Jörg Koch

Prevalence of uveitic secondary glaucoma and success of nonsurgical treatment in adults and children in a tertiary referral center.

Purpose: The aim of this study is to compare treatment strategies, the success of topical and systemic therapy, and the need for glaucoma surgery in children and adults with secondary uveitic glaucoma. Methods: Retrospective observational case series with 1997 consecutive new uveitis patients. Results: Overall, 176 patients (8.8%) suffered from secondary glaucoma (n = 126) or ocular hypertension (n = 50). All patients received topical therapy, and 107 (62%) patients also received systemic glaucoma therapy. Topical therapy was successful (IOP ≤ 21 mmHg) in 24% of adults and 26% of children. Surgery was required in 59% of children and in 35% of adults (p =.02). The number of surgical interventions differed per patient with 2.6 procedures in children compared to 1.6 procedures in adults (p <.001). Conclusions: Only a limited number of patients with secondary uveitic glaucoma can be sufficiently controlled with topical and systemic antiglaucomatous therapy alone. There is a significantly higher need for glaucoma operations in children.

Combined phacoemulsification and pars plana vitrectomy: Clear corneal versus scleral incisions Prospective randomized multicenter study

Purpose: To compare the complications and outcomes of implantation of a foldable intraocular lens (IOL) through a clear corneal incision and implantation of a poly(methyl methacrylate) (PMMA) IOL through a scleral incision in combined phacoemulsification and pars plana vitrectomy. Setting: Departments of Ophthalmology, St. Franziskus Hospital, Muenster, Eye Hospital, Muelheim, and University of Essen, Essen, Germany. Methods: This prospective randomized study included 62 eyes having implantation of a PMMA IOL (811B, Pharmacia) through a scleral incision and 61 eyes having implantation of a polyacrylic (AcrySof®, Alcon) IOL through a clear corneal incision. The preoperative visual acuity, underlying retinal disease, and vitreoretinal surgical maneuvers did not differ between groups. The surgical methods and intraoperative complications were noted. Examinations 2 days and 3 months after surgery included visual acuity, refractive error, keratometry, slitlamp evaluation, tonometry, and ophthalmoscopy. Results: Intraoperatively, both incisions were stable and no serious complications occurred. Two days after surgery, the incidence and quantity of cells and fibrin in the anterior chamber were lower in the clear corneal incision group than in the scleral incision group (P<.05). Corneal endothelial dysfunction was more common in the clear corneal group than in the scleral group (P<.05). Three months after surgery, the astigmatic changes did not differ significantly between groups and the incidence of posterior capsule opacification (PCO) was lower in the clear corneal group (P<.05). Postoperative visual acuity improved significantly in 63% of eyes and 61% of eyes in the scleral group and clear corneal group, respectively. Visual acuity was limited by macular pathology. Conclusions: Both clear corneal and scleral incisions were safe in combined phacoemulsification and vitrectomy. Eyes with smaller clear corneal incisions and foldable IOLs had less postoperative inflammation and PCO.

Effect of repositioning or discarding the epithelial flap in laser-assisted subepithelial keratectomy and epithelial laser in situ keratomileusis

PURPOSE: To evaluate the influence of the epithelial flap after epithelial laser in situ keratomileusis (epi‐LASIK) and laser‐assisted subepithelial keratectomy (LASEK) to correct low to moderate ametropia on visual recovery, epithelial closure, pain, and haze formation. SETTING: Zentrum für Refraktive Chirurgie, Augenabteilung am St. Franziskus Hospital, Münster, Germany. DESIGN: Comparative case series. METHODS: Patients having bilateral epi‐LASIK or bilateral LASEK had 1 treatment with a repositioned epithelial flap and 1 treatment with a discarded flap. Patients were masked to the epithelial replacement. Primary outcomes were visual acuity (decimal scale), diameter of epithelial defect, pain score (subjective visual analog scale 0 to 10), and haze formation (Fantes scale). Postoperative visits were at 1, 2, and 4 days and after 3 months. RESULTS: Twenty patients had epi‐LASIK and 20 patients had LASEK. The mean increase in uncorrected distance visual acuity from 1 day to 3 months was 0.32 to 0.99 (epi‐LASIK flap‐on), from 0.41 to 0.98 (epi‐LASIK flap‐off), from 0.26 to 0.96 (LASEK flap‐on), and from 0.37 to 0.92 (LASEK flap‐off), respectively. At 4 days, epithelial closure was complete in 79 of 80 eyes. Postoperative pain levels decreased comparably in all groups. Haze levels after 3 months were 0.45, 0.43, 0.35, and 0.35 (epi‐LASIK flap‐on, epi‐LASIK flap‐off, LASEK flap‐on, LASEK flap‐off, respectively). Efficacy indices after 3 months were 1.07, 1.09, 1.11, 1.07, respectively. CONCLUSION: No clinically significant differences in terms of visual recovery, epithelial closure time, pain perception, and haze formation between LASEK and epi‐LASIK were detected regardless of epithelial flap retention. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Trabeculectomy or modified deep sclerectomy in juvenile uveitic glaucoma

