Tariq Alasbali

Effect of Sleeping in a Head-Up Position on Intraocular Pressure in Patients with Glaucoma

PURPOSE To determine whether a 30-degree head-up sleeping position decreases nocturnal intraocular pressure (IOP) compared with lying flat in patients with glaucoma. DESIGN Prospective, nonrandomized comparative case series. PARTICIPANTS Seventeen eyes of 17 patients with glaucoma with controlled IOP and new disc hemorrhage. METHODS Patients with a new disc hemorrhage despite well-controlled IOP were evaluated in a sleep laboratory on 2 separate nights, the first night lying flat and the second night in a 30-degree head-up position. Intraocular pressure and blood pressure (BP) were measured every 2 hours from 6 PM to 8 AM. For the 6 PM, 8 PM, 10 PM, and 8 AM measurements (awake period) the subjects were sitting for both nights. For the midnight, 2 AM, 4 AM, and 6 AM measurements (sleep period), the subjects were supine for the first night and 30 degrees head up for the second night. MAIN OUTCOME MEASURE Difference in IOP during the sleep period (midnight to 6 AM) between lying flat and 30-degree head-up positions. RESULTS Seventeen eyes of 17 patients were included. There were no significant differences (P=0.68) between the 2 study visits in IOP during the awake period (6 PM, 8 PM, 10 PM, and 8 AM) when patients were sitting upright. During the sleep period (midnight to 6 AM) the mean IOP was 3.2 mmHg lower in the 30-degree head-up position compared with the flat position (P=0.03; 95% confidence interval, 0.25-6.1 mmHg). Sixteen of 17 patients (94.1%) had lower IOP in the 30-degree head-up position. The reduction in IOP in the 30-degree head-up position was 20% or more in 35% of patients (6/17). There were no differences in BP or ocular perfusion pressure between the 2 positions. CONCLUSIONS The 30-degree head-up sleeping position lowers IOP compared with the flat position. Although this effect varies between individual patients, mean IOP was 20% lower in one third of patients in this series. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.

Is the Ex-PRESS glaucoma shunt magnetic resonance imaging safe?

IntroductionEx-PRESS mini glaucoma shunt is a miniature, stainless steel, nonvalved device used for the treatment of glaucoma. The purpose of this study was to evaluate the safety of the Ex-PRESS glaucoma shunt during magnetic resonance (MR) imaging. MethodsThe effect of a magnetic field on the Ex-PRESS glaucoma shunt was evaluated in 4 scenarios. (1) Wet dish test: the device was placed floating in a dish filled with water and exposed to magnetic fields of 1.5 and 3 Tesla for 30 seconds. (2) Dry dish test: the device was placed on a dry dish and exposed to a magnetic field of 3 Tesla MR for 30 seconds. (3) Intracameral test: the device was floating freely in the anterior chamber of a human cadaver eye and was exposed to a magnetic field of 3 Tesla MR. (4) Scleral fixation test: the device was implanted through the sclera of a human cadaver eye and was exposed to a magnetic field of 3 Tesla MR. ResultsDuring the wet dish test the Ex-PRESS glaucoma shunt immediately moved across the dish with both 1.5 and 3 Tesla MR. No movements were noted during the dry dish test, intracameral test, or the scleral fixation test. ConclusionsAlthough the Ex-PRESS glaucoma shunt is influenced by magnetic field forces, it is likely MR of up to 3 Tesla is safe due to resistance provided by the ocular tissue.

