Karl Mercieca

Outcomes and complications of trabeculectomy enhanced with 5-fluorouracil in adults with glaucoma secondary to uveitis.

Purpose:To analyze the long-term clinical outcomes of 5-fluorouracil (5FU)-enhanced trabeculectomy in patients with glaucoma secondary to uveitis (UG), to compare outcomes with those achieved elsewhere by primary mitomycin C-enhanced trabeculectomy and primary glaucoma drainage implant (GDI) surgery and to consider the optimal surgical approach in this group of patients. Methods:A retrospective analysis of a single-surgeon series of 31 eyes of 25 patients with UG attending the Manchester Uveitis Clinic who had undergone 5FU-enhanced trabeculectomy between October 2002 and August 2010. Main outcome measures were an intraocular pressure (IOP)<21 mm Hg with medications (unqualified success) and with medications (qualified success). Secondary outcome measures were IOP⩽66% of initial IOP. Other risk factors and postoperative complications were also examined. Results:The mean follow-up was 5.1 years. Qualified success for postoperative IOP control of <21 was achieved in 90.3% at 1 year and 76.5% at 5 years. IOP<66% of initial IOP was achieved in 93.5% at 1 year and 82.3% at 5 years. No patients developed long-term hypotony. Patients under 30 years of age at surgery were at a higher risk for bleb failure and 50% in this age group went on to require GDI surgery. Conclusions:This study demonstrates good long-term survival rates of 5FU-enhanced trabeculectomy in patients with UG, comparable with results for primary open-angle glaucoma. The results also compare favorably with those of mitomycin C-enhanced trabeculectomy and GDIs in patients with UG, with a lower risk of complications. We conclude that for patients over 30 years, 5FU-enhanced trabeculectomy is appropriate first-line surgery, whereas GDI surgery should be used as the primary procedure for those under 30 years.

Very Severe HLA B27-associated Panuveitis Mimicking Endophthalmitis: A Case Series

Purpose: To report rare but important instances of very severe, hyperacute HLA B27-associated panuveitis, mimicking infective endophthalmitis and providing challenges to both diagnosis and management. Design: Retrospective case review. Methods: Four patient records were reviewed. Demographic features, clinical findings, course of uveitis, diagnostic/therapeutic measures, and outcomes are reported. Results: All cases presented with severe panuveitis with visual acuities below 6/60 and poor fundal views. Three patients underwent intraocular fluid sampling for microbiology. All required systemic high-dose corticosteroid treatment, and two also needed oral immunosuppression. All eventually required cataract extraction. Final visual acuity varied from 6/12 to 6/6. Conclusions: HLA B27-associated uveitis may be unusually severe and may cause a panuveitis, mimicking infective endophthalmitis. The course may be prolonged and difficult with frequent complications including cataract.

Choroidal nonperfusion with significant subretinal exudation after PDT of predominantly classic CNV: an OCT and FFA study.

Purpose Despite the increasing use of antivascular endothelial growth factors (anti-VEGF), photodynamic therapy (PDT) with Verteporfin® is still considered the gold standard treatment of subfoveal and juxtafoveal classic choroidal neovascularization (CNV). Methods Case report. Results The authors report a case of a 72-year-old man who developed choroidal nonperfusion and significant subretinal fluid formation with associated severe visual loss following PDT of predominantly classic juxtafoveal CNV. Conclusions Although reported separately, these two complications have not been previously reported to occur in association after PDT treatment of classic CNV and may represent exaggeration of normal events occurring after PDT.

Treatment of acute anterior uveitis in the community, as seen in an emergency eye centre. A lesson for the general practitioner?

