David L. McCartney

The Efficacy and Safety of Combined Trabeculectomy Cataract Extraction, and Intraocular Lens Implantation

The safety and efficacy of combined trabeculectomy, extracapsular cataract extraction (ECCE), and posterior chamber intraocular lens (PC IOL) implantation were evaluated by retrospectively analyzing 108 consecutive operations. Postoperatively, 89% of eyes achieved 20/40 or better visual acuity when preoperative macular and optic nerve diseases were excluded. Mean follow-up was 16.8 months. Intraocular pressure (IOP) control (less than or equal to 21 mmHg) was achieved in 92% of eyes; 57% required no medications. Capsulotomy (20%) and transient hyphema (15%) occurred significantly more often (P less than 0.001) than in a comparison group. These results suggest that the combined procedure gives excellent visual rehabilitation and IOP control in the majority of patients included in this analysis.

Cluster of diplopia cases after periocular anesthesia without hyaluronidase

PURPOSE To describe a cluster of cases of iatrogenic diplopia after cataract surgery that occurred in 1998, when hyaluronidase was unavailable for use in periocular anesthetic regimens. SETTING The clinical practices of the authors. METHODS This study comprised a retrospective chart review. RESULTS Twenty-five cases of transient or permanent diplopia were reported. Of these, 13 eyes had retrobulbar and 10 had peribulbar injections; in 2 cases the injection technique was unknown. The inferior rectus was affected in 19 eyes; of these, 1 had a temporary palsy and 18 had permanent restriction. Temporary paresis developed in the lateral rectus in 5 cases and the superior rectus in 2. Eleven cases were submitted by 4 anterior segment surgeons, who collectively had a zero incidence of iatrogenic postoperative diplopia in the preceding 4 to 11 years of practice (approximately 6900 cases). CONCLUSION Hyaluronidase may be more important than previously suspected in preventing anesthetic-related damage to the extraocular muscles. The inferior rectus muscle is particularly vulnerable, presumably because of the injection technique.

Time- and temperature-dependent stability of growth factor peptides in human autologous serum eye drops.

Purposes: To develop a step-by-step production method for human autologous serum (AS) eye drops that was broadly compliant with US Food and Drug Administration requirements for reinjection of processed biological substances. To determine optimum storage conditions for AS eye drops by measuring the concentration of growth factor peptides (GFP) as a function of storage temperature and storage duration. Methods: AS derived from the blood of 3 healthy male volunteers was produced using a closed, vacuum-driven, cascade-filtration system under sterile, low-pyrogen conditions. In-process controls included methods for monitoring protein electrophoretic mobility and degradation rate and the content of free hemoglobin and endotoxin. Stability of transforming growth factor β1, substance P, nerve growth factor, calcitonin gene-related peptide, insulin-like growth factor 1, and epidermal growth factor was evaluated at -15°C, +4°C, +25°C, +37°C, and +42°C at different time intervals (hours to weeks). The main outcome measures were the concentrations of GFP, endotoxin, and lipid peroxidation by-products (a proxy measure for protein degradation) in dilute AS. Results: The stability of GFP varies: transforming growth factor β1, nerve growth factor, epidermal growth factor, and insulin-like growth factor 1 were more temperature and time resistant, but substance P and calcitonin gene-related peptide significantly degraded at +4°C in 24 hours. Endotoxin and lipid peroxidation by-products were not significantly increased by processing. Conclusions: This pilot study developed a closed, cascade-filtration system that was an effective method for the production of high-quality, low-pyrogen AS. The processing method broadly complied with Food and Drug Administration requirements for reinjection of biological substances. Variable GFP stability was observed at +4°C and above. For clinical use, AS should be packaged in daily-use containers, which should be stored frozen; the container in active use should be refrigerated between doses.

Serum growth factor analysis in dry eye syndrome

Background:  To perform a comprehensive serum growth factor analysis in dry eye syndrome patients and to compare this with matched controls.