Conjunctival Complications Related to Ahmed Glaucoma Valve Insertion

Purpose:Conjunctival complications may occur after glaucoma drainage device surgery. We analyzed the frequency, risk factors, management and outcomes of Ahmed glaucoma valve (AGV)-related conjunctival complications. Methods:Retrospective review of postoperative conjunctival complications in patients undergoing AGV insertion. Only subjects with ≥1-year follow-up were included. Results:The charts of 158 subjects with a median age of 64±16.2 years were reviewed. Median follow-up was 43.5 months (range, 12 to 103 mo). Fifty-three (33.5%) wound dehiscences and 14 (8.9%) device exposures were diagnosed 31.6±35.7 and 996±735 days after procedure, respectively (P<0.001). Ninety-one subjects (57.6%) had no conjunctival complications. This uncomplicated group used 3.3 (±1.1) [95% confidence interval (CI): 3.07, 3.51] hypotensive medications before surgery as compared with 3.8 (±1.1) (95% CI: 3.48, 4.10) and 3.9 (±0.9) (95% CI: 3.36, 4.36) for dehiscence and exposure groups, respectively (P=0.01). The inferonasal quadrant was associated with the highest rate of dehiscences (4/7, 57.1%) (95% CI: 18.4, 90.1), followed by the inferotemporal quadrant (30/65, 46.2%) (95% CI: 33.1, 58.2), the superotemporal (15/61, 24.6%) (95% CI: 12.9, 33.8), and the superonasal (4/25, 16%) (95% CI: 10.9-52.0; P<0.0073). There were no differences in dehiscence and exposure rates between limbal versus fornix-based approaches (P=0.54; 95% CI: 24.8-44.9, 24.4-45.7, 5.9-19.6, 3-45.1, respectively). Forty-eight (90.6%) dehiscent wounds resolved with conservative management and 5 were resutured, whereas all exposed devices were managed surgically. Conclusions:Conjunctival dehiscence is usually a benign, common complication after AGV insertion. It does not need repair as long as the tube is well covered. AGV tube or plate exposures are less common, occur later and were promptly repaired as per current practice. Important factors predisposing to these problems include a greater number of preoperative hypotensive medications and the implantation quadrant.

Corticosteroids versus NSAIDs on intraocular pressure and the hypertensive phase after Ahmed glaucoma valve surgery.

PurposeTo compare the effect of topical steroids versus nonsteroidal anti-inflammatory drugs on intraocular pressure (IOP) and the hypertensive phase (HP) after Ahmed glaucoma valve surgery. Patients and MethodsProspective, randomized, double-masked controlled trial. Twenty-eight consecutive consenting patients scheduled for Ahmed glaucoma valve surgery were randomized to receive either postoperative topical dexamethasone or ketorolac. The main outcome measure was IOP. Secondary outcomes included incidence of HP, visual acuity, number of glaucoma medications, postoperative complications, and subsequent procedures. ResultsThe mean postoperative IOP (in mm Hg) in the ketorolac versus dexamethasone arms respectively was as follows: 8.8±4.7 versus 10.0±4.5 at week 1 (P=0.500); 10.7±6.7 versus 17.5±10.4 at week 2 (P=0.053); 11.0±6.5 versus 18.0±7.3 at week 4 (P=0.013); 14.8±8.6 versus 17.5±5.2 at week 6 to 8 (P=0.323); and 14.8±9.6 versus 17.8±7.5 at week 10 to 12 (P=0.374). Four patients (31%) in the ketorolac arm versus 8 patients (53%) in the dexamethasone arm exhibited the HP (P=0.276). Wound leak was the most severe complication and there were 3 cases (23%) in the ketorolac group versus nil in the steroid group (P=0.087). Conjunctival retraction was observed in 8 patients (62%) in the ketorolac arm versus 2 patients (13%) in the dexamethasone arm (P=0.016). ConclusionsMean IOP was greater at all time points postoperatively in the steroid group with the difference between groups statistically significant at week 4. The nonsteroidal anti-inflammatory drug group showed greater wound-healing problems.

Effect of beclomethasone nasal spray on intraocular pressure in ocular hypertension or controlled glaucoma.

