Transactions of the American Ophthalmological Society最新文献

Purpose: To evaluate the results of Ahmed glaucoma valve surgery in neovascular glaucoma and control patients.

Methods: In this retrospective comparative study, we reviewed 76 eyes of 76 patients, comparing the surgical outcomes in control patients (N=38) to matched neovascular glaucoma patients (N=38). Success was defined as intraocular pressure (IOP) > or =6 mm Hg and < or =21 mm Hg, without further glaucoma surgery, and without loss of light perception.

Results: Average follow-up for control and neovascular glaucoma patients was 18.4 and 17.4 months, respectively (P = .550). At last follow-up, mean IOP was 16.2 +/- 5.2 mm Hg and 15.5 +/- 12.5 mm Hg (P = .115) in control and neovascular glaucoma patients, respectively. Life-table analysis showed a significantly lower success for neovascular glaucoma patients compared with controls (P = .0096), with success at 1 year of 89.2% and 73.1%, at 2 years of 81.8% and 61.9%, and at 5 years of 81.8% and 20.6% for control and neovascular glaucoma eyes, respectively. Cox proportional hazards regression analysis showed neovascular glaucoma as a risk factor for surgical failure (odds ratio, 5.384, 95% CI, 1.22-23.84, P = .027). Although IOP control and complications were comparable between the two groups, visual outcomes were worse in neovascular glaucoma patients, with 9 eyes (23.7%) with neovascular glaucoma compared with no controls losing light perception vision (P = .002). The majority with loss of vision (5 of 9) had successful control of IOP during the postoperative period.

Conclusion: Neovascular glaucoma patients have greater risk of surgical failure after Ahmed glaucoma valve surgery compared with controls. Despite improved mean IOP with drainage implants, visual outcomes may be poor, possibly due to progression of underlying disease.

Purpose: Descemet stripping automated endothelial keratoplasty (DSAEK) can be performed with donor tissue prepared with a microkeratome either by the surgeon at the time of surgery or by a technician in the eye bank days before surgery. Are the complications and endothelial survival affected by donor preparation by a surgeon vs a technician?

Methods: A single surgeon at a referral practice performed 225 DSAEK procedures for Fuchs endothelial dystrophy using a similar surgical technique for all cases. Surgeon-cut tissue was used in 49 cases (group 1), and precut tissue was used in 176 cases (group 2). Retrospective analysis was done from a prospectively collected database for donor dislocations, iatrogenic primary graft failure (IPGF), and 6- and 12-month postoperative central endothelial cell density (ECD).

Results: There were no dislocations in group 1 and 3 dislocations in group 2 (P = .224). There were no IPGFs in group 1 and one IPGF in group 2. The preoperative donor ECD was 2948 +/- 382 for group 1 and 2728 +/- 269 for group 2. (P < .001). The cell loss at 6 months was 33% +/- 14% for group 1 and 27% +/- 13% for group 2 (P = .01), and cell loss at 12 months was 34% +/- 13% for group 1 and 27% +/- 14% for group 2 (P = .01). Six-month cell loss for 8.0-mm grafts (n=127) was 30% +/- 16% and for larger grafts (n=98) was 27% +/- 12% % (P = .296).

Conclusions: Precut tissue for DSAEK does not increase the risk of the acute complications of graft dislocation or IPGF. Early endothelial cell loss may be less with precut tissue. Larger graft sizes did not result in significantly higher cell counts at 6 months.

Purpose: A multicenter, 2-visit, open-label, 4-week study was conducted to determine the acceptability of hydroxypropyl cellulose ophthalmic inserts in adult patients with a history of dry eye syndrome (DES).

Methods: At visit 1, patients (N = 520) were evaluated, screened by slit-lamp biomicroscopy, and completed the Ocular Surface Disease Index (OSDI), a validated measure of quality of life. Patients were trained in the proper placement and use of hydroxypropyl cellulose ophthalmic inserts and were contacted by telephone on day 3 of the study. At week 4, patients were given a clinical evaluation and completed a second questionnaire. Answers determined changes in symptoms and quality of life. Adverse events were monitored throughout the study.

Results: Four hundred eighteen patients completed the study and reported significant improvements in discomfort, burning, dryness, grittiness, stinging, and light sensitivity (P = .05) after 4 weeks use of hydroxypropyl cellulose ophthalmic inserts. Significant improvements in clinical signs (keratitis, conjunctival staining, and tear volume) were reported. Contact lens wearers reported significant improvements similar to nonwearers, with a strong trend toward improvement in light sensitivity. Mean OSDI total scores, measuring quality of life, significantly improved by 21.3% (from 41.8 +/- 22.38 to 32.9 +/- 21.97, P < or = .0215). The most commonly reported adverse event leading to discontinuation was blurred vision, observed in 8.7% of patients (n = 45). Compliance during the study was good; 41.5% of subjects were fully compliant. Of the 58.5% of subjects who missed doses, the majority (69.4%) missed only one to five.

