Moataz E. Gheith

Releasable suture technique.

PurposeReleasable scleral flap sutures have been effectively used with trabeculectomy to provide a safer postoperative course. This review will assess the indications for using releasable sutures, with the consideration of their advantages and disadvantages, after trabeculectomy. MethodsA review of the literature provided the most common releasable suture techniques. ResultsReleasable scleral flap sutures reduce the incidence of complications of early postoperative overfiltration after trabeculectomy. As a result, there are fewer cases that might require reformation of the anterior chamber and drainage of suprachoroidal fluid. In contrast to performing laser suture lysis; there is no need for a laser, suture visibility under the conjunctiva is irrelevant, and no contact lens is required. ConclusionsThe use of releasable scleral flap sutures in guarded filtration surgery safely provides an effective and simple way of titrating intraocular pressure postoperatively. It allows the transition from a relatively low flow state to a higher rate of subconjunctival filtration to achieve a satisfactory long-term outcome of glaucoma surgery.

The Early Flat Anterior Chamber After Trabeculectomy A Randomized, Prospective Study of 3 Methods of Management

PurposeTo evaluate prospectively 3 different approaches to the management of a flat anterior chamber (FAC) because of overfiltration in the early postoperative period after trabeculectomy. Materials and MethodsThirty-six eyes diagnosed with a FAC with total iridocorneal touch, but no lenticular touch (grade II) because of overfiltration in the first 14 days after trabeculectomy were randomized prospectively into 3 groups: group 1—anterior chamber reformation with viscoelastic substance; group 2—anterior chamber reformation with balanced salt solution and concurrent drainage of choroidal effusion; and group 3—pharmacologic therapy with atropine, phenylephrine, and in select cases oral acetazolamide. Outcome measures were visual acuity, amount of intraocular pressure (IOP) reduction, and achievement of predetermined target IOP. ResultsTreatment group 2 had a greater number of eyes with acuity decline of two or more lines relative to group 3 (P=0.04). Group 1 had more eyes with acuity decline of two or more lines relative to group 3, but this was not significant (P>0.05). ConclusionsFor grade II FACs because of overfiltration in the early postoperative period after trabeculectomy, reformation of the anterior chamber with drainage of choroidal effusion may be associated with greater long-term trabeculectomy success, but is associated with greater visual acuity loss relative to medicinal therapy alone. Reformation with viscoelastic resulted in a trend toward lowest final IOP in comparison to medicinal therapy alone.

The amount of intraocular pressure rise during pharmacological pupillary dilatation is an indicator of the likelihood of future progression of glaucoma.

Aim: To determine if there is a relationship between the amount of increase in IOP following dilatation with a cycloplegic agent and the future course of glaucoma. Method: A retrospective chart review of 100 eyes from 55 subjects with open-angle glaucoma who had had IOP measured before and after pharmacological pupillary dilatation was performed to establish the rate of progression of glaucoma, based on serial evaluation of the visual fields using the glaucoma staging system 2 (GSS 2), and optic discs using the disc damage likelihood scale (DDLS). Progressive visual field loss was defined as an increase of two or more stages with the GSS 2 and progressive deterioration of the disc was defined as an increase of two or more stages with the DDLS. Mean follow-up time was 7.2 years. Results: A total of 26 eyes showed glaucomatous progression. The likelihood of progression of glaucoma was related to the amount of IOP increase after pharmacological pupillary dilatation. For every 1 mmHg increase in IOP, the odds of progression increased 24% (p = 0.008). The likelihood of progression of glaucoma, however, was not related to the baseline IOP, which was 20.63 mmHg (SD = 4.59 mmHg) in those showing deterioration of disc or field and 19.72 mmHg (SD = 5.32 mmHg) in those not worsening according to our definition. Conclusion: In patients with open-angle glaucoma, the amount of increase in IOP caused by pharmacological pupillary dilatation is related to the likelihood of future progression of glaucoma.

Should an iridectomy be routinely performed as a part of trabeculectomy? two surgeons' clinical experience

PurposeTo investigate the effects of performing peripheral iridectomy on the outcome of trabeculectomy.MethodsRetrospective chart review of the medical records of 75 patients (75 eyes) who underwent trabeculectomy surgery, with or without peripheral iridectomy, who had been followed for more than 1 year. Data were collected preoperatively, 1 day postoperatively, on days 30–90 postoperatively, and 1–3 years postoperatively. The collected data included visual acuity, intraocular pressure, bleb development, postoperative inflammation, and complications. Thirty-six eyes (48%) had cataract extraction at the time of trabeculectomy. A peripheral iridectomy was performed in 43 cases (57%). Students t-test was used for the statistical analyses.ResultsPatients having peripheral iridectomy had more inflammation on days 30–90 than those who did not have peripheral iridectomy performed (in patients having cataract extraction with trabeculectomy (P=0.018) and those not having cataract extraction (P=0.038)). There was no statistically significant difference in intraocular pressure in eyes with or without iridectomy. Postoperative complications were rare in both groups but greater in number in the eyes with peripheral iridectomy.ConclusionsTrabeculectomy performed without peripheral iridectomy appears to be as effective in lowering intraocular pressure as when performed with peripheral iridectomy, but it is a safer procedure, with a lower incidence of postoperative inflammation. It may be an advantage to avoid performing peripheral iridectomy during trabeculectomy in eyes that are not predisposed to postoperative shallowing of the anterior chamber or pupillary block.

Post-peripheral iridotomy inflammation in patients with dark pigmentation.

