Philipp C. Jacobi

Primary phacoemulsification and intraocular lens implantation for acute angle-closure Glaucoma

OBJECTIVE To evaluate the safety and efficacy of primary phacoemulsification and intraocular lens implantation (PPI) for acute angle-closure glaucoma (ACG). STUDY DESIGN Prospective, nonrandomized comparative trial. PARTICIPANTS AND INTERVENTION Forty-three eyes of 43 patients with acute ACG and uncontrolled intraocular pressure (IOP) were treated by PPI. Thirty-two eyes of 32 patients treated by conventional surgical iridectomy (CSI) constituted the control group. MAIN OUTCOME MEASURES Postoperative visual acuity, IOP, number of antiglaucoma medications, complications, and secondary surgical interventions, if any, required for IOP control. RESULTS Glaucoma control was achieved in 31 eyes (72%) in the PPI group and in 11 (35%) in the CSI group (P = 0.01). Mean preoperative IOP was 40.5 +/- 7.6 mmHg (standard deviation) and 39.7 +/- 7.8 mmHg, respectively (P = 0.46). Mean postoperative IOP was 17.8 +/- 3.4 mmHg (PPI group) and 20.1 +/- 4.2 mmHg (CSI group) after a mean follow-up of 10.2 +/- 3.4 months (P = 0.03). Postoperatively, the mean number of ocular hypotensive medications was 0.18 +/- 0.45 (PPI group) and 0.45 +/- 0.62 (CSI group) (P = 0.0001). Relative increase in postoperative best-corrected visual acuity (logarithm of the minimum angle of resolution) was 0.52 +/- 0.29 (PPI group) and 0.19 +/- 0.21 (CSI group), respectively (P = 0.0001). Additional surgery was necessary in 5 eyes (11.5%) in the PPI group and in 20 eyes (63%) in the CSI group (P = 0.01). Intraoperative and postoperative complications were few and manageable. CONCLUSIONS CSI in patients with acute ACG was effective in reducing IOP initially but was associated with multiple surgical reinterventions. Conversely, primary PPI turned out to be safe and effective in reducing IOP and improving visual acuity. These results affirm that lens extraction may be considered the better procedure in uncontrolled ACG when faced with options of CSI or PPI.

Primary viscocanalostomy versus trabeculectomy in white patients with open-angle glaucoma: A randomized clinical trial

PURPOSE To compare viscocanalostomy, a nonpenetrating procedure for glaucoma treatment, with trabeculectomy. DESIGN Randomized controlled trial. PARTICIPANTS Twenty white subjects (20 eyes) with open-angle glaucoma with no history of surgery were enrolled. METHODS Ten subjects were randomly assigned to viscocanalostomy according to Stegmanns technique and 10 subjects to a modified Cairns trabeculectomy. A complete ophthalmologic examination was performed the day before surgery and postoperatively. Further visits were scheduled monthly for 6 to 8 months after surgery. MAIN OUTCOME MEASURES Success was defined as intraocular pressure (IOP) between 7 and 20 mmHg, with no medication. RESULTS After a mean follow-up of 6 months (range, 6-8 months), success was obtained in 5 of 10 cases in the trabeculectomy group and in no case in the viscocanalostomy group. With Kaplan-Meiers method, subjects with viscocanalostomy showed shorter postoperative IOP-reduction periods than subjects undergoing trabeculectomy. CONCLUSIONS According to the results of this short-term study, trabeculectomy was more effective than viscocanalostomy in lowering IOP in glaucomatous eyes of white patients.

Prognosis of primary ab externo surgery for primary congenital glaucoma

BACKGROUND The strategy of pressure reducing surgery in primary congenital glaucoma has changed over the last decade. Ab externo filtering procedures—for example, trabeculectomy or trabeculotomy combined with trabeculectomy, have now been accepted even as primary intervention. METHODS The authors reviewed 61 eyes in 35 consecutive patients with primary congenital glaucoma, who underwent different types of initial ab externo surgery between 1988 and 1996 (median follow up 36 months) to determine the efficacy of different surgical techniques and the influence of various risk factors. RESULTS Trabeculotomy was performed in 17 eyes (27.9%), trabeculotomy with trabeculectomy in 15 eyes (24.6%), and trabeculectomy in 29 eyes (47.5%). Regarding age, preoperative intraocular pressure, corneal diameter, ocular axial length, and incidence of corneal haze the subgroups were comparable. Success rates of trabeculotomy, trabeculectomy, and a combined procedure did not significantly differ when assessed by life table analysis. Patient age under 3 months (p=0.014) and an ocular axial length of 24 mm or more (p=0.016) proved to be major risk factors for primary ab externo surgery failure. A second operation was necessary in 20 of 61 eyes (32.8%) during follow up. CONCLUSION Prognosis of primary ab externo glaucoma surgery in primary congenital glaucoma seems to be governed more by the individual course and severity of the disease than by modification of surgical techniques.