Conclusions: Hydroxypropyl cellulose ophthalmic inserts significantly reduced symptoms and clinical signs of moderate to severe DES. They also significantly improved DES in patients wearing contact lenses. Patients experienced a statistically significant improvement in quality of life, as measured by the OSDI, of 21.3%.

Purpose: To compare outcomes across Trabectome, iScience (canaloplasty), trabeculectomy, and aqueous shunts regarding intraocular pressure (IOP), adjunctive medications, and complications after glaucoma-only and combined glaucoma-phacoemulsification surgeries for open-angle glaucomas.

Method: A literature review compares success rates, complications, efficacy, and limitations of traditional and novel glaucoma surgical procedures.

Results: Trabectome and canaloplasty provide modest IOP reduction with minimal intraoperative or postoperative complications. Results of Baerveldt glaucoma implant IOP reduction are comparable to trabeculectomy, but typically this shunt requires more postoperative IOP-lowering medication to achieve a success rate comparable to trabeculectomy.

Conclusion: Trabeculectomy is still the most effective IOP-lowering procedure performed today but continues to have the highest serious complication rates. Trabectome and canaloplasty are reasonable surgical therapy choices for patients in which IOPs in the mid-teens seem adequate.

Purpose: To present contemporary information regarding the continued inability to reliably predict visual acuity following successful retinal reattachment surgery.

Methods: Literature review.

Results: Anatomical results of surgery for retinal detachment continue to be far superior to visual results. Clinical factors that have been considered important in predicting postoperative visual acuity include preoperative vision, duration of detachment, height of detachment, and preoperative potential acuity meter results. Recently, optical coherence tomography (OCT) studies have been employed for the purpose of predicting postoperative visual acuity, but to date none of these devices can precisely forecast postoperative vision in an individual eye.

Conclusions: Preoperative visual acuities appear to be the most important clinical variants correlating with postoperative visual results. Although advanced OCT techniques have identified preoperative and postoperative anatomical alterations that correlate with preoperative and postoperative visions in groups of eyes, no single specific finding indicates unequivocal visual success, and most reports continue to include examples of exceptions to statistical trends.

Purpose: To study the refractive outcomes of 3-port lens-sparing vitrectomy (LSV) for subtotal retinal detachments due to retinopathy of prematurity (ROP). Lens-sparing vitrectomy may provide superior refractive outcomes by limiting induced myopia of prematurity.

Methods: This is a retrospective, consecutive, nonrandomized, comparative (paired eye) study. Entrance criteria were previous complete ablative laser for threshold ROP in both eyes, followed by LSV in one eye for stage 4A traction retinal detachment. Both eyes then maintained complete retinal attachment. Main outcome variables were cycloplegic refraction, keratometry, and biometric values for axial length, lens thickness, and anterior chamber depth.

Results: Nine patients met inclusion criteria. Lens-sparing vitrectomy eyes were significantly less myopic than control eyes (-6.78 D vs -10.33 D, P < .005). The reduction in myopia in LSV eyes was predominantly due to increased anterior chamber depth (3.81 mm +/- 0.217 vs 2.96 mm +/- 0.232, P < .005). There was a minor contribution from reduced corneal power in LSV eyes (43.89 D +/- 0.253 vs 44.20 D +/- 0.265, P < .005). There was a minor negative impact from increased lens thickness in LSV eyes (3.85 +/- 0.32 mm vs 3.74 +/- 0.31, P < .005). There was no significant difference in axial length or lens power between the LSV and control groups.

Conclusions: The data demonstrate that infant eyes undergoing 3-port LSV for stage 4A ROP develop less myopia than fellow eyes treated with laser alone. The difference is due to posterior displacement of the lens-iris diaphragm with a smaller contribution from reduced corneal power. The reduction in myopia may improve functional outcomes following 3-port LSV for stage 4A ROP.

Purpose: To evaluate the outcomes of consecutive patients who underwent transscleral sutured posterior chamber intraocular lens (TS PCIOL) implantation as well as patients who had combined penetrating keratoplasty (PK) and TS PCIOL.

Methods: Data from all patients who had sutured PCIOL insertion performed by the same surgeon (V.S.N.) between January 2003 and June 2007 were compiled and analyzed.

