Peter Shah

Trabeculectomy in the 21st century: a multicenter analysis.

OBJECTIVE To evaluate the efficacy and safety of current trabeculectomy surgery in the United Kingdom. DESIGN Cross-sectional, multicenter, retrospective follow-up. PARTICIPANTS A total of 428 eyes of 395 patients. METHODS Consecutive trabeculectomy cases with open-angle glaucoma and no previous incisional glaucoma surgery from 9 glaucoma units were evaluated retrospectively. Follow-up was a minimum of 2 years. MAIN OUTCOME MEASURES Surgical success, intraocular pressure (IOP), visual acuity, complications, and interventions. Success was stratified according to IOP, use of hypotensive medications, bleb needling, and resuturing/revision for hypotony. Reoperation for glaucoma and loss of perception of light were classified as failures. RESULTS Antifibrotics were used in 400 cases (93%): mitomycin C (MMC) in 271 (63%), 5-fluorouracil (5-FU) in 129 (30%), and no antifibrotic in 28 (7%). At 2 years, IOP (mean ± standard deviation) was 12.4 ± 4 mmHg, and 342 patients (80%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP without IOP-lowering medication, whereas 374 patients (87%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP overall. An IOP ≤18 mmHg and 20% reduction of preoperative IOP were achieved by 337 trabeculectomies (78%) without IOP-lowering treatment and by 367 trabeculectomies (86%) including hypotensive medication. Postoperative treatments included suture manipulation in 184 patients (43%), resuturing or revision for hypotony in 30 patients (7%), bleb needling in 71 patients (17%), and cataract extraction in 111 of 363 patients (31%). Subconjunctival 5-FU injection was performed postoperatively in 119 patients (28%). Visual loss of >2 Snellen lines occurred in 24 of 428 patients (5.6%). A total of 31 of the 428 patients (7.2%) had late-onset hypotony (IOP <6 mmHg after 6 months). In 3 of these, visual acuity decreased by >2 Snellen lines. Bleb leaks were observed in 59 cases (14%), 56 (95%) of which occurred within 3 months. Two patients developed blebitis. Bleb-related endophthalmitis developed in 1 patient within 1 month postoperatively and in 1 patient at 3 years. There was an endophthalmitis associated with subsequent cataract surgery. CONCLUSIONS This survey shows that good trabeculectomy outcomes with low rates of surgical complications can be achieved, but intensive proactive postoperative care is required.

The epidemiology and etiology of pediatric ocular trauma.

Eighteen million people worldwide have uniocular blindness from traumatic injury. Injuries occur disproportionally commonly in childhood. Every year a quarter of a million children present with serious ocular trauma. For the vast majority the injury is preventable. We review the international literature that identifies high-risk circumstances.

Pig eye trabeculectomy-a wet-lab teaching model.

PurposeA teaching model for trabeculectomy is described using pig eyes prepared in formalin.MethodThe model enables trainee surgeons to practice various aspects of tissue handling required for successful trabeculectomy including the construction of a fornix-based conjunctival flap, scleral flap with buried releasable sutures, and water-tight conjunctival closure.ResultsExposure to the necessary skills required to perform trabeculectomy surgery can be improved by the use of wet laboratory practice.ConclusionsTrabeculectomy surgery experience is becoming more limited as fewer procedures are being performed due to the efficacy of recent medications. Wet laboratories will become an increasingly important aspect of a comprehensive ophthalmology training programme.

