Noa Geffen

CO2 laser-assisted sclerectomy surgery, part II: multicenter clinical preliminary study.

PurposeTo evaluate the efficacy of CO2 laser-assisted sclerectomy surgery (CLASS) in primary and pseudoexfoliative open-angle glaucoma. Materials and MethodsPatients for primary filtration surgery underwent CLASS with a CO2 laser system (OT-134-IOPtiMate, IOPtima Ltd., Ramat Gan, Israel). This self-controlled system gradually ablates and removes scleral layers until percolating fluid absorbs the energy, attenuating further tissue ablation. Intraocular pressure (IOP) was measured at baseline, 1, 2, 4, and 6 weeks, and 3, 6, and 12 months, respectively. Complete success was defined as 5⩽IOP⩽18 mm Hg and 20% IOP reduction with no medication at a 12-month endpoint visit, and qualified success as the same IOP range with or without medication. ResultsThirty of 37 patients completed 12 months of follow-up. Mitomycin C was used in 25 procedures (83.3%). The mean baseline IOP of 26.3±7.8 mm Hg (mean±SD) dropped to 14.4±3.4 and 14.3±3.1 mm Hg at 6 and 12 months, respectively, with 42.4% and 40.7% IOP reduction at 6 and 12 months, respectively (P<0.001). Complete success was achieved by 76.7% and 60% of the patients at 6 and 12 months, respectively, whereas qualified success was achieved by 83.3% and 86.6% of the patients at 6 and 12 months, respectively. Complications were mild and transitory with no sequela. ConclusionsShort-term and intermediate results suggest that CLASS may become a simple, safe, and effective means of choice for the treatment of open-angle glaucoma.

CO2 laser-assisted sclerectomy surgery part I: concept and experimental models.

PurposeTo evaluate the safety and performance of a second-generation device for CO2 laser-assisted sclerectomy surgery system in experimental models. Materials and MethodsLaser-assisted deep sclerectomy using a modified CO2 laser system (OT-134—“IOPtiMate”; IOPtima Ltd, Israel) was performed in 3 experimental models: enucleated pig eyes, human cadaver eyes, and live rabbit eyes. A half-thickness scleral flap was created, and a CO2 laser with a beam-manipulating system was used to achieve deep scleral ablation over the Schlemm canal zone. Aqueous percolation and scleral perforation rates were recorded. Intraocular pressure was monitored in live rabbits up to 21 days postoperatively. The shape and location of the scleral ablation zone, thermal damage, and the healing process were examined by histopathological analysis. ResultsDeep scleral ablation and aqueous percolation were repeatedly achieved in all the models. Micro-perforations occurred in 4/18 human eyes (22.2%), in 4/23 rabbit eyes (17.4%), and in none of the 38 porcine eyes. Mean intraocular pressure in the rabbits was significantly decreased (by 6.3±3.6 mm Hg) on the first postoperative day (P<0.0001) and gradually returned to normal. In all but one of the cadaver eyes, effective fluid percolation was achieved. Histology in each case disclosed deep scleral craters with a thin intact sclero-corneal tissue layer at the ablation area. Mild thermal damage, limited to the ablated scleral walls was detected and resolved after 10 days. ConclusionsThe results in these experimental studies indicated that CO2 laser-assisted sclerectomy surgery using the OT-134 system is a safe and efficacious procedure for achieving effective fluid percolation.

Phacoemulsification-induced injury in corneal endothelial cells mediated by apoptosis: In vitro model

PURPOSE: To characterize the mechanism of injury caused by phacoemulsification and examine the protective effect of ascorbic acid in cultured bovine corneal endothelial cells (CECs). SETTING: Goldschleger Eye Research Institute, Sackler Faculty of Medicine, Tel‐Aviv University, Tel‐Aviv, Israel. METHODS: To minimize the direct mechanical effects of phacoemulsification on CECs, cells cultured on gas‐permeable flexible membranes were exposed to phacoemulsification. Apoptosis was assayed by immunohistochemistry using anticaspase‐3 antibody. RESULTS: Phacoemulsification caused a significantly higher rate of apoptosis (mean apoptotic nuclei per square millimeter, 334 ± 29 [SD] versus 45 ± 12) 48 hours after exposure (P<.001). Results were similar in CECs exposed to hydrogen peroxide for 48 hours as a positive control (mean 345 ± 6 and 376 ± 1 at hydrogen peroxide concentrations of 50 μM and 100 μM, respectively). Addition of ascorbic acid (1 or 10 mM) significantly decreased the 48‐hour apoptotic nuclei count induced by phacoemulsification (mean 219 ± 15 and 130 ± 29, respectively) (P<.001). Application of shear forces up to 2000 seconds−1 for 60 minutes did not increase the rate of apoptotic nuclei. CONCLUSIONS: Flexible membranes covered with cultured CECs, used as a new model that mimics in vivo conditions, minimized the mechanical damage caused by ultrasonic vibrations and turbulent currents, which destroy cells grown on hard surfaces. Phacoemulsification damage was not mediated by mechanical or shear forces but resulted from free‐radical formation that apparently triggered cellular cascades, leading to apoptosis. Cell death was significantly reduced by the addition of ascorbic acid, probably via a free radical–scavenging mechanism.

