Christoph Kranemann

Phacoemulsification and goniosynechialysis in the management of unresponsive primary angle closure.

Purpose:To evaluate the effectiveness of phacoemulsification and goniosynechialysis (PEGS) in managing acute and subacute primary angle closure unresponsive to conventional therapy. Materials and Methods:Retrospective series of patients of six glaucoma-trained surgeons with primary angle closure that did not respond to medical management, Nd:YAG laser peripheral iridotomy, or argon laser peripheral iridoplasty. Results:A total of twenty-one patients with an average age of 65.6 years were included. Underlying mechanism of angle closure included pupillary block (n = 18) and plateau iris (n = 3). Average intraocular pressure (IOP) immediately prior to PEGS was 40.7 mm Hg, and mean follow-up time after PEGS was 11.7 months. PEGS decreased mean IOP by 25 mm Hg (62%), and mean number of medications from 3.8 pre-surgery to 1.7 post-surgery (55%). Mean LogMar visual acuity improved after PEGS, from 0.64 to 0.44 (Paired t test t = 4.120 P = 0.001). Subsequent trabeculectomy was necessary in one case (5%). Conclusions:Phacoemulsification with goniosynechialysis may be an effective treatment option for primary angle closure unresponsive to conventional therapy.

Revisiting early postoperative follow-up after phacoemulsification

Purpose: To determine whether postoperative evaluation of routine phacoemulsification can be safely and effectively performed on the day of surgery and 4 days postoperatively and evaluate the incidence and management of early intraocular pressure (IOP) elevations 3 to 7 hours postoperatively in patients with or without glaucoma. Setting: Community‐based hospital. Methods: This retrospective series comprised 465 consecutive patients who had phacoemulsification and intraocular lens implantation. All patients had postoperative follow‐up on the day of surgery (3 to 7 hours postoperatively) and at 4 days. Patients were classified into 2 groups: nonglaucoma (NG), 396 patients; and glaucoma (GL), 69 patients. The main outcome measures were the incidence and management of postoperative complications including IOP spikes, wound leaks, uveitis, and endophthalmitis. Results: Three to 7 hours postoperatively, 73 NG (18.4%) and 32 GL (46.4%) patients had IOP elevations greater than 28 mm Hg, a significant change from baseline (P < .0001). Fourteen NG (3.6%) and 13 GL (18.8%) patients had IOP elevations greater than 40 mm Hg (P < .0001). Significant IOP elevations were effectively managed with a paracentesis with or without short‐term antiglaucoma medications on the day of surgery, with 75 NG (18.9%) and 39 GL (56.5%) patients requiring IOP intervention. There were no IOP elevations greater than 21 mm Hg on the next day or at 4 days. There were no complications that were missed at the same‐day evaluation that may have been identified at the 1‐day postoperative visit. Conclusions: The results indicate that after routine phacoemulsification, patients can be safely and effectively reviewed on the day of surgery and 4 days postoperatively to identify and manage early postoperative IOP spikes. A significant number of patients, particularly those with preexisting glaucoma, had potentially harmful IOP spikes 3 to 7 hours postoperatively.

Ultrasound biomicroscopic analysis of iris-sutured foldable posterior chamber intraocular lenses.

PURPOSE To report ultrasound biomicroscopic (UBM) findings of iris-sutured foldable posterior chamber intraocular lenses (PCIOLs). DESIGN Prospective, noninterventional consecutive case series. METHODS Fifteen eyes with foldable acrylic IOL implantation using peripheral iris suture fixation in the absence of capsular support were included. UBM was used to determinate the haptic position in relation to the ciliary sulcus and ciliary body in these eyes. Additionally, anterior chamber depth, lens tilt, site of suture fixation, focal iris or angle abnormalities, and relationship of iris to lens were determined. Main outcome measures were haptic position, anterior chamber depth, and iris anatomic changes. RESULTS Of the 30 haptics imaged, 16 (53.3%) were positioned in the ciliary sulcus. Nine (30%) haptics were found over the ciliary processes, and 5 (16.7%) were over pars plana. No patients were found to have peripheral anterior synechiae present at the haptic position. The mean (+/- standard deviation) depth of the anterior chamber was 3.84 +/- 0.36 mm. The iris profile was altered in all patients at the iris-haptic suture fixation site. No angle abnormalities or tilted lenses were found. CONCLUSIONS Iris-sutured PCIOL haptics were found to be in the ciliary sulcus or over the ciliary body with no significant tilt on UBM analysis. The procedure respects the angle anatomy, and no evidence of angle closure was found. The anterior chamber was deeper than has been reported previously for scleral sutured PCIOLs and was similar to that of pseudophakic eyes. This may have implications for surgical technique, IOL power calculations, and postoperative complications.