Visual Outcomes after Blunt Ocular Trauma

OBJECTIVE To describe the prognosis and retinal location in patients presenting with acute traumatic maculopathy and extramacular retinal injuries. DESIGN Retrospective, noninterventional case series. PARTICIPANTS AND CONTROLS All patients presenting with commotio retinae or sclopetaria retinae to the Birmingham Midland Eye Centre Eye Casualty from October 1, 2007, to February 23, 2011. METHODS The notes of all patients presenting with ocular trauma in the specified time period were examined to identify suitable patients and demographic and injury data were extracted. MAIN OUTCOME MEASURES Outcome was assessed by visual acuity (VA). RESULTS For macular commotio retinae, 53 patients were identified, of whom 34 had adequate follow-up to determine final VA. The median presenting VA was 20/40; 25 patients (74%) recovered to ≥ 20/30. The median extent of visual recovery was 0.18 logarithm of the minimum angle of resolution (logMAR). For extramacular commotio retinae, 117 patients were identified, of whom 58 had adequate follow-up to determine final VA. The median presenting VA retinae was 20/30; 55 patients (95%) recovered to ≥ 20/30. The median extent of visual recovery was logMAR 0.076. There was 1 case of extramacular sclopetaria retinae. The 3 most common retinal locations of extramacular commotio retinae, in order of frequency, were inferotemporal (37%), temporal (17%), and superotemporal (17%); <5% of cases were in a nasal location. CONCLUSIONS This is the first report on the prognosis of acute traumatic maculopathy and extramacular commotio retinae. After macular injury, 26% of patients were left with a VA of ≤ 20/30, although the proportion with visual impairment is higher than this because (1) a deterioration from 20/15 to 20/30 is significant to many patients; and (2) additional patients are visually impaired by symptomatic paracentral visual field defects despite a normal VA. Reduced VA after extramacular commotio retinae may represent occult macular injury or previously undiagnosed visual impairment in the affected eye. Extramacular commotio occurs mostly in an inferotemporal to temporal location, consistent with direct trauma to the sclera overlying the injured retina. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Social media use by patients with glaucoma: what can we learn?

Much health‐related information is available on the internet but its quality is known to be variable. This research aimed to analyse the ophthalmic content of social media platforms which has yet to be formally assessed.

Acute transient corneal endothelial changes following selective laser trabeculoplasty

To report for the first time acute transient corneal endothelial changes following selective laser trabeculoplasty.

The role of social deprivation in severe neovascular age-related macular degeneration

Background/aims Advances in therapy have improved outcomes for patients with neovascular age-related macular degeneration (nAMD). Prompt access to treatment is a priority and may be used as a key performance indicator. In this study, we investigate how social deprivation may impact on access to services, treatment and visual impairment registration. Methods Patients were identified retrospectively through the Certificate of Visual Impairment system for the University Hospitals Birmingham Medical Retina service. The Index of Multiple Deprivation (IMD) 2007 score was calculated for each patient. The impact of deprivation, age, gender and ethnicity on key stages in the care pathway was assessed. Results 120 patients were identified. Patients with greater social deprivation were under-represented, had worse visual acuity at first presentation (correlation of the better-seeing eye with IMD 0.225 (p=0.013)) and had sight-impairment registration earlier (correlation −0.246; p=0.007). Deprivation did not affect time to first appointment, and was not associated with a higher rate of non-attendance. Conclusions The late presentation and under-representation of patients with greater social deprivation is a serious concern. Our study strongly suggests that this vulnerable group is encountering barriers in accessing treatment in nAMD, and that these occur prior to entry into the Hospital Eye Service.

ReGAE 1 : using the Shah–Cross model as an orientating framework in African-Caribbean glaucoma research

The inter-relationship between health-care research, policy and service development is convoluted and difficult to articulate. This paper describes a framework for planning research into a range of ophthalmic conditions differentially associated with specific ethnic groups. It discusses the utility of the ‘Shah–Cross Model’ in mapping development of a glaucoma research project, and communicating its implications for local eye-care policy and ophthalmic services directed towards detection and management of primary open-angle glaucoma in the African-Caribbean population in the UK.

Iridoschisis associated with nanophthalmos and bullous keratopathy

Iridoschisis is a rare condition in which the iris stroma splits into anterior and posterior layers. Iridoschisis is associated with anterior segment abnormalities including keratoconus, lens subluxation and angle-closure glaucoma. We describe the first case in which iridoschisis has occurred in association with nanophthalmos. We also report the rare complication of irido-corneal touch and subsequent corneal decompensation. Nanophthalmos and irido-corneal touch are sight-threatening associations of iridoschisis and should be excluded in all patients with this rare condition.

ReGAE 9: baseline factors for success following augmented trabeculectomy with mitomycin C in African-Caribbean patients

Background:  To identify the baseline factors influencing success following trabeculectomy with mitomycin C in a case series of African‐Caribbean patients.