (180.6 +/- 128.5 weeks without encapsulation, 229.0 +/- 129.3 weeks with encapsulation, P less than 0.009). Bleb encapsulation occurred in 42 of 272 eyes with previous argon laser trabeculoplasty, but in only 4 of 85 eyes without any previous anterior segment laser (P less than 0.01). Encapsulated filtering blebs developed in 4 of 12 (33.3%) eyes with congenital glaucoma and 4 of 9 (44.4%) eyes with juvenile glaucoma (P less than 0.0002). The intraocular pressures (IOPs) in the eyes with encapsulated filtering blebs were significantly elevated at 1, 2, and 3 postoperative weeks, and at final follow-up compared with eyes without bleb encapsulation.