Abstract Background: Acute anterior uveitis (AAU) is a potentially serious ocular condition, which frequently presents to the General Practitioner (GP). In some cases, it can be misdiagnosed with consequent delay in the initiation of appropriate treatment. Objectives: To analyse the diagnostic features of AAU presenting to the emergency service at Manchester Royal Eye Hospital; to investigate the prior management of AAU in the community and identify management problems amenable to constructive feedback. Methods: A list of reasonable standards expected from primary carers was compiled and information collected prospectively by nurse practitioners over two months using a specifically designed pro-forma. Data was analysed against these standards and compared to the relevant literature. Results: Of the AAU patients 18/69 had previously seen the GP. 14 had first episodes, 4 were recurrent. Mean interval between symptom onset and eye emergency attendance was 9.2 days compared to 4.3 days for those not seen by GP. Symptoms elicited, in those previously seen by a GP, were: ocular pain (18/18); photophobia (17/18); unilateral red eye (17/18); and blurred vision (15/18). GP performed ocular examination in 12 patients. Seven patients were not treated by GP but referred on the same day. The other 11 patients were prescribed topical antibiotics by GP and 2/11 also received topical steroid. 9 of these 11 patients eventually self-checked into eye emergency, whereas two were subsequently referred after re-visiting the GP. Conclusion: A significant number of AAU patients present to the GP and may be misdiagnosed with an alternative condition such as conjunctivitis. Awareness of AAU presentation and the need for prompt referral, to avoid potential visual loss, needs to be improved by providing feedback to GPs following patient attendance to eye emergency services.

Primary Open Angle Glaucoma is Associated with MR Biomarkers of Cerebral Small Vessel Disease

This prospective study tests the hypotheses that: 1) glaucoma is associated with evidence of cerebral small vessel disease; 2) that imaging biomarkers of cerebral small vessel disease in POAG and NTG will show different characteristics. 12 normal controls, 7 patients with primary open angle glaucoma (POAG) and 9 patients with normal tension glaucoma (NTG) were recruited. Ophthalmological clinical assessment and MR imaging of the brain were performed. MR imaging was used to quantify white matter lesion load, frequency of dilated perivascular spaces (PVS) and abnormalities in cerebral hydrodynamics. Patients with POAG had significantly greater white matter lesion load (p < 0.05), more PVS in the centrum semiovale (p < 0.05) and had higher overall PVS scores than controls (p < 0.05). In the POAG group, optic cup-to-disc ratio (CDR) was positively correlated with deep white matter hyperintensities (R2 = 0.928, p < 0.01). Mean deviation on the Humphrey visual field assessment was negatively correlated with deep white matter lesion load (R2 = −0.840, p < 0.01), total white matter lesion load (R2 = −0.928, p < 0.01) and total PVS (R2 = −0.820, p < 0.01). MR evidence of cerebral small vessel disease is strongly associated with a diagnosis of POAG and with the severity of abnormalities in CDR and visual field.

Acute conjunctivitis in primary care: antibiotics and placebo associated with small increase in the proportion cured by 7 days compared with no treatment

Commentary on: Jefferis J, Perera R, Everitt H, et al. Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis. Br J Gen Pract2011;61:e545–e548.[OpenUrl][1] Acute infective conjunctivitis is the commonest ocular problem encountered in general practice. Traditionally most patients were prescribed topical antibiotics, essentially to cover for bacterial causes. Despite some evidence of improved clinical and microbiological remission rates with antibiotic use in bacterial conjunctivitis, most patients with acute infective conjunctivitis will get better without antibiotics.1 ,2 Viral infections are more common than bacterial, especially in adults, and are usually self-limiting.1,–,3 With this knowledge, prescribing guidance has changed in the last decade and suggests delayed or deferred use of topical antibiotics.2 ,4 ‘Over-the-counter’ chloramphenicol risks unnecessary treatment and delayed diagnosis of alternative conditions. The authors conducted an individual patient … [1]: {openurl}?query=rft.jtitle%253DBr%2BJ%2BGen%2BPract%26rft.volume%253D61%26rft.spage%253De545%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx

Intraoperative conversion from phacoemulsification to manual extracapsular cataract extraction

The importance ofwoundplacement is demonstrated in a patient who had cataract surgery 4 years after keratolimbal allograft and tube-shunt surgery. Based on the tube location and efforts to avoid an inferiorly placed wound, the main wound was made adjacent to a keratolimbal allograft junction. After the IOL was inserted, the edge of 1 segment became elevated. Four 10-0 nylon sutures were required to reappose the 2 segments to prevent leakage at the junction, and 3 sutures were required at the main wound to ensure Seidel negative testing (Figure 3).