Determining size and characteristics of metal intraocular foreign bodies using helical CT scan.

Purpose To carry out a pilot study comparing the size of various types of metallic intraocular foreign bodies as imaged on computed tomographic (CT) scan to their actual size, and to determine the features of different types of metals on CT scan. Methods Metallic foreign bodies of predetermined standardized sizes were prepared from iron, silver, copper, aluminium, and lead. The metallic pieces/shards were each inserted into the vitreous of a cows eye and helical CT scan (MX twin, Picker) was performed to image the intraocular foreign bodies, using soft tissue and bone window settings. Slice section thickness was 1.3 mm, with intervals of 0.6 mm. Milliampere per second was 265 and pitch 0.7. Results The size of all types of metals as measured on CT was larger than the actual size. Iron was enlarged by a factor of 2.29, silver 1.77, copper 1.26, and aluminum 1.17. All metals had features including central core, ring density, and artifacts which varied for each type of metal, giving each one a characteristic appearance Conclusions Helical CT scan could be useful in estimating the type and size of an intraocular metal foreign body made from iron, silver, copper, aluminium, or lead. (Eur J Ophthalmol 2009; 19: 861–5)

PROGNOSTIC VALUE OF HYPERREFLECTIVE FOCI IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATED WITH BEVACIZUMAB.

Purpose: To study the prognostic value of optical coherence tomography hyperreflective foci (HF) in neovascular age-related macular degeneration. Methods: Charts of naive neovascular age-related macular degeneration eyes treated with intravitreal bevacizumab between January 2011 and January 2014 were reviewed, and optical coherence tomography was collected at baseline, 3 months, and 12 months. The presence, location (inner vs. outer retinal layers), and number (few = [0–10], moderate [11–20], many [>20]) of HF were graded. Results: Overall, charts of 111 eyes were reviewed and 76 eyes of 73 patients fulfilled inclusion criteria. Baseline best-corrected visual acuity was lower in eyes with HF > 20 (P = 0.001), inner layer HF (P = 0.009), increased central retinal thickness (P < 0.001), and intraretinal fluid (P < 0.001). Baseline HF > 20 (P = 0.002), inner layer HF (P = 0.01), increased central retinal thickness (P < 0.001), and intraretinal fluid (P = 0.001) had worst best-corrected visual acuity at 12 months. Eyes with intraretinal fluid, HF > 20, and HF adjacent to intraretinal fluid demonstrated a greater reduction in central retinal thickness; only baseline HF > 20 remained significant in multivariate analysis (P < 0.001). Eyes with a reduction in HF (P = 0.02) and resolution of inner layer HF (P = 0.01) had a greater central retinal thickness reduction. Conclusion: Quantity and location of HF are of prognostic value in intravitreal bevacizumab–treated naive neovascular age-related macular degeneration. Increased awareness of specialists interpreting optical coherence tomography scans toward the number and location of HF is prudent.

The Effect of Labor on the Intraocular Pressure in Healthy Women.

Purpose: To investigate the effect of modern vaginal labor using epidural anesthesia on the intraocular pressure (IOP) and on the mean ocular perfusion pressure (MOPP) in healthy women. Patients and Methods: In this prospective observational study, eligible candidates were healthy pregnant women for vaginal delivery with epidural anesthesia, with a singleton pregnancy, who were admitted to the delivery room in the first phase of the first stage of labor. Demographic data as well as medical and obstetric history were obtained at baseline, followed by performance of a biomicroscopic examination. IOP, maternal heart rate, systolic blood pressure, and diastolic blood pressure were measured in the first, second and third stages of labor, 24±2 and 48±2 hours postpartum. IOP was not measured during the contraction phase of stage 2. MOPP was expressed as the difference between the arterial blood pressure and the IOP. Measurements were performed throughout the different stages of labor and were compared with baseline values. Results: Thirty healthy white women were enrolled. Four women dropped out due to unexpected cesarean sections. The average age was 31.8±4.7 years. Nineteen participants received oxytocin during delivery. Twenty-three women were placed in a supine position, whereas 3 in a left decubitus position. No statistically significant changes were recorded in IOP (P=0.50) or MOPP (P=0.17) throughout the different stages of vaginal labor in this study. Conclusions: Vaginal delivery under epidural anesthesia is unlikely to cause significant damage to the optic nerve in healthy women.

Survey of intravitreal injection techniques among retina specialists in Israel.

