Saurabh Goyal

Effect of primary selective laser trabeculoplasty on tonographic outflow facility: a randomised clinical trial

Purpose To investigate the effect of 180° versus 360° primary selective laser trabeculoplasty (SLT) on tonographic outflow facility and intraocular pressure (IOP). Design Prospective, single masked randomised clinical trial. Participants Patients with untreated primary open angle glaucoma or ocular hypertension both with IOP >21–35 mmHg. Methods 40 patients randomly treated with 180° or 360° SLT after baseline tonographic outflow facility (electronic Schiøtz tonography) and IOP measurements were repeated after 1 month. One eye from each patient was randomly selected for analysis. Eight untreated eyes were included as a control group. Main Outcome Measures Tonographic outflow facility and IOP difference. Responders were defined as having at least a 20% reduction in IOP. Results Three patients were excluded due to poor tonography. There were 18 eyes in the 180° group and 19 eyes in the 360° group. Tonographic outflow facility increased significantly (180° p=0.003, 360° p=0.005) and IOP decreased significantly (180° and 360° p<0.001) from baseline. There were no significant differences between the two groups as regards the increase in tonographic outflow facility (180° group 37.5%, 360° group 41%, p=0.23) and decrease in IOP (180° group 24%, 360° group 35%, p=0.35). There were similar number of responders in 180° group (72%) as compared to 360° group (89.5%, p=0.23). Tonographic outflow facility and IOP did not change significantly from baseline in the control group (tonographic outflow facility: 8% increase p=0.48, IOP: 4% decrease p=0.33). Conclusions Primary SLT significantly increased the tonographic outflow facility and decreased IOP in patients with primary open angle glaucoma and ocular hypertension but no statistically significant differences were found between the 360° and 180° groups. The level of IOP reduction due to primary SLT treatment could not be explained by the increase in tonographic outflow facility alone. Clinical trial registration ISRCTN66330584, Current Controlled Trials. 1/11/2006

Cystic fibrosis presenting with corneal perforation and crystalline lens extrusion.

We describe a 5-month-old female Caucasian infant who presented with corneal perforation and crystalline lens extrusion secondary to Pseudomonas aeruginosa endophthalmitis and was later diagnosed with cystic fibrosis (CF). To our knowledge, this is the first report of CF presenting with P. aeruginosa endophthalmitis.

Phacoemulsification plus endoscopic cyclophotocoagulation versus phacoemulsification alone in primary open-angle glaucoma

Purpose: To examine the efficacy and safety of combined phacoemulsification and endoscopic cyclophotocoagulation (phaco-ECP) compared to phacoemulsification alone in patients with primary open-angle glaucoma (POAG). Methods: We performed a retrospective notes review of 99 consecutive clinical records of patients with POAG from 2 London eye departments. A total of 69 patients who underwent phaco-ECP and 30 sex- and age-matched control patients who underwent cataract surgery alone were included. Data on intraocular pressure (IOP), visual acuity (VA), number of ocular hypotensive medications, and postoperative complications were collected over 12 months. The primary outcome measure was defined as an IOP within normal limits (<21 mm Hg) and at least a 20% reduction in IOP from baseline. Results: Mean IOP was significantly decreased in both groups after 1 year (p<0.001 from baseline). The success rate was significantly higher in the phaco-ECP group (69.6%) than in the phaco group (40%) after 1 year (p = 0.004). Reduction in mean IOP and number of medications was also greater in the phaco-ECP group after 1 year (IOP reduction: 4.5 ± 5.13 mm Hg vs 1.83 ± 3.61 mm Hg; p = 0.007; number of medications reduction: 0.73 ± 0.71 vs 0.23 ± 0.56; p = 0.001). Both groups achieved a similar improvement in VA. There was a higher incidence of minor and self-limiting complications in the phaco-ECP group (p<0.047). Conclusions: Phaco-ECP resulted in a greater reduction in IOP and number of medications than phacoemulsification alone in POAG.

Gonioscopically Guided Nonpenetrating Cyclodialysis Cleft Repair: A Novel Surgical Technique

ABSTRACT Aim We present a novel surgical technique for repair of persistent and symptomatic cyclodialysis clefts refractory to conservative or minimally invasive treatment. Background Numerous surgical techniques have been described to close cyclodialysis clefts. The current standard approach involves intraocular repair of cyclodialysis clefts underneath a full-thickness scleral flap. Technique Our technique employs intraoperative use of a direct gonioscope to guide a nonpenetrating surgical repair. Subsequently, a significantly less invasive, nonpenetrating technique utilizing a partial-thickness scleral flap can be performed that reduces potential risks associated with intraocular surgery. The direct gonioscope is also used for confirmation of adequate surgical closure of the cyclodialysis cleft prior to completion of surgery. This technique has been successfully carried out to repair traumatic chronic cyclodialysis clefts associated with hypotony in two patients. There were no significant adverse events as a result of using this technique. Conclusion The novel technique described increases the likelihood of successful and permanent repair of cyclodialysis clefts with resolution of symptoms associated with hypotony, through direct intraoperative visualization of the cleft. Clinical significance Gonioscopically guided nonpenetrating cyclodialysis cleft repair offers significant benefits over previously described techniques. Advantages of our technique include gonioscopic cleft visualization, enabling accurate localization of the area requiring repair, and subsequent confirmation of adequate closure of the cleft. Using a partial-thickness scleral flap is also less invasive and reduces risks associated with treatment of this potentially challenging complication of ocular trauma. How to cite this article Rodrigues IAS, Shah B, Goyal S, Lim S. Gonioscopically Guided Nonpenetrating Cyclodialysis Cleft Repair: A Novel Surgical Technique. J Curr Glaucoma Pract 2017;11(1):31-34.

Glaucoma Surgery in Scleromalacia: Using Endoscopic Cyclophotocoagulation where Conventional Filtration Surgery or Angle Procedures are contraindicated.

ABSTRACT Aim To describe the surgical management of glaucoma in a patient with severe scleromalacia, and secondary angle closure. Introduction The management of glaucoma with coexisting scleromalacia plus secondary angle closure is challenging as most commonly performed incisional glaucoma surgery as well as minimally invasive glaucoma surgery (MIGS), which targets the drainage angle are all contraindicated. Case report Medically refractory glaucoma in a 60-year-old male with a 30-year history of granulomatosis with polyangiitis resulting in extensive severe scleromalacia, cicatricial lower lid retraction with significant conjunctival exposure, and widespread synechial angle closure from chronic anterior uveitis was managed with combined phacoemulsification cataract surgery, and endoscopic cyclophotocoagulation (ECP). Careful postoperative management with intensive immunosuppression was used to successfully prevent complications related to the surgery, which resulted in improved visual acuity, and control of intraocular pressure (IOP). Conclusion The ECP is a minimally invasive procedure that targets inflow of aqueous, and can be safely and successfully used to control IOP in challenging patients with complex secondary glaucoma, where the use of traditional incisional surgery, and other MIGS procedures are all contraindicated. Clinical significance The choice of surgical treatment for medically refractory glaucoma needs to be selected based on the circumstances of individual patients, and take into consideration the condition of the sclera, conjunctiva and drainage angle, against the safety and efficacy of possible treatments. How to cite this article Rodrigues IAS, Lindfield D, Stanford MR, Goyal S. Glaucoma Surgery in Scleromalacia: Using Endoscopic Cyclophotocoagulation where Conventional Filtration Surgery or Angle Procedures are contraindicated. J Curr Glaucoma Pract 2017;11(2):73-75.