Rahamim Avisar

Effect of Coffee Consumption on Intraocular Pressure

BACKGROUND: Many ophthalmologists instruct patients with glaucoma to avoid coffee, although data supporting this practice are insufficient. OBJECTIVE: To estimate the effect of drinking coffee on intraocular pressure (IOP). METHODS: In this crossover study, the effect of the consumption of regular (180 mg caffeine in 200 mL beverage) and decaffeinated coffee (3.6 mg caffeine in 200 mL beverage) was compared in patients with normotensive glaucoma (n = 6) or ocular hypertension (n = 22). IOP was monitored in both groups at 30, 60, and 90 minutes after coffee ingestion. RESULTS: In patients with normotensive glaucoma who drank regular coffee, the mean ± SD changes in IOP at 30, 60, and 90 minutes were 0.9 ± 0.5, 3.6 ± 1.1, and 2.3 ± 0.66 mm Hg, respectively; in those who drank decaffeinated coffee, they were 0.75 ± 0.36, 0.70 ± 0.4, and 0.4 ± 0.6 mm Hg, respectively. The corresponding values in patients with ocular hypertension were as follows: after regular coffee, 1.1 ± 0.7, 3.4 ± 1.0, and 3.0 ± 2.7 mm Hg; and after decaffeinated coffee, 0.6 ± 0.4, 0.9 ± 0.2, and 0.5 ± 0.5 mm Hg. The difference in the change in IOP from baseline after ingestion of regular versus decaffeinated coffee was statistically significant in each group at 60 and 90 minutes. Subjects who drank regular coffee demonstrated a greater elevation in IOP; this elevation may be clinically significant. CONCLUSIONS: Intake of caffeinated beverage (≥180 mg caffeine) may not be recommended for patients with normotensive glaucoma or ocular hypertension.

Pterygium surgery: fibrin glue versus Vicryl sutures for conjunctival closure.

Purpose: To compare the short-term results of conjunctival closure in pterygium surgery using fibrin adhesive versus Vicryl sutures with respect to operative time, postoperative ocular signs and symptoms, and overall patient satisfaction. Methods: A comparative prospective randomized clinical trial was performed in 65 patients (65 eyes) with primary nasal pterygium. Surgery in all patients consisted of the bare sclera technique combined with intraoperative mitomycin C. Patients were randomized to undergo conjunctival closure with a fibrin tissue adhesive (Quixil; n = 39) or 8-0 Vicryl absorbable interrupted sutures (n = 26). Clinical assessment was performed on days 1, 3, 10, and 21 after surgery. Patients completed a questionnaire at each follow-up visit, grading pain, discomfort, and satisfaction with the procedure. The groups were compared for operative time, ocular signs and symptoms, and overall satisfaction. Results: Average operative time was 16 minutes (range, 14-16 minutes) in the fibrin glue group and 20 minutes (range, 20-29 minutes) in the Vicryl suture group (P < 0.05). Significantly less pain, photophobia, foreign body sensation, irritation, epiphora, itching, local hyperemia, conjunctival chemosis, and dry eye were noted in the subjects treated with glue than in controls (P < 0.05). There were no complications during the 3-week follow-up period in the glue-treated patients. One of the patients in the suture group had a medically treatable corneal delle. Conclusion: The use of fibrin glue in pterygium surgery significantly reduces operative time and patient symptoms, pain, and discomfort. A longer follow-up is needed to evaluate the influence of fibrin glue on rate of recurrence and long-term complications.

Fibrin Glue versus Vicryl Sutures for Primary Conjunctival Closure in Pterygium Surgery: Long-Term Results

Purpose: To compare the long-term results of conjunctival closure with fibrin adhesive or Vicryl sutures in pterygium surgery. Methods: The study was performed in 81 patients (81 eyes) with primary nasal pterygium. Surgery in all patients consisted of the bare sclera technique combined with intraoperative administration of mitomycin C 0.02%. Patients were randomized to undergo conjunctival closure with a fibrin adhesive (Quixil) (n = 42) or Vicryl sutures (n = 39). Clinical assessment was performed on postoperative days 1, 3, 10, and 21 and thereafter at 3, 6, and 12 months. All patients completed a questionnaire at each follow-up visit grading pain, discomfort, and satisfaction with the procedure. The groups were compared for operative time, ocular signs and symptoms, overall satisfaction, and recurrence rate. Results: Average operative time was 16 min in the fibrin-glue group and 28 minutes in the Vicryl-suture group (p < 0.05). Significantly less pain and discomfort were noted in the subjects treated with glue than in controls (p < 0.05). Satisfaction was significantly higher in the study group (p < 0.04). There were no complications during follow-up period in the glue-treated patients; one patient in the suture group had a medically treatable corneal dellen. At the end of follow-up, recurrent pterygium developed in five (11.9%) eyes of the fibrin-glue group and in three (7.7%) eyes of the Vicryl-suture group (p < 0.05). Conclusions: The use of fibrin glue in pterygium surgery significantly reduces operative time and patient pain compared with suturing. However, it may be associated with a higher recurrence rate.