Results: Group 1 consisted of 69 eyes of 67 patients who had TS PCIOL only. Mean age was 65.1 years, and mean follow-up was 14.25 months. Mean best spectacle-corrected visual acuity (BSCVA) was 20/80 preoperatively and 20/40 postoperatively. Group 2 consisted of 38 eyes of 37 patients who had combined PK and TS PCIOL. Mean age was 70.21 years, and mean follow-up was 14.29 months. Mean BSCVA was <20/250 preoperatively and between 20/70 and 20/80 postoperatively. In both groups, there were no reported cases of choroidal hemorrhage or hyphema. There was one case (0.9%) of suture erosion (group 1). There were no redislocations, lens tilting, suture breakage, or graft rejections. Postoperative complications included uveitis in 1 eye (0.9%), glaucoma in 5 (4.7%), cystoid macular edema in 6 (5.6%), and retinal detachment in 2 (1.9%).

Conclusions: The TS PCIOL procedure, as done by the ab externo method, is safe and effective. It has few intraoperative or postoperative complications, and it improves visual acuity in patients requiring either TS PCIOL alone or combined PK and TS PCIOL. Ultimately, in considering TS PCIOL, patient selection, surgical method, and the surgeon's comfort with the technique must be weighed.

Purpose: To report a retrospective case series of 1127 Trabectome surgical procedures, including 738 Trabectome-only and 366 Trabectome-phacoemulsification surgeries.

Methods: Electroablation of meshwork via a temporal corneal incision. Outcomes included changes in intraocular pressure (IOP) and medication use, complications, and Kaplan-Meier success estimates.

Results: For all cases, mean preoperative IOP of 23.8 +/- 7.7 mm Hg decreased by 39% to 16.5 +/- 4.0 mm Hg at 24 months (n = 50). Intraoperative reflux bleeding occurred in 77.6%. Medications decreased from 2.8 to 1.2 by 24 months. Sixty-five patients (5.8%) had IOP elevation > 10 mm Hg above baseline on day 1. Failure led to trabeculectomy in 5.9% (n = 67) and shunt installation in 1.6% (n = 18). Kaplan-Meier failure was defined across groups with at least 2 weeks follow-up as IOP > 21 mm Hg with or without medications and not reduced by 20% below baseline on 2 consecutive visits or repeat surgery. For Trabectome-only cases, mean preoperative IOP of 25.7 +/- 7.7 mm Hg was reduced by 40% to 16.6 +/- 4.0 mm Hg at 24 months (n = 46). No prolonged hypotony, choroidal effusion, choroidal hemorrhage, or infections occurred. Failure led to trabeculectomy in 8.1% (n = 60) and shunt installation in 1.9% (n = 14). Medications decreased from 2.93 to 1.2 by 24 months. For Trabectome-phacoemulsification cases, baseline IOP of 20.0 +/- 6.2 mm Hg decreased at 12 months to 15.9 +/- 3.3 mm Hg (18%) (n = 45) and medications decreased from 2.63 +/- 1.12 to 1.50 +/- 1.36. Sixteen (4.4%) of 365 had prior failed trabeculectomy, and 139 of 365 (38%) had prior laser trabeculoplasty.

Conclusion: Trabectome offers a minimally invasive method of improving IOP control in open-angle glaucomas.

Purpose: To visualize structural alterations of the cornea, iris, and lens in patients with exfoliation syndrome (XFS) using a noncontact in vivo laser scanning confocal microscope and to correlate these with the clinical features.

Methods: The cornea, iris, and lens of 30 eyes with XFS were imaged using the Rostock Cornea Module of Heidelberg Retina Tomograph II (50x noncontact Nikon lens, an estimated 1 to 2 mum transverse resolution, 500x500-mum field of view). Serial transverse section images, as well as anterior segment photographs, were taken and analyzed.

Results: The corneal stroma and endothelium of 19 eyes (63%) showed different amounts and sizes of scattered small hyperreflective deposits. The irides revealed hyperreflective deposits on the anterior outer surfaces and/or pupillary margin corresponding to exfoliation material (XFM) and/or pigment granules. The anterior lens capsule showed varying degrees of peripupillary fibrillar hyperreflective deposits, hyperreflective areas with apparent epithelial cells centrally, and uniform epithelial cells in the clear intermediate zone. On the anterior capsule in 4 pseudophakic eyes, XFM appeared as hyperreflective round deposits. Hyperreflective floating deposits were seen in the aqueous humor in the pupillary region of the posterior chamber of 6 eyes (20%).

Conclusions: Noncontact in vivo confocal microscopy permits visualization of XFM in the cornea, iris, and lens. This new technique may improve early detection of anterior segment abnormalities by providing information about subclinical cellular pathology, such as early pregranular XFS.