Rubina Rahman

Long term results and complications of trabeculectomy augmented with low dose mitomycin C in patients at risk for filtration failure

AIM To determine the results and complications up to 5 years after trabeculectomy with 0.02% mitomycin C (MMC) in glaucoma patients at risk for failure of filtration surgery. METHODS A consecutive series of 21 eyes from 20 patients who underwent trabeculectomy with MMC 0.02%, with an exposure time of 2 minutes, was retrospectively analysed and the results were compared with previously published data. RESULTS The mean preoperative intraocular pressure (IOP) was 28 mm Hg on an average of 2.8 glaucoma medications, and the mean postoperative IOP after 3 years was 14 mm Hg on an average of 0.4 medications. Three years after trabeculectomy, 17 of 21 (80.9%) eyes had an IOP of less than 21 mm Hg without medical treatment. Using Kaplan-Meier life table analysis the 5 year probability of an IOP less than 21 mm Hg without medication was 67% and with medication was 90%. Two patients required further glaucoma surgery during the first postoperative year, and another developed hypotonous maculopathy which was reversed after bleb revision. Seven patients developed visually significant cataract as a late consequence of the surgery. There were no bleb related infections. CONCLUSION In the long term MMC 0.02% used for 2 minutes intraoperatively is an effective adjunctive treatment in glaucoma patients at risk for bleb failure and in this dose is associated with few complications.

Phacoemulsification with intraocular lens implantation after trabeculectomy.

PurposeTo determine the effect of phacoemulsification with intraocular lens (IOL) implantation, using a superior clear-corneal incision, on the long-term intraocular pressure (IOP) control in patients who have undergone previous trabeculectomy. MethodsTwenty-eight consecutive patients who underwent phacoemulsification with IOL implantation (phaco group) at least 3 months after trabeculectomy were identified and matched to 28 patients who underwent trabeculectomy only (trabeculectomy-only group) with respect to age, gender, IOP, and duration of follow-up. The mean IOP was compared 1 and 2 years after phacoemulsification, and the surgical success rate in each group was determined by Kaplan-Meier survival analysis. ResultsThe mean IOP 1 year after cataract surgery was significantly higher (P = 0.025) in the phaco group (15.6 ± 3.5 mm Hg) than in the trabeculectomy-only group (13.4 ± 2.5 mm Hg), but at 2 years the difference was not statistically significant (15.3 ± 3.1 mm Hg in the phaco group compared with 14.3 ± 3.2 mm Hg in the trabeculectomy-only group;P = 0.35). Two years after surgery, 5 of 28 patients in the phaco group and 1 of 28 patients in the trabeculectomy-only group had commenced or were using additional topical medication (P = 0.089). If the introduction of glaucoma medication was considered a “failure,” then the IOP control was significantly better in the trabeculectomy-only group using two different criteria for surgical failure. ConclusionAlthough phacoemulsification and IOL implantation through a superior clear-corneal incision have little effect on mean IOP in a group of patients who have undergone previous trabeculectomy, this procedure may jeopardize the long-term IOP control in individual patients.

Pupillary capture after combined management of cataract and vitreoretinal pathology

Purpose: To report the incidence, pathogenesis, and management of pupillary capture after combined phacoemulsification with intraocular lens (IOL) implantation and vitreoretinal surgery. Setting: Oxford Eye Hospital, The Radcliffe Infirmary, Oxford, United Kingdom. Methods: This retrospective case review comprised 12 patients who developed pupillary capture after combined phacoemulsification, IOL implantation, and pars plana vitrectomy (PPV). Eleven IOLs were implanted in the capsular bag, and 1 was sulcus fixated. All patients had a long‐acting gas tamponade and were advised to lie face down postoperatively. All patients subsequently had IOL repositioning using a bimanual technique. Results: The incidence of pupillary capture was 8.95% and occurred a mean of 3.25 weeks postoperatively. At least 6 clock hours of the pupillary margin were captured by the optic except in 1 case in which the pupillary capture was total. Half the patients had posterior capsule opacification that required a neodymium:YAG laser capsulotomy after IOL repositioning. Conclusions: The incidence of pupillary capture after combined phacoemulsification, IOL implantation, PPV, and injection of long‐acting gas was high. This complication can be minimized by creating a smaller capsulorhexis, having the patient maintain a strict face‐down position, securing wound closure, and injecting an air bubble into the air chamber to push the iris–lens diaphragm posteriorly.