Ultrasound biomicroscopy in sturge-weber-associated glaucoma

PURPOSE To evaluate Sturge-Weber-associated glaucoma using ultrasound biomicroscopy. METHOD Case report. Clinical examination combined with ultrasound biomicroscopy was performed in a patient with Sturge-Weber-associated glaucoma. RESULTS In the patients left eye, which had Sturge-Weber-associated glaucoma, a 360-degree supraciliary effusion, dilated superficial and intrascleral vessels, and an open angle were detected by ultrasound biomicroscopy. CONCLUSION The presence of dilated intrascleral vessels and supraciliary fluid support the hypothesis of increased episcleral venous pressure as the cause of elevated intraocular pressure in this syndrome.

Laser trabeculoplasty: an investigation into factors that might influence outcomes.

OBJECTIVE To examine the effectiveness of argon (ALT) or selective (SLT) laser trabeculoplasty (LTP) in lowering intraocular pressure (IOP) and to determine whether patient-related factors had any impact on outcome. DESIGN Retrospective review. PARTICIPANTS 500 patients treated with LTP over 14 years. METHODS This study was conducted at Sunnybrook Health Sciences Centre, University of Toronto. Five patient-related characteristics were used as dependent variables-age, race, gender, pseudophakic status, and pseudoexfoliation. IOP decrease and treatment failure at 12 months were the main outcome variables. RESULTS 500 eyes of 500 patients were included, 350 after ALT and 150 after SLT. The mean ± standard deviation baseline IOP was significantly higher in the patients treated by ALT than in those treated by SLT (24.2 ± 5.4 versus 22.2 ± 4.6, p < 0.0001) at baseline but not at 1 year (19.6 ± 5.1 versus 19.5 ± 6.1, p = 0.41). When the final IOP was examined by multiple regression analysis, there was a significant effect in favor of ALT over SLT (p = 0.03) and for patients with higher baseline IOPs (p < 0.0001). No significant effect was found for any of the demographic subgroupings. However, when the outcome variable was success or failure, only the baseline IOP remained significant. CONCLUSIONS Specific patient characteristics do not significantly influence LTP outcome after 12 months of follow-up. The most powerful predictor of either final IOP or clinical success was a higher baseline IOP, but ALT may have a better ability to lower IOP.

Prostaglandin agonist effect on matrix metalloproteinase aqueous levels in glaucoma patients

OBJECTIVE To determine whether the aqueous levels of matrix metalloproteinases (MMPs) differ between patients with glaucoma treated with topical prostaglandin analogues and normal, nonglaucomatous control patients. Also, to note any difference in MMP levels between latanoprost, travoprost, and bimatoprost that might suggest a difference in efficacy or mechanism of action between these drugs. DESIGN Prospective, observational study. PARTICIPANTS Patients who were scheduled to undergo routine intraocular surgery (phacoemulsification or combined phacotrabeculectomy) as part of their standard clinical care were included. Eighteen eyes of 18 patients with glaucoma using any 1 prostaglandin analogue (latanoprost, travoprost, or bimatoprost) were compared with 8 normal control patients. METHODS This was a multicentre study. Aqueous humour (0.2 mL) was aspirated at the beginning of the intraocular surgery through a clear corneal paracentesis. MMP-2 and -9 were quantified in the aqueous of all participants using enzyme-linked immunosorbent assay. RESULTS There was no significant difference in the levels of either MMP-2 (p = 0.216) or MMP-9 (p = 0.552) between the control patients and the patients with glaucoma on prostaglandins. There was no difference in the levels of MMP-2 or -9 between the latanoprost, travoprost, or bimatoprost groups. CONCLUSIONS The levels of MMP-2 and -9 in aqueous of glaucomatous eyes on topical prostaglandin analogues were the same as those of normal age-matched control patients. This could reflect either a return to normal levels with efficacious treatment or a lack of difference between disease and nondisease states.