PurposeThe purpose of this study is to report the effectiveness of trabeculectomies (TE) and modified deep sclerectomies (mdS) in a group of patients with juvenile uveitic secondary glaucoma.MethodsThis is a retrospective analysis of 16 TE and eight mdS.ResultsPostoperatively, an IOP reduction to 11.6u2009±u20094.7xa0mmHg was achieved in the TE group and to 18.5u2009±u200911.4xa0mmHg in the mdS group (pu2009=u20090.045). In the TE group, 14 patients showed postoperative success, one limited success and another was a failure compared to four successes and four failures in the mdS group (pu2009=u20090.041). The mean number of complications was 1.25u2009±u20091.49 in the TE group and 0.38u2009±u20090.74 after mdS (pu2009=u20090.11). In the mdS group, four patients (50%) needed additional glaucoma surgery compared to one TE patient (pu2009=u20090.023).ConclusionBoth surgical techniques showed a marked reduction of IOP. Trabeculectomy has a higher probability of achieving success and lowering IOP.

Long-term reduction of laser flare values after trabeculectomy but not after cyclodestructive procedures in uveitis patients

The aim of this study was to examine long-term changes of laser flare (LF) after trabeculectomy (TE) and transscleral diode cyclophotocoagulation (TDCPC) in patients with uveitic secondary glaucoma. Retrospective, single-center analysis. Overall, 40 TE (mean follow-up 21.1xa0months) and 68 TDCPC (mean follow-up 21.8xa0months, Pxa0=xa00.38) procedures were performed. The intraocular pressure (IOP) level was consistently lower in the TE group at the preoperative visit and at each follow-up visit, while IOP reduction was similar in both groups (Pxa0=xa00.91). LF decreased from 59.4 photons/ms at baseline to 41.9 photons/ms in the TE group (Pxa0=xa00.017) and remained unchanged in the TDCPC group (71.2 vs. 70.7 photons/ms, Pxa0=xa00.84). No significant increase in the number of complications could be observed at the end of the postoperative follow-up, while best-corrected visual acuity drop and cataract formation was higher in the TE group. TE significantly reduced postoperative LF values. Higher LF values did not increase the development of new complications in this study, but an increased occurrence of cataract formation was seen in the TE group.

Multiplex Cytokine Analysis of Aqueous Humor in Juvenile Idiopathic Arthritis-Associated Anterior Uveitis With or Without Secondary Glaucoma

Patients with juvenile idiopathic arthritis often develop chronic anterior uveitis (JIAU). JIAU patients possess a particularly high risk for developing secondary glaucoma when inflammatory inactivity has been achieved. By using multiplex bead assay analysis, we assessed levels of pro- and anti-inflammatory cytokines, chemokines, or metalloproteinases in the aqueous humor (AH) of patients with clinically inactive JIAU with (JIAUwG) or without secondary glaucoma (JIAUwoG), or from patients with senile cataract as controls. Laser-flare photometry analysis prior to surgery showed no significant differences between JIAUwG or JIAUwoG. Compared with the control group, levels of interleukin-8, matrix metalloproteinase-2, -3, -9, serum amyloid A (SAA), transforming growth factor beta-1, -2, -3 (TGFβ-1, -2, -3), and tumor necrosis factor-alpha in the AH were significantly higher in patients with clinically inactive JIAUwG or JIAUwoG. Samples from JIAwoG patients displayed significantly higher levels of SAA (Pu2009<u20090.0116) than JIAUwG patients. JIAUwG patients showed an increased level of TGFβ-2 in AH samples compared with JIAUwoG (Pu2009<u20090.0009). These molecules may contribute to the clinical development of glaucoma in patients with JIAU.

Hypermotility of an iris-fixated anterior chamber phakic intraocular lens due to nontraumatic iris laxity.

Purpose Permanent immovability of phakic intraocular lenses (pIOLs) for the correction of high myopia is crucial in avoiding injury to the corneal endothelium and maintaining visual acuity. Unstable position of iris-fixated pIOLs due to traumatic or nontraumatic disenclavation of the haptic has been described previously. Methods and Results We report a different mechanism of repeated excessive implant motility in both eyes of a young woman who developed late nontraumatic elongation of the iris fibers to which an iris-claw pIOL was fixated. This led to increased motility of the pIOLs with blinking causing mild iritis. Subsequent bilateral successful re-enclavation to other iris fibers ameliorated these symptoms. After 2.5 years, these iris fibers, too, were elongated, causing excessive movements of the pIOLs and consecutive endothelial cell loss necessitating removal of the pIOLs. The etiology of this iris fiber laxity remains unclear. Conclusions Surgeons should be aware of this rare potential complication.