Accuracy of intraocular lens power estimation in eyes having phacovitrectomy for macular holes

PURPOSE: To report the accuracy of intraocular lens (IOL) power estimation in eyes having combined phacoemulsification and vitrectomy for macular holes and to compare the axial length (AL) in those eyes with that in the fellow eyes. SETTING: Calderdale Royal Hospital, Halifax, West Yorkshire, United Kingdom. METHOD: The mean and standard deviation of the refractive aim, achieved refraction, and postoperative prediction error (calculated as difference between achieved refraction and refractive aim) were determined in 40 patients who had phacovitrectomy with gas tamponade for the treatment of idiopathic macular holes. The percentage of patients with an achieved refraction within ±0.50 diopter (D), ±1.00 D, and more than 2.00 D of the refractive aim was recorded. The mean absolute error (MAE) of the postoperative prediction error was calculated. In addition, the AL in eyes with macular holes was compared with that in fellow eyes. Axial lengths were measured using applanation A‐scan ultrasound. RESULTS: Of eyes having phacovitrectomy, 45.0%, 67.5%, and 90.0% achieved a postoperative refraction within ±0.50 D, ±1.00 D, and ±2.00 D, respectively, of the refractive aim; 10.0% of eyes were more than −2.00 D from the refractive aim. The overall postoperative prediction error ranged from +1.64 D to −2.51 D. The mean refractive aim was +0.30 ± 0.72 D and the mean achieved refraction, −0.09 ±1.25 D. There was no clinically significant difference between the means. The mean postoperative prediction error was −0.39 ± 1.01 D, suggesting a myopic overcorrection occurred postoperatively. The MAE of the postoperative prediction error was 0.83 D. The mean AL was 23.40 mm in operated eyes and 23.46 mm in fellow eyes. CONCLUSIONS: The achieved refraction after phacovitrectomy for macular holes was comparable to results after phacoemulsification alone. The myopic overcorrection after phacovitrectomy might be a result of the gas bubble causing forward displacement of the capsular bag and IOL or inaccuracies in AL and keratometry measurements. Aiming for residual hyperopia may counteract the overcorrection. There was no difference in AL between eyes with macular holes and fellow eyes.

Phacoemulsification and foldable intraocular lens implantation combined with 23-gauge transconjunctival sutureless vitrectomy

PURPOSE: To evaluate the effectiveness, technical feasibility, outcomes, and complications of phacoemulsification and intraocular lens (IOL) implantation combined with 23‐gauge transconjunctival sutureless vitrectomy. SETTING: Ophthalmology Department, Calderdale Royal Hospital, Halifax, United Kingdom. METHOD: This retrospective noncomparative interventional case series evaluated the results of 23‐gauge transconjunctival sutureless vitrectomy combined with phacoemulsification and IOL implantation. Primary outcome measures included suture, complication, and hypotony rates; logMAR visual acuity; and intraocular inflammation. RESULTS: Sixty consecutive patients (60 eyes) were included. The mean visual acuity was 0.87 logMAR ± 0.68 (SD) preoperatively and 0.46 ± 0.34 logMAR 6 weeks postoperatively; the improvement was statistically significant (P<.0001). The 23‐gauge ports were self‐sealing in all eyes but 4 (6.7%), in which a single pars plana port was sutured. The mean intraocular pressure was 24.0 ± 15.6 mm Hg 1 day postoperatively. Eight eyes (13.0%) had postoperative hypotony (<10 mm Hg); all recovered spontaneously within 24 hours. Of the eyes in which long‐term tamponade was not necessary (n =12), all 3 with no endotamponade and 3 of 9 with air tamponade had postoperative hypotony; the difference was not statistically significant (P = .09). CONCLUSIONS: Combined transconjunctival sutureless vitrectomy and phacoemulsification was effective and safe in managing simultaneous cataract and vitreoretinal pathology. The self‐sealing incisions did not adversely affect the overall surgical or visual outcomes, led to faster visual rehabilitation, and reduced ocular inflammation. The use of air tamponade when no long‐term endotamponade was necessary appeared to reduce the risk for hypotony.

Long-term effect of cataract surgery on intraocular pressure after trabeculectomy: extracapsular extraction versus phacoemulsification.

Purpose: To compare the effect of phacoemulsification with intraocular lens (IOL) implantation on long‐term intraocular pressure (IOP) control in glaucoma patients who had previous trabeculectomy with the effect on IOP control in similar patients after extracapsular cataract extraction (ECCE) with IOL implantation Setting: Oxford Eye Hospital, Oxford, England. Methods: Twenty‐eight consecutive patients who had phacoemulsification with IOL implantation (phaco group) at least 3 months after trabeculectomy were identified from hospital records, and 28 patients who had ECCE with IOL implantation (ECCE group) were matched retrospectively to the phaco group with respect to age, sex, diagnosis, and IOP. In both groups, the IOP before cataract extraction was compared with the IOP at intervals up to 2 years after cataract extraction. A Kaplan‐Meier survival analysis was performed. Results: The mean IOP in the phaco group did not differ significantly from the mean IOP before cataract extraction at any interval. Twelve months after cataract extraction, the mean IOP in the ECCE group was significantly higher than preoperatively (P = .01); however, the mean IOP did not differ between groups over time (P = .704). There was significantly better long‐term IOP control in the phaco group as determined by Kaplan‐Meier survival analysis and the log‐rank test (P = .038). Conclusion: After trabeculectomy, phacoemulsification provided better long‐term IOP control than ECCE; however, the mean IOP was not significantly lower.