Fibrin Glue as a Suture Substitute: Histological Evaluation of Trabeculectomy in Rabbit Eyes

Purpose: To describe the outcome of the use of fibrin adhesive (Quixil) in penetrating trabeculectomy in a rabbit model. Methods: Fibrin adhesive was used experimentally to attach the conjunctiva and the scleral flap in two groups of 17 New Zealand albino adult rabbits (34 eyes). In the first experiment (20 eyes), the fibrin adhesive was used to reattach the tissue after conjunctival peritomy and scleral flap only in 14 eyes (experiment I). In 6 eyes (controls), the conjunctiva was attached with nylon sutures. In the second experiment (14 eyes), the fibrin adhesive was used after conjunctival peritomy, scleral flap, and penetrating trabeculectomy in 8 eyes (experiment II). In a control group of 6 eyes, nylon sutures were used to attach the scleral flap and the conjunctiva after penetrating trabeculectomy. Biomicroscopy and histopathological examinations were performed on postoperative days 1, 3, 7, 14, 21, and 30. Intraocular pressure was measured before and after surgery in the second experiment. Main outcome measures are histological presence of adhesive in the tissue, degree of capillary congestion, inflammatory reaction, collagen density [scar formation] and clinical (IOP measurements before and after surgery, conjunctival chemosis, anterior chamber reaction, presence of filtering bleb and wound leakage). Results: In experiments I and II, the adhesive was well identified histologically in the tissue as an amorphic eosinophilic substance for up to day 3 and nearly disappeared by day 7. An acute inflammatory reaction was noted for up to 14 days, which converted to chronic inflammation with collagen deposits and scar formation by day 30. Similar inflammatory reaction was observed in the control group. The adhesive had no adverse effects on ocular tissue compared with sutures. One eye in experiment II demonstrated wound dehiscence. Intraocular pressure dropped from 17.35 mmHg preoperatively to 8.28 mmHg on postoperative day 1 in experiment II, and from 17.2 mmHg to 11.5 mmHg in the controls. No significant change in intraocular pressure was noted in experiment I. Conclusions: The fibrin adhesive had no adverse effects on ocular tissue compared with sutures. It might serve as an effective substitute for conjunctival and scleral wound closure in trabeculectomy surgery.

Lysozyme Content of Tears in Patients With SjÖGren's Syndrome and Rheumatoid Arthritis

In 37 patients and 143 control patients we estimated tear fluid lysozyme content by the Micrococcus lysodeikticus agar diffusion assay. We found no correlation between the titer of lysozyme in tear fluid and the rate of tear flow. Decrease in lysozyme production was found to be a sensitive indicator of the involvement of the lacrimal system in Sjögrens syndrome.

Effect of mitomycin C in pterygium surgery on corneal endothelium.

Purpose: To evaluate changes in endothelial cell count after pterygium surgery with 5-minute application of mitomycin C (MMC) 0.02%. Methods: The study participants included 24 consecutive patients (17 men and 7 women) who underwent pterygium surgery with MMC at a major tertiary center between September and October 2005. The bare sclera technique was used in all cases. After excision of the head and neck of the pterygium, a surgical sponge soaked with MMC 0.02% was placed on the exposed sclera for 5 minutes, with the conjunctival layer draped over the sponge. Thereafter, the sclera was irrigated with balanced salt solution, and surgery was completed. Endothelial images were acquired at the center of the cornea with a specular microscope (average of 3 measurements) before surgery and at 1 week, 1 month, and 3 months after surgery. Results: Mean preoperative endothelial cell count was 2254 ± 128 cells/mm. The percentage of postoperative cell loss was 21.25% ± 2.8% at 1 week, 24.26% ± 1.8% at 1 month, and 21.05% ± 3.2% at 3 months. The difference in cell count from the preoperative value was significant at all time points (P < 0.02). There were no adverse drug effects and no serious operative complications. Conclusions: A 5-minute application of MMC 0.02% to the bare sclera during pterygium surgery has an immediate and significant effect on endothelial cell density, which remains stable for up to 90 days. Furthermore, longer-term studies are needed of different concentrations and durations of the drug and of procedures wherein MMC is applied before excision of the pterygium head.

Intraoperative mitomycin C 0.02% for pterygium: effect of duration of application on recurrence rate.

Purpose. To compare the effect of a 3- and 5-minute intraoperative application of topical mitomycin C 0.02% on the recurrence of pterygium. Methods. A comparative, prospective clinical design was used. The study population consisted of 134 consecutive patients with unilateral primary advanced pterygium (growth of 3 mm or more horizontally from the limbus). All underwent excision of the lesion, leaving the sclera bare. At completion of surgery, topical mitomycin C 0.02% was applied for 3 minutes in the first 60 patients (group A) and for 5 minutes in the remaining 74 patients (group B). The patients were followed for 26 months by slit-lamp biomicroscopic examination of the anterior segment. Recurrent pterygium was defined as the postoperative appearance of a fibrovascular tissue crossing the limbus. Results. After 12 months of follow-up, pterygium recurred in 20 patients (33.3%) in group A and in two patients (2.7%) in group B. After 15 months, the recurrence rates were 36.6% and 5.4%, respectively, and remained unchanged at 26 months. There were no cases of drug toxicity in either group. Conclusions. Five-minute intraoperative application of a single dose of 0.02% mitomycin C is safe and more effective than a 3-minute application in recurrence of pterygium.