PurposeTo evaluate the effect of 6 weeks administration of beclomethasone nasal spray on intraocular pressure (IOP) in patients with ocular hypertension or controlled primary open-angle glaucoma. Patients and MethodsRandomized double-masked controlled trial. Patients were randomized to twice daily beclomethasone versus placebo saline nasal spray. There were a total of 4 study visits: baseline and weeks 2, 4, 6 after starting the spray. Each study visit was at the same time within a 1-hour time window. Primary outcome measure was IOP. Secondary measures included visual acuity, anterior segment changes, patient reported side effects, and compliance. Study endpoint was 6 weeks from the start of treatment or an IOP increase of >20% from baseline. A sample size calculation suggested that 8 patients in each arm would be sufficient to detect a difference of 3.2 mm Hg with a power of 80%. ResultsNineteen consecutive consenting patients completed the study—9 in the steroid arm and 10 in the placebo arm. There were no statistically significant differences between groups in baseline characteristics, IOP at each study visit, or change in IOP from baseline at any time point. At 6 weeks, the change in mean IOP from baseline was +0.50±1.52 versus +0.70±1.44 mm Hg in the steroid and saline nasal spray groups, respectively (P=0.77). ConclusionsPatients with ocular hypertension and primary open-angle glaucoma showed no evidence of IOP elevation after 6 weeks use of beclomethasone nasal spray.

Digital Ocular Massage for Hypertensive Phase After Ahmed Valve Surgery

PurposeTo examine the role of ocular massage during the hypertensive phase after Ahmed valve surgery MethodsNonrandomized prospective study. ResultsEighteeen patients with intraocular pressure (IOP) above target 1 to 8 weeks after Ahmed glaucoma drainage device surgery underwent digital ocular massage. The mean IOP 1 hour after massage was 4.3 mm Hg lower than before massage (18.8%, P=0.0008). We used a 20% reduction in IOP at 1-hour postmassage to differentiate responders from nonresponders and by this definition 50% responded to ocular massage. One patient (5.6%) responded well but was unable to perform massage at home. The remaining 8 patients (44.4%) performed regular digital massage and the 20% drop in IOP was maintained at the 2-week, 6-week, and 6-month review, although by 6 months 50% required glaucoma drops to achieve target IOP. There were no massage-associated complications in this series. ConclusionsDigital ocular massage has a useful role to play in the management of the hypertensive phase after Ahmed glaucoma drainage device surgery. In this series 50% of patients achieved a 20% drop in IOP with massage.

Evaluation of investigator bias in industry-funded clinical trials of latanoprost

OBJECTIVE To determine whether sponsorship of prostaglandin analogue (PGA) clinical trials results in investigator bias in outcomes when studying intraocular pressure (IOP). DESIGN Retrospective, observational cohort study. METHODS A PubMed search was performed for latanoprost or Xalatan, bimatoprost or Lumigan, and travoprost or Travatan, with limits to humans, clinical trials, and English language. Inclusion criteria included randomized controlled trials, open-angle glaucoma, monotherapy with a PGA, baseline IOP ≥ 21 mm Hg, washout period, and minimum 1-month follow-up. Each article was reviewed by 2 independent reviewers. The results of IOP for each PGA were categorized as being sponsored by the parent company (the company manufacturing the PGA); by the competing company (the company manufacturing competing glaucoma therapy); or by a nonindustry source. The mean IOP and changes in IOP from baseline were compared among the 3 categories of sponsorship. RESULTS Only studies involving latanoprost were analyzed because of the low number of studies meeting the inclusion criteria for bimatoprost and travoprost. We found 29 and 13 studies that provided 1- and 3-month data, respectively, for analysis. The mean baseline IOPs in the 3 groups (parent company, competing company, nonindustry) were not significantly different (p = 0.47). The mean IOP at 1 (p = 0.72) and 3 months (p = 0.59) and the change in IOP from baseline (p = 0.83 and 0.90, respectively) were not significantly different in the 3 groups. A random-effects metaregression controlling for the covariates of blinding, naïveté to PGAs, and baseline IOP < 24 mm Hg or ≥ 24 mm Hg did not change the findings. CONCLUSION There was no evidence of investigator bias in determining outcomes for IOP in these clinical trials of latanoprost.