Five-year results of 5-fluorouracil augmented needling revision of failing blebs.

BACKGROUND AND OBJECTIVE To report the 5-year intraocular pressure (IOP) outcomes of patients requiring a 5-fluorouracil (5-FU) needling revision compared to a matched sample. PATIENTS AND METHODS Forty eyes receiving 5-FU bleb needling revision were matched to 40 patients not needled. IOP was recorded preoperatively and annually to 5 years. The main outcome measure was surgical success: IOP control without medications or surgery. RESULTS Thirty-two patients with 5-FU needling revision (80.0%) required anti-glaucoma medication postoperatively versus 28 control patients (70%) (P > .05). Thirty-two patients with 5-FU needling revision were complete or qualified successes compared to 36 control patients (P = .34). Eight patients with 5-FU needling revision (20%) had a reoperation versus 4 control patients (10%) (P > .05). CONCLUSION 5-FU needling revision can produce long-term IOP control levels similar to those who did not require the procedure. No statistically significant differences between the two groups was seen in either the use of medications or further surgery.

Use of Machine Learning on Contact Lens Sensor–Derived Parameters for the Diagnosis of Primary Open-angle Glaucoma

PURPOSE To test the hypothesis that contact lens sensor (CLS)-based 24-hour profiles of ocular volume changes contain information complementary to intraocular pressure (IOP) to discriminate between primary open-angle glaucoma (POAG) and healthy (H) eyes. DESIGN Development and evaluation of a diagnostic test with machine learning. METHODS Subjects: From 435 subjects (193 healthy and 242 POAG), 136 POAG and 136 age-matched healthy subjects were selected. Subjects with contraindications for CLS wear were excluded. PROCEDURE This is a pooled analysis of data from 24 prospective clinical studies and a registry. All subjects underwent 24-hour CLS recording on 1 eye. Statistical and physiological CLS parameters were derived from the signal recorded. CLS parameters frequently associated with the presence of POAG were identified using a random forest modeling approach. MAIN OUTCOME MEASURES Area under the receiver operating characteristic curve (ROC AUC) for feature sets including CLS parameters and Start IOP, as well as a feature set with CLS parameters and Start IOP combined. RESULTS The CLS parameters feature set discriminated POAG from H eyes with mean ROC AUCs of 0.611, confidence interval (CI) 0.493-0.722. Larger values of a given CLS parameter were in general associated with a diagnosis of POAG. The Start IOP feature set discriminated between POAG and H eyes with a mean ROC AUC of 0.681, CI 0.603-0.765. The combined feature set was the best indicator of POAG with an ROC AUC of 0.759, CI 0.654-0.855. This ROC AUC was statistically higher than for CLS parameters or Start IOP feature sets alone (both P < .0001). CONCLUSIONS CLS recordings contain information complementary to IOP that enable discrimination between H and POAG. The feature set combining CLS parameters and Start IOP provide a better indication of the presence of POAG than each of the feature sets separately. As such, the CLS may be a new biomarker for POAG.

Efficient and Economical Follow-up After Phacoemulsification

We agree with the authors of the article on early follow-up after phacoemulsification 1 that there will be an increase in the intraocular pressure (IOP) between 6 and 24 hours postoperatively. The main aim of examining the patient routinely, within 6 to 8 hours or the next day, is to check the IOP. In rare cases, there may be other incidental findings. We practice a system in which all our uncomplicated phacoemulsification surgeries are “true” day cases. All patients (except those who have a contraindication for oral acetazolamide) receive 2 tablets of acetazolamide 250 mg slow release. The first tablet is taken immediately after surgery and the second, that night. A routine follow-up examination is performed 7 to 14 days after surgery, with strict instructions to return if there are any problems. We have not encountered difficulties with this regimen. As most of our patients who have cataract surgery