Bimanual trabecular aspiration in pseudoexfoliation glaucoma: An alternative in nonfiltering glaucoma surgery

OBJECTIVE The primary cause of intraocular pressure (IOP) elevation in pseudoexfoliation glaucoma is obstruction of the intertrabecular spaces by exfoliation material. Previously, the authors reported on a new concept of nonfiltering glaucoma surgery-trabecular aspiration-designed to increase trabecular outflow in pseudoexfoliation glaucoma. In the current study, a description of the modified instrument, its refined surgical technique, and long-term clinical results will be given to substantiate the efficacy of trabecular aspiration in the surgical management of pseudoexfoliation glaucoma. STUDY DESIGN The study design was a prospective and nonrandomized study. PARTICIPANTS A total of 68 eyes of 54 patients suffering from medically uncontrolled pseudoexfoliation glaucoma were treated by bimanual trabecular aspiration. Thirty-four eyes of 28 pseudoexfoliative patients treated by standard trabeculectomy constituted the control group. INTERVENTION Trabecular debris and pigment were cleared with a suction force of 100 to 200 mmHg under light tissue-instrument contact using a modified intraocular aspiration probe. The aspiration cannula is 400 microm in diameter and horizontally angulated at 45 degrees. Irrigation of the anterior chamber was performed via a separate irrigation cannula. MAIN OUTCOME MEASURES The IOP and number of medications before and after surgery were measured. RESULTS In 42 eyes of 36 patients, trabecular aspiration was performed in combination with cataract extraction and lens implantation. The IOP dropped from 32.4 +/- 7.2 mmHg (range, 23-52 mmHg) under maximal tolerated medical therapy before surgery to 18.7 +/- 1.7 mmHg (range, 16-23 mmHg) at 2 years after surgery, with 54% of patients being controlled without medication. In 22 eyes of 19 patients, trabecular aspiration was performed as primary surgical intervention. The IOP dropped from 31.3 +/- 7.1 mmHg (range, 23-42 mmHg) before surgery to 16.8 +/- 3.4 mmHg (range, 12-23 mmHg) at 18 months after surgery, with 45% of patients not taking medication. CONCLUSIONS Bimanual trabecular aspiration is safe and efficacious in decreasing IOP both with and without cataract extraction in pseudoexfoliation glaucoma. However, there seems to be a slight regression in effect over time attributed to undisturbed liberation of exfoliative debris. Argon-laser trabeculoplasty before trabecular aspiration reduces the IOP-lowering effect of this procedure. A prospective, randomized, multicenter study is warranted to finally assess the potential of trabecular aspiration in pseudoexfoliation glaucoma.

Goniocurettage for removing trabecular meshwork: clinical results of a new surgical technique in advanced chronic open-angle glaucoma

PURPOSE To elucidate the long-term outcome of goniocurettage as a new technique in trabecular microsurgery for advanced open-angle glaucoma. METHODS In a prospective, nonrandomized clinical trial, 25 eyes of 25 patients with a mean age +/- SD of 72.7+/-10.1 years (range, 50 to 89 years) with uncontrolled chronic open-angle glaucoma that had undergone failed filtering procedures were treated by goniocurettage. Trabecular tissue was scraped away from the chamber angle by means of an instrument similar to a microchalazion curette (diameter, 300 microm). RESULTS Before surgery, intraocular pressure ranged from 29 to 48 mm Hg (mean +/- SD, 34.7+/-7.1 mm Hg), and mean number of antiglaucoma medications was 2.2+/-0.56. Follow-up averaged (+/-SD) 32.6+/-8.1 months (range, 30 to 45 months). Overall success, defined as postoperative intraocular pressure of 19 mm Hg or less with one pressure-reducing agent, was attained in 15 eyes (60%), with five eyes (20%) being controlled without medication. Considering all successfully treated patients, the mean intraocular pressure was 17.7+/-3.1 mm Hg (range, 10 to 19 mm Hg) at the final visit. Mean intraocular pressure reduction was 17.1+/-7.1 mm Hg in these eyes, representing a net decrease from baseline of 49%. Number of antiglaucoma medications dropped to 0.63+/-0.29. Complications included localized Descemet membrane detachment in five eyes (20%) and moderate anterior chamber bleeding in four eyes (16%). CONCLUSIONS This new surgical technique can effectively control intraocular pressure for long periods of time in patients with open-angle glaucoma and a history of failed filtering procedures. Goniocurettage may be a suitable alternative to surgical treatment of glaucoma patients with excessive conjunctival scarification.