A forecast of ophthalmology practice trends in Saudi Arabia: A survey of junior residents

PURPOSE The aim of this study is to identify the trends in practice pattern among current ophthalmology residents in Saudi Arabia. MATERIALS AND METHODS Ophthalmology residents in Saudi Arabia responded anonymously to a written survey between November 2007 and February 2008. The survey contained questions on demographic information, medical education, residency training, career goals and factors influencing their career choice. The data were categorized by gender. The influence of gender on outcome was assessed in a univariate fashion using the Chi-square or Fisher exact test when appropriate. A P-value of 0.05 or less was considered statistically significant for all analyses. RESULTS A total of 68 out of 85 residents (80%) responded to the survey. Over one-half of the residents preferred to pursue a fellowship within Saudi Arabia (53%), while others (25%) planned to train in North America. The majority of respondents wished to practice in an urban setting (63%). Anterior segment was the most desired subspecialty, while general ophthalmology and glaucoma were not a popular choice. Most residents were interested in refractive surgery (77%) and research (75%). The main factor influencing the decision to pursue ophthalmology was the ability to combine medicine and surgery (97%), while a positive elective experience was also an important factor, particularly for female respondents (91% vs. 57%; P < 0.001). CONCLUSION Concerted efforts are required to encourage adoption to ophthalmic practice in public institutions rather than in private practice. In addition training in underrepresented subspecilaties should be encouraged to ensure adequate ophthalmic care for all citizens of Saudi Arabia.

Achieving Controlled Intraocular Pressure and Restoration of Vision Following Proactive Treatment of Total Choroidal Detachment Due to Endocyclophotocoagulation.

Ocular hypotony due to choroidal detachment (CD) following endocyclophotocoagulation (ECP) is transient. If hypotony lasts for more than 1 week, it could affect vision. This is a case of refractory glaucoma following cataract surgery that was managed by ECP. We drained subchoroidal fluid as CD did not resolve after 1 week. After 5 months, the intraocular pressure was restored to 16 mmHg with one topical glaucoma medication, uncorrected vision improved to 20/300, and with aphakic soft contact lens, it was 20/50. Ophthalmologists facing such complications need not panic and manage hypotony, and the prognosis of such intervention seems to be promising.

Outcome of Ahmed valve implantation when preoperative IOP less than 21 mm Hg.

PurposeTo examine the results of Ahmed glaucoma drainage device (GDD) implantation in patients with a preoperative intraocular pressure (IOP) of 20 mm Hg or less. MethodsNoncomparative retrospective case series. ResultsSixty-six surgeries in 63 patients were analyzed. Mean follow-up was 51 months. The mean drop in IOP was 3.8 mm Hg (23.3%, P<0.0001) at 12 months and 3.9 mm Hg (24.0%, P<0.0001) at final follow-up. The number of glaucoma medications used postoperatively was significantly less than preoperatively. Although the mean visual acuity was poorer postoperatively this did not reach statistical significance. Surgical success was defined as IOP ≥5 mm Hg and 20% lower than preoperatively with or without hypotensive therapy, visual acuity perception of light or better and no further glaucoma surgery. About 57.6% and 53.0% of patients were considered a success at 12 months and final follow-up, respectively. Fourteen patients (21.2%) underwent additional glaucoma surgery, 8 of which had a second Ahmed GDD inserted whereas 6 had cyclodestruction. All failures were due to inadequate IOP control or further glaucoma surgery, with no cases considered failures due to vision loss or hypotony. Perioperative complications developed in 6 cases (9.1%) whereas long-term problems related to surgery occurred in 8 cases (12.1%). ConclusionsIn patients with IOPs of 20 mm Hg or less who require IOPs in the low teens and below Ahmed GDD surgery does seem to be an effective option. The success rates of surgery, however, must be balanced against the risk of complications. In addition, the relative merits of Ahmed GDD implantation versus mitomycin trabeculectomy and/or nonvalved GDDs requires further investigation.