Continuous intraocular pressure recordings during lamellar microkeratotomy of enucleated human eyes

PURPOSE: To analyze the course of intraocular pressure (IOP) during lamellar microkeratotomy (LMK) in enucleated human eyes using 3 microkeratome systems. SETTING: Department of Ophthalmology, Texas Tech University Health Sciences Center, Lubbock, Texas, U.S.A. METHODS: Sixteen enucleated human globes were cannulated through the optic nerve, and IOP was recorded continuously while the eyes had standard LMK flap creation. Three microkeratomes were used: Carriazo‐Barraquer (Moria Inc.), Innovatome (Innovative Optics Inc.), and Hansatome (Bausch & Lomb). RESULTS: During the vacuum affixation phase, the IOP reached a mean plateau of 97.9 mm Hg with the Hansatome, 135.8 mm Hg with the Innovatome, and 150.0 mm Hg with the Carriazo‐Barraquer. During applanation and cutting, the IOP rose to mean plateau of 154.7 mm Hg, 151.8 mm Hg, and 175.8 mm Hg, respectively. Statistical analysis using Kruskal‐Wallis testing suggested a difference in mean IOP elevation between the 3 microkeratomes during the vacuum affixation phase (P = .0394) but no difference during the applanation and cutting phase (P = .506). CONCLUSION: The IOP during LMK was higher than previously reported, and this may increase the risk for complications in certain patient groups.

Visual field changes after laser in situ keratomileusis.

Purpose: To determine whether laser in situ keratomileusis (LASIK) affects the central 30‐degree visual field. Setting: University‐based ophthalmology practice. Methods: This nonrandomized clinical trial comprised 14 normal patients (27 eyes) scheduled to have LASIK for myopia or myopic astigmatism. Automated static perimetry was performed before and 6 months after surgery using the Octopus 1‐2‐3 perimeter and the Dynamic‐32 test strategy. Patient data included sex, age, preoperative and postoperative refractive errors, preoperative and postoperative best corrected visual acuity, preoperative corneal thickness, programmed optical zone, programmed total ablation diameter, and duration of microkeratome suction. All surgery was performed using the same Alcon LADARVision 4000 excimer laser. The main outcome measures were the mean sensitivity (MS) change in the central 15‐degree visual field and the MS change in the 15‐ to 30‐degree visual field. A multivariate analysis of the MS change as a function of preoperative clinical parameters was performed. Results: There was no significant change in the MS in the central 15‐degree visual field; between 15 and 30 degrees, there was a statistically significant decrease of −0.82 dB ± 1.40 (SD) (P = .01, 2‐tailed t test). The decline in MS was positively correlated with refractive error and corneal thickness; it was negatively correlated with the programmed optical zone diameter. Conclusions: Automatic static perimetry can detect decreased sensitivity in the midperipheral visual field after myopic LASIK. It may be a useful quantitative subjective test for measuring the effects of future improvements in surgical technique on vision quality.

Pseudallescheria boydii keratitis.

A case of Pseudallescheria boydii keratitis is presented. The patient was successfully treated with topical natamycin and systemic itraconazole in conjunction with penetrating keratoplasty, leading to visual acuity of 20/40.

The Effect of Topical Substance-P Plus Insulin-like Growth Factor-1 (IGF-1) on Epithelial Healing After Photorefractive Keratectomy in Rabbits

Purpose To determine whether topical Substance-P (SP) plus insulin-like growth factor-1 (IGF-1) can improve corneal healing after photorefractive surface ablation in a rabbit. Methods After a 9.0-mm corneal de-epithelialization using a combination of chemical (18% alcohol) and mechanical debridement, excimer photorefractive surface ablation was performed bilaterally in eight rabbits (16 eyes) with an 8.0-mm ablation zone and 70-μm depth. The right eye was treated with SP (250 μg/mL) and IGF-1 (25 ng/mL) in hyaluronic acid, one drop twice a day, and the other eye treated with only hyaluronic acid. The epithelial healing process was documented photographically twice a day until healing was complete. Six rabbits were sacrificed 6 weeks after photorefractive keratectomy (PRK) and corneas examined histologically. Results Seven of eight rabbit eyes treated with SP/IGF-1 healed in a shorter time than the untreated eye. For rabbit #6, both eyes healed at the same time. The average healing time (total time until wound closure) for the treated eyes was 99 hours, while the average healing time for the untreated eyes was 170 hours (P = 0.0490). A persistent epithelial defect was found in two of the nontreated eyes but none in the treated eyes. Corneal pathology showed some degree of epithelial separation in the central corneal wound in three out of six nontreated eyes and in just the treated eye of rabbit #6. Conclusion Topical SP plus IGF-1 increases the epithelial healing rate after PRK. There may have been beneficial effects upon cell adhesion as well. Translational Relevance Better and faster healing.