Morphological variability of the trabecular meshwork in glaucoma patients: implications for non-perforating glaucoma surgery

BACKGROUND/AIMS Morphological variability of the trabecular meshwork could be of considerable importance for the proper intraoperative outcome of non-perforating antiglaucomatous surgery, such as deep sclerectomy and viscocanalostomy. The aim of this study was therefore to assess qualitative and quantitative characteristics of the trabecular meshwork in glaucoma patients undergoing trabeculectomy. METHODS Trabeculectomy specimens from 177 glaucoma patients were prepared for light microscopy; 100 specimens were found to be suitable for qualitative assessment and quantitative computerised image analysis; measurements were taken of the meridional diameter of Schlemms canal as well as the thickness of the trabecular meshwork at different positions. RESULTS The mean meridional diameter of Schlemms canal was 290 μm with the smallest values in the young patients with infantile and secondary glaucomas. the thickness of the trabecular meshwork ranged between 50–70 μm in the anterior region and between 100–130 μm for the posterior portion. The thickness of the anterior meshwork significantly decreased with age. The pigmentation of excised trabecular meshwork was found to be weak or even lacking in 68 patients. In 20 glaucoma patients the uveal meshwork was covered by an endothelial layer. CONCLUSIONS From the morphological point of view the risk of inadvertent perforation during deep sclerectomy in older, white glaucoma patients should be taken into account even by an experienced surgeon, because the anterior meshwork in these cases is very thin and trabecular pigmentation that can be used as a topographic landmark is often lacking. The functional success of non-perforating glaucoma surgery in many patients may be limited by endothelial covering of the trabecular meshwork.

Ultrasound biomicroscopy and its value in predicting the long term outcome of viscocanalostomy.

Aims: To examine whether the early postoperative morphology at the site of sclerectomy, as visualised by ultrasound biomicroscopy (UBM), is an indicator of the mechanisms that lower intraocular pressure (IOP) and/or predictors of the long term outcome of viscocanalostomy. Methods: 15 eyes of 14 patients with medically uncontrolled open angle glaucoma and no history of surgery underwent viscocanalostomy according to Stegmann’s technique. Ultrasound biomicroscopy was performed during the first month after surgery. The following parameters were assessed: dimensions of the intrascleral “lake,” presence of a filtering bleb, presence of a subconjunctival cavity or a suprachoroidal hypoechoic area, and the thickness of the residual trabeculocorneal membrane. A complete ophthalmological examination was performed the day before and the day after surgery. Follow up visits were scheduled 1 week, 4 weeks, 6 months, and 12 months after surgery. Results: At 1 year successful control of IOP (<20 mm Hg) was achieved without further manipulation or medication in six of 15 eyes. The size of the intrascleral “lake” (average 0.62 mm3) did not correlate with later IOP; however, a visible route under the scleral flap and accidental perforation of the trabeculocorneal membrane were associated with long term lowering of IOP. Normal thickness of the trabeculocorneal membrane (0.10–0.15 mm) was indicative of IOP control with and without medication. When UBM showed an early collapse of the intrascleral cavity, control of IOP was not achieved. Other UBM findings did not predict long term function. Conclusion: In accordance with previous studies, the authors found that UBM examination is a useful method to evaluate outflow mechanisms after glaucoma surgery. This study shows that UBM imaging of external filtration during the early postoperative period can be used to predict the success of viscocanalostomy. However, to establish conclusively what parameters of UBM predict successful viscocanalostomy a larger number of patients must be studied.

