Iqbal Ike K. Ahmed

A comparison of topical and retrobulbar anesthesia for trabeculectomy.

PurposeTo compare the safety and efficacy of topical versus retrobulbar anesthesia for primary trabeculectomy MethodsA prospective study of 36 consecutive patients undergoing trabeculectomy who were randomized to receive topical (n = 18) or retrobulbar (n = 18) anesthesia. Operating conditions, patient comfort, and surgical outcome were evaluated. SettingsTertiary-care university hospital ambulatory surgical center. ResultsThere were no differences in operating conditions (P = 0.14), pain during (P = 0.54) or after (P = 0.76) surgery, or supplemental anesthesia required (P = 0.34) between the two groups. Very few patients in either group were bothered by touch sensation, tissue manipulation, or the microscope light. Chemosis, subconjunctival hemorrhage and eyelid hemorrhage were seen exclusively in the retrobulbar group (P <0.03), and were all attributable to the injection. Inadvertent eye movement was present more frequently in the topical group (P = 0.01), although this did not pose a problem to the surgeon. No surgical complications were encountered in either group. ConclusionTopical anesthesia is a safe and effective alternative to retrobulbar anesthesia for primary trabeculectomy.

Initial Clinical Experience With the CyPass Micro-Stent: Safety and Surgical Outcomes of a Novel Supraciliary Microstent.

Purpose:To evaluate safety and clinical outcomes of a novel supraciliary device, the CyPass Micro-Stent, for surgical treatment of open-angle glaucoma when implanted in conjunction with cataract surgery. Patients and Methods:Subjects (n=142) with open-angle glaucoma and cataract underwent combined phacoemulsification, with intraocular lens insertion, and microstent implantation into the supraciliary space of study eyes (n=167). Two analysis cohorts were prespecified based upon medicated baseline intraocular pressure (IOP): ≥21 mm Hg (cohort 1, n=65) or <21 mm Hg (cohort 2, n=102). Glaucoma medications were discontinued or tapered at surgery, and restarted at investigator discretion. The main postoperative outcome measures were adverse events, IOP changes, and number of IOP-lowering medications. Results:Mean±SD follow-up was 294±121 days. No major intraoperative or postoperative complications occurred. Preoperative baseline mean IOP was 20.2±6.0 mm Hg and mean number of IOP-lowering medications was 2.0±1.1. Cohort 1 showed a 35% decrease in mean IOP and a 49% reduction in mean glaucoma medication usage; cohort 2 demonstrated a 75% reduction in mean medication usage while maintaining mean IOP<21 mm Hg. For all eyes, mean IOP at 12 months was 15.9±3.1 mm Hg (14% reduction from baseline). Early and late postoperative IOP elevation occurred in 1.2% and 1.8% of eyes, respectively. Two subjects developed mild transient hyphema, and none exhibited prolonged inflammation, persistent hypotony, or hypotony maculopathy. Conclusions:CyPass Micro-Stent implantation, combined with cataract surgery, resulted in minimal complications and reduced IOP and IOP-lowering medication use at 12 months postoperatively.

Ab externo scleral fixation of the Cionni modified capsular tension ring

&NA; The Cionni modified capsular tension ring (CTR) allows for scleral fixation in cases of significant zonular dialysis, providing long‐term centration of in‐the‐bag foldable intraocular lenses. Previous techniques of suture placement require placement of the primary incision along the axis of zonular weakness or enlarging and/or distorting the primary incision to attain proper positioning. They also use blind passes of the needle under the iris to approximate the ciliary sulcus. We describe an external closed‐system approach for preplacing 10‐0 polypropylene sutures in the ciliary sulcus for a Cionni modified CTR under topical anesthesia. This technique does not use blind passes of the suture needle and results in accurate placement of the sutures in the ciliary sulcus under a closed and stable system.

Topical versus retrobulbar anesthesia for combined phacotrabeculectomy: prospective randomized study

Purpose: To compare the safety and efficacy of topical and retrobulbar anesthesia for combined phacotrabeculectomy. Setting: Tertiary‐care university hospital ambulatory surgical center. Methods: In this prospective study, 40 consecutive patients having combined phacotrabeculectomy were randomized to receive topical (n = 20) or retrobulbar (n = 20) anesthesia. Operating conditions, patient comfort, and surgical outcome were evaluated. Results: There was no significant between‐group difference in operating conditions (P = .56), pain during (P = .41) or after (P = .23) surgery, or supplemental anesthesia required (P = .49). Few patients in either group were bothered by tissue manipulation or the microscope light, although more patients in the topical group were slightly bothered by touch sensation (P = .05). Chemosis, subconjunctival hemorrhage, and eyelid hematoma were seen almost exclusively in the retrobulbar group (P < .05). Inadvertent eye movement was present more frequently in the topical group (P = .04), although this did not pose a problem to the surgeon. Conclusion: Topical anesthesia is a safe and effective alternative to retrobulbar anesthesia for combined phacotrabeculectomy.

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.

Fracture and dislocation of a glass intraocular lens optic as a complication of neodymium:YAG laser posterior capsulotomy: Case report and literature review.

UNLABELLED An 83-year-old man presented with a 1-year history of blurry vision in his left eye. Bilateral cataract surgery and ciliary sulcus posterior chamber intraocular lens (IOL) implantation had been performed 11 years earlier. The corrected distance visual acuity (CDVA) was 20/60 in the left eye. Slitlamp examination revealed moderate posterior capsule opacification. Neodymium:YAG laser posterior capsulotomy was performed and complicated by IOL fracture and immediate dislocation of optic fragments into the anterior chamber. An IOL exchange was performed, and the damaged IOL was removed in 7 pieces. A 3-piece acrylic IOL was suture fixated to the posterior iris. Pathologic analysis showed that the damaged IOL was made of glass supported by a polyimide frame. Twelve months after the IOL exchange, the CDVA was 20/60. FINANCIAL DISCLOSURE Dr. Ahmed is a consultant to Alcon Laboratories, Inc., Abbott Medical Optics, Inc., and Bausch & Lomb. Dr. Mamalis is a consultant to Anew Optics, Inc., and Medennium, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Incisional Therapies: Canaloplasty and New Implant Devices

Incisional surgery for the treatment of glaucoma was first described in 1896 with surgical iridectomy, 1 followed by corneo–scleral trephination in the 1920s 2 and full thickness procedures in the 1950s. 3 In 1968, Cairns described the technique of trabeculectomy, 4 still considered by many today to be the gold standard of glaucoma surgery. Techniques have been modified and the addition of adjunctive antimetabolites has perhaps improved the original procedure to enhance long-term success and survival, as measured by intraocular pressure reduction and control, but the common final goal remains to create and maintain a nonphysiologic fistula from the anterior chamber to the subconjunctival space. Although lowering of intraocular pressure (IOP) is undisputable and well established, the generous complication profile of these procedures is well known. Both short-term and long-term risks of blebitis, endophthalmitis, hypotony, overfiltration, bleb leaks, dysesthesia, overhang, encapsulation, corneal dellen, endo thelial cell loss, episcleral fibrosis, aqueous misdirection, and accelerated cataract formation are some of the many potential complications, most of which are lifetime risks for patients undergoing trabeculectomy. 5