Conjunctival bleb compression sutures: An effective method of addressing hypotony after trabeculectomy or trabeculectomy-related procedures

Purpose: Over-filtration is a well-known complication of trabeculectomy and related procedures, especially with adjunctive antimetabolites. Secondary hypotony can result in reduced visual acuity and compromise long-term surgical success. Persistent hypotony requires intervention and we describe an effective adaptation of placing conjunctival compression sutures directly over the scleral flap. Methods: A retrospective consecutive case series of all patients who underwent conjunctival compression suturing from 2012 to 2014 at Manchester Royal Eye Hospital, UK. Under sub-tenon’s anaesthesia, two 9/0 nylon figure-of-eight transconjunctival sutures were placed horizontally across the bleb: the first over the anterior flap/ostium and the second over the posterior flap edge to reduce flow through the trabeculectomy flap. Results: A total of 10 patients underwent conjunctival compression suturing, and all patients had successful reversal of hypotony and symptom resolution within 1 week with corresponding clinical improvement. Intraocular pressure control was maintained without topical pressure-lowering agents in seven patients (median = 10 mmHg, range = 7–12 mmHg) with a median follow-up of 35.9 months (range = 11–61 months). Two patients required topical therapy to maintain intraocular pressure ≤ 14 mmHg and one patient’s hypotony returned after 10 months but remained untreated due to pre-existing poor vision. No patients required a return to theatre. Conclusion: This series demonstrates that conjunctival compression sutures can successfully provide long-term control of trabeculectomy-bleb-related hypotony. This technique offers an effective alternative for glaucoma surgeons in addressing post-trabeculectomy hypotony.

Trabeculectomy bleb needling and antimetabolite administration practices in the UK: a glaucoma specialist national survey

Aims To evaluate, describe and quantify the diversity in postoperative antimetabolite administration and bleb needling practices among glaucoma specialists performing trabeculectomy surgery within the UK and Ireland. Methods A cross-sectional online survey was distributed to all consultant glaucoma specialists who are on the United Kingdom and Eire Glaucoma Society (UKEGS) contact list. Participants were asked specific questions about their current practices for post-trabeculectomy antimetabolite administration followed by questions directly related to bleb needling procedures. Results 60 (83%) of UKEGS glaucoma subspecialty consultants completed the survey. 70% of respondents administered 5-fluorouracil (5-FU) in their clinic room while 30% used a separate treatment room. Doses of 5-FU varied considerably but 70% used 5 mg as standard. Techniques used to reduce corneal toxicity included precipitation with amethocaine (44%) or benoxinate (14%), saline wash (14%) and modified injection technique (8%). Topical antibiotics and/or betadine were used to prevent infection following 5-FU injection in just over 50%. Bleb needling was exclusively performed in operating theatre by 56% of respondents and solely at the slit lamp in the clinic room by 12%. A further 30% used a combination of both theatre and outpatient clinic rooms. Anti-metabolites used were 5-FU (72%) and mitomycin C (22%) with 12% using either of the two substances. Conclusions There is a significantly wide variety of current practices for antimetabolite administration and bleb needling within the UK and Ireland. This may be influenced by a glaucoma surgeon’s specific experience and audit results as well as particular clinical set-up, availability of antimetabolite and clinic room space.

Vascularisation of the anterior lens capsule in an eye with excellent visual acuity

A 53-year-old phakic female with a history of nanophthalmos and hyperopia was incidentally found to have unilateral neovascularisation on the left inferoanterior lens surface on routine review for ocular hypertension.