Corneal endothelial morphologic features in toxic anterior segment syndrome.

Purpose: To investigate the clinical and laboratory findings of toxic anterior segment syndrome (TASS) following cataract surgery with intraocular lens (IOL) implantation, with emphasis on the morphologic features of the corneal endothelium. Methods: A single-center retrospective observational case-control design was used. The sample consisted of 15 patients (mean age 60.3 ± 11.2 years) with a diagnosis of TASS following unilateral cataract surgery with IOL implantation. In all cases, cataract surgery with IOL implantation had already been performed in the fellow pseudophakic eye without complications. Data on the corneal endothelial morphologic features in both eyes were collected from the files as follows: endothelial cell density, coefficient of variation of cell size, and percentage of hexagonal cells. Values in the eyes with TASS (study group) were compared with the fellow eyes (control group). Between-group differences were analyzed with Students t test at a significance level of 5%. Results: The eyes with TASS were characterized by a significantly lower endothelial cell density than the control eyes (2302 ± 220 cells/mm2 vs. 2853 ± 145 cells/mm2), higher mean cell area (coefficient of variation; 38 ± 1.4 vs. 24 ± 2.5), and lower mean percentage of hexagonal cells (22 ± 1.5% vs. 48 ± 3.2%; P < 0.01 for all). Common presenting symptoms and signs were blurred vision (60%), anterior segment inflammation (100%), and cell deposition (20%). Conclusions: TASS following cataract surgery with intraocular lens implantation is associated with a low corneal endothelial cell density.

Endothelial cell loss during pterygium surgery: importance of timing of mitomycin C application.

Purpose: To determine if the timing of mitomycin C (MMC) application during pterygium surgery affects endothelial cell loss. Methods: A retrospective, nonrandomized, case-series design was used. The study group included 40 patients who underwent pterygium surgery with the bare sclera technique. MMC 0.02% was applied intraoperatively for 5 minutes, either before (16 patients) or after (24 patients) excision of the head of the pterygium. Endothelial images were acquired at the center of the cornea with a specular microscope before surgery and at 3 intervals during follow-up (average of 3 measurements each). Differences in cell loss from baseline were analyzed by paired t test. Results: In the group in which MMC was applied post excision, mean preoperative endothelial cell count was 2254 ± 128 cells per square millimeter. Mean postoperative values were 1775 ± 63 cells per square millimeter at 1 week (percentage cell loss, 21.25% ± 2.8%), 1707 ± 41 cells per square millimeter at 1 month (24.26% ± 1.8%), and 1780 ± 72 cells per square millimeter at 3 months (21.05% ± 3.2%). The difference in cell count from the preoperative value was significant at all time points (P < 0.02). In the group in which MMC was applied before excision, mean preoperative endothelial cell count was 2352 ± 118 cells per square millimeter, and mean postoperative values were 2345 ± 120 cell per square millimeter at 1 week, 2260 ± 162 cells per square millimeter at 1 month, and 2230 ± 144 cells per square millimeter at 3 months. No endothelial cell loss was documented in this group. Conclusion: The endothelial cell loss associated with the use of MMC during pterygium surgery might be avoided by applying MMC before excision of the pterygium head, so that it does not come into contact with the corneal surface.

The combination of topical ceftazidime and aminoglycosides in the treatment of refractory pseudomonal keratitis

Abstract · Background: Pseudomonal keratitis is a serious and potentially blinding infection. · Methods: We treated 12 patients with culture-positive fulminant pseudomonal keratitis with a topical combination of ceftazidime ophthalmic solution (50 mg/ml) and aminoglycosides (14 mg/ml). None of these patients had responded to the standard initial therapy with topical fortified gentamicin or tobramycin (14 mg/ml) combined with cefazolin (50 mg/ml). · Results: Substitution of cefazolin by ceftazidime achieved a remarkable clinical improvement during the first 24–48 h of administration in all cases. The average time of healing after initiation of the combination of ceftazidime and fortified aminoglycosides was 21±15 days. No serious side effects accompanied ceftazidime administration. In vitro susceptibility testing showed resistance to gentamicin or tobramycin in 33% of cases (4/12) and sensitivity to ceftazidime in all cases. · Conclusions: The combination of ceftazidime, in a 5% solution, and fortified aminoglycosides (1.4%) may be a useful, safe and effective topical therapy for the treatment of pseudomonal keratitis resistant to aminoglycosides.