Purpose The purpose of this study was to describe antivascular endothelial growth factor intravitreal injection techniques of retinal specialists in order to establish a cornerstone for future practice guidelines. Methods All members of the Israeli Retina Society were contacted by email to complete an anonymous, 19-question, Internet-based survey regarding their intravitreal injection techniques. Results Overall, 66% (52/79) completed the survey. Most (98%) do not instruct patients to discontinue anticoagulant therapy and 92% prescribe treatment for patients in the waiting room. Three quarters wear sterile gloves and prepare the patient in the supine position. A majority (71%) use sterile surgical draping. All respondents apply topical analgesics and a majority (69%) measure the distance from the limbus to the injection site. A minority (21%) displace the conjunctiva prior to injection. A majority of the survey participants use a 30-gauge needle and the most common quadrant for injection is superotemporal (33%). Less than half routinely assess postinjection optic nerve perfusion (44%). A majority (92%) apply prophylactic antibiotics immediately after the injection. Conclusion The majority of retina specialists perform intravitreal injections similarly. However, a relatively large minority performs this procedure differently. Due to the extremely low percentage of complications, it seems as though such differences do not increase the risk. However, more evidence-based medicine, a cornerstone for practice guidelines, is required in order to identify the intravitreal injection techniques that combine safety and efficacy while causing as little discomfort to the patients as possible.

Laser-assisted techniques for penetrating and nonpenetrating glaucoma surgery.

The use of lasers is slowly pervading all sub-specialties of Ophthalmology, especially glaucoma, and lasers are slowly replacing many glaucoma surgeries. Conventional trabeculectomy has so far remained the gold standard for glaucoma surgery, and efforts are being made to develop a new surgical approach to overcome the limited success rate and safety issues of the traditional trabeculectomy. There is a great interest in using lasers to create an ab interno and ab externo penetrating and nonpenetrating filtering surgery. Theoretically, laser-assisted surgery offers the potential advantage of improved accuracy, repeatability, and safety, although the main drawback of using lasers for this purpose is the potential collateral damage induced by the scattered energy. Collateral thermal damage adjacent to the sclerostomy site is believed to be detrimental to the long-term success of the filtering procedure. Employing a laser with high water absorbance and low light scattering reduces the extent of collateral thermal damage and improves the long-term surgical success. An increasing number of different radiation sources were examined for penetrating and nonpenetrating glaucoma surgery with various success rates.

The effect of gatifloxacin 0.3% or moxifloxacin 0.5% on corneal healing, ocular tolerability and toxicity following pterygium surgery

Abstract Purpose: To compare the rate of corneal epithelial healing and ocular tolerability following pterygium surgery between gatifloxacin and moxifloxacin. Methods: In this double masked, prospective, controlled study 40 patients were randomized to receive prophylactic topical gatifloxacin 0.3% or moxifloxacin 0.5% following pterygium surgery. Patients were examined on days 1, 3, 7 and 21 post-operatively or until complete corneal epithelial healing. The primary outcome measure was the area of corneal epithelial defect during the post-operative period. Patients graded post-operative ocular pain, foreign body sensation, tearing, general burning sensation and burning sensation post-antibiotic drops instillation on a scale of 1–5. Conjunctival hyperemia and superficial punctate keratopathy (SPK) were measured on a scale of 0–3. Results: No significant differences between groups were found in terms of corneal epithelial defect percentage over time (p = 0.989) and there was no significant difference between groups on each of the post-operative days. No significant differences were noted in terms of post-operative ocular pain, foreign body sensation, tearing, general burning sensation, burning sensation post-antibiotic drops instillation, conjunctival hyperemia and SPK. Conclusions: Gatifloxacin and moxifloxacin showed equivalent results in terms of corneal epithelial healing and ocular tolerability following pterygium surgery. This study suggests that there was no apparent added epithelial toxicity due to the presence of benzalkonium chloride in the gatifloxacin preparation when compared to moxifloxacin.

Trans-scleral selective laser trabeculoplasty (SLT) without a gonioscopy lens(Conference Presentation)

Developing a one-second automatic glaucoma treatment using trans-scleral laser trabeculoplasty (LTP) without a gonioscopy lens Purpose: Developing an LTP device for delivering multiple simultaneous trans-scleral applications of low energy laser irradiation to the trabecular meshwork (TM) for reducing Intraocular Pressure (IOP). Methods: Concept proof: A randomized, masked, controlled one was performed on open angle glaucoma patients. The control group underwent conventional SLT (100 laser spots through a gonioscope for 360 degrees directly on the TM). The trial group underwent irradiation by the same laser at the same irradiation parameters on the sclera overlying the TM. Topical glaucoma therapy was not changed during the 12 months trial. Feasibility trial: Using optimized laser parameters, 60 discrete applications were administered on similar locations of patients’ sclera. Results: Concept proof: Trans-scleral applications: (N=15), IOP decrease from 20.21 mmHg before treatment to 16.00 (27.1%) at one year. The corresponding numbers for the control group (n=15), were 21.14 mmHg and 14.30 (23.4%). There was no statistical difference between the two groups in IOP reduction. The complications rate was significantly higher in the control group. Trial 2: IOP was reduced from an of 25.3 mmHg to 19.3 (23.7%) in the 11 patients. Conclusions: Laser coherency, lost in tissue transmission, is not required for the therapeutic effect. The new method will possibly enable treatment of angle closure glaucoma as well as simultaneous applications of all laser spots to the sclera. When used conjointly with target acquisition, will make feasible an automatic glaucoma treatment in less than one second.