A comparison of several methods of macular hole measurement using optical coherence tomography, and their value in predicting anatomical and visual outcomes

Background/Aims To compare several methods of macular hole measurement using optical coherence tomography (OCT), and to assess their predictive capability against anatomical and visual outcomes in a single cohort of patients. Methods A retrospective study of 50 eyes undergoing standardised macular hole surgery. All patients underwent preoperative OCT scanning with measurement of macular hole inner opening diameter, minimum linear diameter, base diameter and macular hole height. Values were calculated for the macular hole index and the tractional hole index. Results Logistic regression analyses indicated that the preoperative base diameter, macular hole inner opening and minimum linear diameter were associated with both anatomical and visual success. Derived parameters as alternatives to these basic ophthalmic parameters add little to the modelling of either anatomical or visual success. Conclusion Base diameter, macular hole inner opening and minimum linear diameter can each be used to predict anatomical and/or functional success in macular hole surgery. Preoperative base diameter is the most useful variable in this regard, as it holds the strongest association with anatomical and visual outcome and is easily measured on a OCT scan.

Outcomes of sulfur hexafluoride (SF6) versus perfluoroethane (C2F6) gas tamponade for non-posturing macular-hole surgery

Aim To compare the outcomes of non-posturing macular-hole surgery using sulfur hexafluoride (SF6) gas versus perfluoroethane (C2F6) for idiopathic macular hole repair. Design Interventional, comparative cohort study. Methods 39 eyes of 38 patients undergoing macular-hole surgery with SF6 were compared with another consecutive group of 39 eyes (39 patients) in whom C2F6 was used. All patients were operated on by a single surgeon and underwent 23G transconjunctival phakovitrectomy with no prone posturing in the postoperative period. The best-corrected Snellens visual acuity (VA) was converted to the logarithm of minimal angle of resolution (logmar) visual acuity for analysis. Optical coherence tomography documentation of anatomical closure and complications of surgery were recorded. Results Primary hole closure was achieved in 89.75% in the C2F6 group and 87.2% in the SF6 group. Secondary closure after non-posturing redo surgery with heavy oil (Oxane-HD) was 100% in both groups. The mean preoperative VA in the C2F6 group and SF6 group was 0.81 logMAR and 0.78 respectively. 2 weeks after surgey, SF6 was completely absorbed in all cases, and the mean VA improved to 0.5 logMAR; however, it remained 1.9 logMAR in the C2F6 group. The final mean VA at 6 months was 0.44 (range 0–0.78) and 0.38 (range 0–1) in the C2F6 and SF6 group respectively. There were no instances of pupillary capture in the SF6 group, whereas there were four in the C2F6 group. Conclusion Macular-hole surgery with SF6 gas achieves similar results to C2F6 and is absorbed faster, allowing quicker visual rehabilitation for the patient.

Floaterectomy: combined phacoemulsification and deep anterior vitrectomy.

&NA; We describe a 1‐stage surgical technique to treat vitreous floaters. Phacoemulsification is combined with a deep anterior vitrectomy through a posterior curvilinear capsulorhexis followed by implantation of a posterior chamber intraocular lens. The technique was used in 10 eyes of 6 patients. Six months postoperatively, 8 eyes had a best corrected visual acuity (BCVA) of 6/6 with complete resolution of symptoms. Two eyes of 1 patient developed cystoid macular edema that reduced final BCVA to 6/18 bilaterally. In this case, the floaters may have been the result of previously undiagnosed intermediate uveitis.

Early surgery for epiretinal membrane preserves more vision for patients

PurposeTo establish whether early vitrectomy for epiretinal membrane (ERM) is preferable to delayed surgery.MethodsWe carried out a retrospective study of 120 eyes from 120 patients with pre-operative visual acuity (VA) of 6/60 or better. Pre-operative logMAR score was considered to act as an appropriate proxy measure for time of surgical procedure, with scores of 0.3 or less considered to represent early surgery, scores of 0.4 or 0.5 considered to represent medium surgery, and scores of 0.6 or more considered to represent late surgery for ERM. Patients were either pseudophakic at the time of vitrectomy or underwent combined phaco-vitrectomy for symptomatic ERM.ResultsEvaluation of parameter coefficients indicated that controlling for other factors, a delay of the surgical procedure from a state of early to medium corresponded to an increase (ie, disbenefit) of 0.074 units in post-operative logMAR score (95% confidence interval −0.001–0.15). A delay of the surgical procedure from a state of early to late corresponded to an increase (ie, disbenefit) of 0.21 units in post-operative logMAR score (95% confidence interval 0.13–0.29). Mean post-operative VA for early surgery was 0.16, out of which 36.2% of patients had a LogMAR score of 0.1 or better. This is in comparison to 17.2% in late ERM (those with a pre-operative logMAR score of 0.6 or more).ConclusionWe conclude that early surgery is associated with a lower (ie, better) post-operative logMAR score. Vitrectomy for early symptomatic ERM, in carefully selected patients, is beneficial in preserving excellent vision and allows quicker visual rehabilitation.