A retrospective chart review of four patients who had Nd:YAG peripheral iridotomy performed for narrow anterior chamber angle and subsequently developed marked inflammation after tapering anti-inflammatory steroids. These cases were possibly predisposed to this reaction by the heavy pigmentation of their irides based on race, their use of latanoprost, or the conjunction of these factors.

The value of intraocular pressure asymmetry in diagnosing glaucoma

Purpose:To investigate the amount of intraocular pressure (IOP) asymmetry in a large group of ethnically diverse patients with and without glaucoma, and to delineate the risk for glaucoma which increasing amounts of IOP asymmetry confer upon the patient. Patients and Methods:Collaborative retrospective study of 326 glaucoma patients and 326 controls. Former Wills Eye Institute fellows collected single pre-treatment measurements of IOP on patients diagnosed as having definite glaucoma based on characteristic optic nerve damage and confirmatory visual field damage. Patients with a normal eye examination who had normal-appearing optic discs and no apparent glaucoma, or who had a normal eye examination in association with refractive error or cataract, were used as controls. Results:Intraocular pressure asymmetry is a significant risk factor for having glaucoma (odds ratio, 2.14; 95% confidence interval, 1.86-2.47; P<0.001). Absence of IOP asymmetry between the fellow eyes is associated with a 1% probability of having glaucoma. A difference of 3 mm Hg is associated with a 6% probability of having glaucoma, and a difference of >6 mm Hg with a 57% probability of having glaucoma. The association between IOP asymmetry and glaucoma status is significant for subjects with both elevated IOP (P=0.014) and statistically normal IOP (maximum IOP⩽21 mm Hg; P<0.001). Conclusions:Inter-eye asymmetry of IOP is a common finding in patients with glaucoma. There is a direct relationship between the amount of IOP asymmetry between the fellow eyes and the likelihood of having glaucoma.

Progressive Optic Neuropathy in Congenital Glaucoma Associated with the Sirsasana Yoga Posture

The authors describe a case of progressive optic neuropathy in a patient with congenital glaucoma who had routinely practiced the Sirsasana (headstand) yoga posture for several years. Ophthalmic examination included best-corrected visual acuity, anterior segment examination, indirect ophthalmoscopy, ultrasound pachymetry for central corneal thickness, and intraocular pressure before, during, and after maintaining the Sirsasana posture for 5 minutes. Intraocular pressure increased significantly during the Sirsasana posture. Transient elevation in intraocular pressure during yoga exercises may lead to progressive glaucomatous optic neuropathy, especially in susceptible patients with congenital glaucoma.

Oral Niacin Can Increase Intraocular Pressure

The intraocular pressure of a 73-year-old man with a history of primary open-angle glaucoma had been approximately 21 and 17 mm Hg in the right and left eyes, respectively, while taking latanoprost 0.005% and dorzolamide hydrochloride 2%. When taking 500 mg of oral niacin (also known as vitamin B3 or nicotinic acid), his intraocular pressure increased to 37 and 27 mm Hg in the right and left eyes, respectively, on one occasion. On reexamination, the intraocular pressure had increased to 28 and 23 mm Hg in the right and left eyes, respectively. Each time the niacin was stopped, the intraocular pressure decreased to the original levels.

Limitations of the Heidelberg Retina Tomograph

Glaucoma is a progressive optic neuropathy where damages that occur at the optic nerve head and the retinal never fiber layer are associated with changes in the visual field. The Heidelberg Retina Tomograph (Heidelberg Engineering, Carlsbad, CA), a scanning laser ophthalmoscope, performs a three-dimensional topographic analysis of the optic nerve head and the retinal never fiber layer. The Heidelberg Retina Tomograph has been reported to be a reliable and objective method of identifying structural changes prior to the occurrence of visual field defects. In our series of patients, all had significant visual field defects but normal Heidelberg Retina Tomograph results, including rim area and Moorfield regression analysis. It is important to recognize that interpreting the Heidelberg Retina Tomograph results alone may be misleading; however, when combined with careful clinical evaluation of the optic nerve head and the visual field, the Heidelberg Retina Tomograph may provide valuable information in assisting the clinician with the diagnosis and management of glaucoma.

Managing refractory glaucoma with a fixed combination of bimatoprost (0.03%) and timolol (0.5%).

Glaucoma is a chronic progressive optic neuropathy characterized by progressive loss of retinal ganglion cells, which manifests clinically with loss of optic disc neuroretinal rim tissue, defects in the retinal nerve fiber layer, and deficits on functional visual field testing. The goal of glaucoma treatment is to reduce the intraocular pressure to a level that prevents or minimizes the progressive loss of vision. The current standard of management for the newly diagnosed primary open angle glaucoma (PAOG) patient is to start topical medication. Available topical medications include: beta-adrenergic antagonists, alpha-adrenergic agonists, carbonic anhydraze inhibitors, prostaglandin analogues and miotics. In some patients, IOP is not adequately controlled by monotherapy. In those refractory patients, where more efficacy is required, shifting to another medication or adding a second medication is indicated. The complimentary action between two drugs serves as the basis for combination medications. One avenue of delivering a second medication is through a fixed combination medication that has the advantage of providing two medicines within one drop. Bimatoprost/timolol represents a new fixed combination which is clinically and statistically more effective than either of its active constituents for patients with refractory glaucoma. As regard the safety of the combination, there were no signs or symptoms of intolerance and the incidence of conjunctival hyperemia was clinically and statistically significantly less than each of the two components separately. Bimatoprost/timolol fixed combination offers cost and time savings, which may enhance compliance; also reducing the amount of preservative applied to the eye, will improve tolerability and may also favorably improve eventual surgical outcomes in patients who might require filtering procedures.