Tal Raviv

Pericardial patch grafts in glaucoma implant surgery.

Purpose: The authors determine the safety and effectiveness of pericardial patch grafts in glaucoma implant surgery.Methods: A retrospective chart review was conducted on all patients who underwent a glaucoma implant procedure with the use of a pericardial patch graft to cover the subconjunctival portion of the tube at The New York Eye and Ear Infirmary between September 1, 1995 and June 30, 1996. Charts were assessed for evidence of delle formation, graft rejection, graft-related infection, graft thinning, or tube erosion.Results: Forty-four eyes of 44 patients were enrolled. Mean follow-up was 10.2 ± 4.0 months (range, 2.3 to 18.6 months). Infection, tube erosion, graft rejection, and graft-related inflammation did not occur. Five eyes were noted to have asymptomatic thinning of the patch without evidence of tube erosion.Conclusions: Preserved human cadaveric pericardial patch grafts appear to be well-tolerated for use with glaucoma drainage devices. As with other grafting material, potential for graft thinning is possible and further long-term experience is needed.

Serious ocular complications of cosmetic iris implants in 14 eyes.

PURPOSE: To report the presentation and subsequent management of a series of patients presenting with cosmetic iris implants. SETTING: New York Eye and Ear Infirmary, New York, New York, USA. DESIGN: Case series. METHODS: In this evaluation of patients with NewColorIris cosmetic iris implants, data collected included patient demographics, visual acuity, intraocular pressure (IOP), endothelial cell count, and slitlamp examination findings at presentation. Medical and surgical interventions and the postoperative course were recorded. RESULTS: Fourteen eyes of 7 patients (ages 22 to 60; 71% men) were identified. Nine eyes (64%) presented with decreased visual acuity, 7 (50%) had elevated IOP, 5 (36%) had corneal edema, and 5 (36%) had anterior uveitis. All 14 eyes had explantation of the iris prosthesis (range 4 to 33 months after placement). The minimum follow‐up after implant removal in all eyes was 2 months (range 2 to 28 months). Intraoperative complications included suprachoroidal hemorrhage during explantation in 1 eye. Postoperative complications included corneal edema (8 eyes), cataract (9 eyes), and increased IOP/glaucoma (7 eyes). Secondary surgeries included Descemet‐stripping automated endothelial keratoplasty (5 eyes), cataract extraction with intraocular lens placement (7 eyes), trabeculectomy (3 eyes), glaucoma drainage implant placement (3 eyes), and penetrating keratoplasty (1 eye). CONCLUSIONS: The cosmetic iris implants may result in severe ocular morbidity. Complications in our series included uveitis, glaucoma, corneal edema, and decreased visual acuity. Although explantation helped stabilize symptoms, additional medical and surgical intervention to control IOP and corneal decompensation was required in many cases. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Grossly false applanation tonometry associated with interface fluid in susceptible LASIK patients.

We applaud Rehany and coauthors’ 1 case report about paradoxical hypotony after laser in situ keratomileusis (LASIK). We believe this syndrome may become more commonplace as treatment with LASIK continues to grow and must be carefully screened for in susceptible patients. While intraocular pressure (IOP) measurements are known to be affected by LASIK, this newly described fluid dynamic phenomenon can have serious consequences if not properly diagnosed. We had a similar experience with grossly false IOPs in a patient. Our case was a 42-year-old man with a history of penetrating keratoplasty in 1993 for keratoconus in the right eye. Besides keratoconus in the left eye, the patient had no significant ocular history. Because of irregular astigmatism/anisometropia (26.00 25.50 3 165 5 20/30) and contact lens intolerance, the patient had astigmatic keratotomy (AK) in the spring of 2000. He subsequently had laser vision correction in 2 steps: creation of a corneal flap (nasal hinge) followed by ablation under the flap with the VISX S2 laser 1 month later. The patient did well post-LASIK, with a best corrected visual acuity (BCVA) of 20/40 (21.00 20.75 3 155) 1 month later. Because old pigmented keratic precipitates were present in the graft, the patient remained on prednisolone acetate 1% (Pred Fortet) 2 times/day with a plan to taper over the next month. Two weeks later, the patient presented with mild ocular discomfort and reduction in vision. The BCVA was 20/60 (21.75 22.25 3 155) with an IOP of 18 mm Hg (Goldmann applanation). The cornea looked slightly edematous, and a faint interface haze was noted. There was no increase in endothelial keratic precipitates or anterior chamber reaction. Nevertheless, with a suspicion of diffuse lamellar keratitis (DLK) versus early graft rejection, Pred Forte was increased to 8 times/day. Over a 2 week follow-up, the BCVA dropped to 20/400 and the myopia increased (28.50 25.00 3 180). The patient reported an increase in pain and irritation. Topography revealed 6.0 diopters (D) of steepening compared with the immediate postoperative topography. Slitlamp examination revealed an even more edematous cornea with microcystic edema and a thin interface fluid pocket similar to that described by Rehany and coauthors. Intraocular pressure was 20 mm Hg (Goldmann applanation), but finger tension revealed markedly elevated pressure. The patient was immediately placed on ocular antihypertensives and acetazolamide, and the steroids were cut down to once a day. Within 1 day, there was significant improvement in symptoms and vision. One week later, the refraction and BCVA returned to their postoperative baseline—20/40 (22.25 23.00 3 115) with no symptoms. Topography normalized and finger tension was soft with a Goldmann tonometry of 15 mm Hg. The thin interface fluid pocket was no longer present. The patient’s last examination revealed a BCVA of 20/30 (20.75 21.00 3 125) with normal finger tension and IOPs. The graft was clear with no signs of rejection or flap interface fluid. The AK groove was well apposed. He was taken off all pressurelowering agents, without recurrence. This case, the one from Rehany and coauthors, and 2 others in the literature illustrate a dangerous new masquerade syndrome in postoperative LASIK patients. Our patient’s process was consistent with steroid-induced glaucoma, causing a transudative interface fluid pocket. The high pressure also induced high myopia secondary to increased corneal curvature. In retrospect, the diagnosis of DLK in our patient was erroneous, a misinterpretation of the fluid/haze in the interface. Paradoxically, steroid treatment of the DLK worsened the steroid-induced glaucoma and the condition. While similar cases of this syndrome had their flaps lifted and the interface irrigated, our case responded to medical IOP lowering on its own, suggesting that the likely cause of the fluid is a pressure-related transudative process and not the presence of DLK. Clinicians should have a high index of suspicion for this newly described syndrome, especially when treating atypical DLK. It may seem archaic, but finger tension