Multifocal intraocular lens implantation in pediatric cataract surgery

OBJECTIVE To evaluate implantation of a zonal-progressive multifocal intraocular lens (IOL) in children. STUDY DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS Thirty-five eyes of 26 pediatric patients aged 2 to 14 years with multifocal IOL implantation at one institution with more than 1 year of follow-up. INTERVENTIONS Standard surgical procedure comprised an anterior capsulorrhexis, lens material aspiration via two side-port incisions, temporal tunnel incision, and multifocal IOL (SA40-N; Allergan, Irvine, CA) implantation in all eyes. In 24 eyes (68%), a 5-mm posterior capsulorrhexis was created with forceps, followed by an anterior vitrectomy in 19 of those eyes (54%). RESULTS Twenty-six patients (35 eyes) had an average follow-up of 27.4 +/- 12.7 months (range, 12-58 months). At last follow-up, best-corrected distance visual acuity improved significantly (P = 0.001), 71% of eyes with a visual acuity of 20/40 or better and 31% of eyes with a visual acuity of 20/25 or better. In the 9 bilateral cases, spectacle dependency was moderate, with only 2 children (22%) reporting the permanent use of an additional near correction. The remaining children were either using distance-correction only (4 patients; 44%) or no glasses at all (3 patients; 33%). Stereopsis also improved significantly after multifocal IOL implantation (P = 0.01). Sixteen eyes (46%) experienced obscuration of the entrance pupil that required intervention, with 10 requiring a second intraocular surgery. Four eyes required an anterior membranectomy for persistent fibrinous membrane. Intraocular lens decentration requiring surgical intervention developed in six eyes. CONCLUSIONS Multifocal IOL implantation is a viable alternative to monofocal pseudophakia in this age group.

Multifocal Intraocular Lens Implantation in Prepresbyopic Patients with Unilateral Cataract

OBJECTIVE To evaluate the benefits of implantation of a zonal-progressive multifocal intraocular lens (IOL) in prepresbyopic patients with unilateral cataract. STUDY DESIGN Prospective, nonrandomized, comparative trial. PARTICIPANTS Ninety-five eyes of 95 prepresbyopic patients aged between 14 and 40 years with either multifocal or monofocal IOL implantation at two institutions and with more than 6 months follow-up. INTERVENTIONS Temporal clear corneal phacoemulsification and foldable IOL implantation was performed in all eyes. In 54 patients, a zonal-progressive optic multifocal IOL (Array SA40-N, Allergan, Irvine, CA) was implanted, whereas 41 patients received a monofocal IOL and served as controls. RESULTS Preoperative patient demographics, mean postoperative spherical equivalent, astigmatism, and uncorrected and best-corrected distance visual acuities were similar in the two groups. Patients with a multifocal IOL achieved a significantly better uncorrected near visual acuity than patients with monofocal IOL (0.18 versus 0.37; P = 0.0001). With distance correction only, mean near visual acuity was 0.17 versus 0.43 (P = 0.0001). Best-corrected near visual acuity was 0.11 for both groups (P = 0.91), with +1.43 diopters (D) for the multifocal group and +2.35 D for the monofocal group (P = 0.0001). Spectacle dependency differed significantly between the two groups, with 21 patients (51%) of the monofocal group commonly requiring an additional plus add for near tasks compared with 5 patients (9%) in the multifocal group (P = 0.001). Stereopsis was superior in the multifocal group (P < 0.001), with 42 (77%) and 33 (61%) patients with a multifocal IOL responding positively to the Lang and Titmus tests, respectively. In the monofocal group; only 20 (48%) and 9 (22%) patients gave correct answers. CONCLUSIONS Multifocal IOL implantation is a viable alternative to monofocal pseudophakia in prepresbyopic patients with unilateral cataract.

Adjunctive mitomycin C in primary trabeculectomy in young adults: a long-term study of case-matched young patients

Abstract · Objective: The purpose of this study was to determine the efficacy of initial mitomycin C (MMC)-augmented trabeculectomy for uncomplicated glaucoma in young patients. · Methods: A retrospective chart review was performed on all glaucoma patients aged between 15 and 40 years without previous surgery that underwent initial trabeculectomy with MMC between 1988 and 1995 at the University Eye Hospital of Cologne. Success (survival) was defined as an intraocular pressure (IOP) of 21 mmHg or lower, with (qualified success) or without (complete success) glaucoma medications. The results were compared with a case-matched control group that did not receive antiproliferative therapy. · Results: Eleven eyes of 11 patients fulfilled the inclusion criteria of initial MMC-augmented trabeculectomy. Using cumulative life-table analysis the success rate was 91% at 1 year and 73% at 5 years for the control group. For the MMC group the success rate was 91% at 1 year and 5 years, respectively. At final visit, mean IOP was significantly (P<0.001) lower for the MMC group (13.3±3.9 mmHg) than for controls (18.0±1.3 mmHg). Significant differences were also found in the complication rate: complications associated with excessive aqueous overfiltration, such as shallow anterior chamber (36%), choroidal detachment (45%) and persistent hypotony (27%), featured particularly in the MMC group. Conversely, scarring of the filtering bleb (18%) and Tenon’s cysts (18%) were observed exclusively in control eyes. · Conclusion: The present results suggest that initial MMC trabeculectomy for uncomplicated glaucoma in young patients significantly reduces IOP and number of adjunctive medications, postoperatively, albeit at the price of a high incidence of hypotony.