How to cite this article:
Thangamathesvaran L, Crane E, Modi K, Khouri AS. Outcomes of Resident-versus attending-performed Tube Shunt Surgeries in a United States Residency Program. J Curr Glaucoma Pract 2018; 12 (2):53-58.
Introduction: Glaucoma is a chronic optic neuropathy with increasing global prevalence, necessitating trainees in ophthalmology to be well-trained in the surgical modalities used to manage glaucoma. It is also important to not compromise patient safety and treatment efficacy for training and education. The purpose of our analysis is to compare postoperative outcomes of resident versus (vs.) attending performed tube shunt surgeries (TS).
Materials and methods: A retrospective, chart review was performed of patients who had undergone TS between 2009 and 2015 at Rutgers University in Newark, New Jersey, USA. Inclusion criteria was patients with a confirmed diagnosis of glaucoma, who underwent either an Ahmed or Baerveldt TS, and had at least two evaluation visits before the surgery to establish baseline characteristics. Exclusion criteria were patients with follow up for less than 1 year. The main outcome measure was the surgical success at 1 year follow up after TS. Surgical success was defined according to recommendations from the Glaucoma Surgical Trials guidelines published by the World Glaucoma Association (WGA):
20% reduction in IOP and absolute IOP ≤ 21 mm Hg (criteria 1)
30% reduction in IOP and absolute IOP ≤ 18 mm Hg (criteria 2)
Results: A total of 120 cases: 60 attending and 60 resident cases that met all the inclusion criteria and none of the exclusion criteria were included. The mean intraocular pressure (IOP) one year post surgery were 15.06 ± 3.55 and 15.21 ± 5.17 mm Hg for attendings and residents respectively (p = 0.422). At the 1 year time point, 87% of resident cases and 95% of attending cases met the qualifications of criteria 1 for success. Kaplan Meier analysis was performed and did not show a significant difference in the outcome (p = 0.325). At the 1 year time point, 80% of attending and resident cases met the qualifications of criteria 2 for success. Kaplan–Meier analysis was performed and did not show a significant difference in the outcome (p = 0.401). There were no differences in complication and failure rates between resident and attending performed cases. Resident-performed cases had a longer intraoperative time in comparison to attending performed cases (p = 0.02).
Conclusion: Resident-performed surgeries are as effective as attending performed surgeries. Resident-performed TS does not compromise safety and better prepares future physicians to deliver optimal care.
Clinical Significance: Attendings may consider incorporating more resident performed, attending supervised TS procedures into their clinical practice as surgical training to manage common ophthalmological conditions like glaucoma is essential to residency training.
Zeba A Syed,
Ali F Yahya,
Samir A Melki
Introduction: A continuous method of measuring intraocular pressures (IOP) could be advantageous in the management of glaucoma. This report aims to analyze the potential savings from visit reduction of continuous IOP measurements obtained with an intraocular device.
Materials and methods: We constructed a model adapted from a prior study based on the number of glaucoma patients among 5% of the Medicare population.
Results: We found that the implementation of a device that continuously measures IOP can result in a reduction of 23.21% in yearly costs from glaucoma outpatient visits.
Conclusion: Continuous IOP monitoring has the potential to alleviate the economic burden of the current management structure of patients with glaucoma.
Clinical Significance: In an era of elevated healthcare costs, continuous IOP monitoring offers an option to improve the care of glaucoma patients through visit reduction, also resulting in a 23.21% reduction in yearly expenses related to glaucoma clinical visits.
Karl J Mercieca,
Cecilia H Fenerty,
Laura R Steeples,
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Mercieca KJ, Fenerty CH, Steeples LR, Drury B, Bhargava A. Precipitants of 5-Fluorouracil in Trabeculectomy Bleb Management: A Comparative Laboratory Study. J Curr Glaucoma Pract 2018; 12 (2):64-66.
Aim: Concerns regarding 5-Fluorouracil (5-FU) corneal toxicity have resulted in various ways of reducing its corneal exposure during post-operative trabeculectomy bleb manipulation. This study investigates the properties of various topical agents used to induce the precipitation of this compound.
Materials and methods: This is a double-blind, descriptive, laboratory study comparing five different potential precipitants of 5-FU (proxymetacaine (proxy), oxybuprocaine (oxy), amethocaine (ameth), fluorescein (flor), proxymetacaine + fluorescein (proxy-flor) to a control group (normal saline). A 0.01 mL of each anonymized agent was applied next to a clear round comparison marker in a transparent sterile container set on a dark background. 5-FU (0.01 mL of 50 mg/mL) was subsequently applied to each agent. The induced changes in transparency were imaged and compared to the transparency of the central marker. For each application, pH changes were also noted.
Results: Proxy, flor and proxy + flor did not result in any discernible 5-FU precipitation. Oxy resulted in a moderate visible change, and ameth produced very significant precipitation. Application of proxy, oxy, ameth, and proxy + flor resulted in the neutralization of the 5-FU\'s alkaline pH.
Conclusion: We propose using a cotton-tipped bud dipped in ameth applied at the injection site as the recommended method to avoid 5-FU corneal exposure in these cases.
Clinical significance: Practitioners should be aware of the differences in precipitation of 5-FU by different types of topical anesthetics and modify techniques of anesthesia and 5-FU administration accordingly.
Iqbal Ike K Ahmed
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Popovic M, Campos-Möller X, Saheb H, Ahmed II. Efficacy and Adverse Event Profile of the iStent and iStent Inject Trabecular Micro-bypass for Open-angle Glaucoma: A Meta-analysis. J Curr Glaucoma Pract 2018; 12 (2):67-84.
Aim: This meta-analysis explores the efficacy and adverse event profile of the iStent, an ab interno implant for the treatment of open-angle glaucoma.
Methods: A systematic literature search of Ovid MEDLINE and EMBASE was used to identify peer-reviewed original studies that provided efficacy data on the first or second generation iStent for at least five eyes. Intraocular pressure (IOP) was the primary efficacy endpoint, while the number of medication classes was the secondary outcome. Weighted mean differences were reported for continuous endpoints, while a relative risk was computed for dichotomous variables.
Review Results: The search revealed 545 results, of which 1767 eyes from 28 studies were included. The cohort age was 71.4 ± 5.4 years, and 44.9% of patients were male. There was a significantly greater IOP reduction after the use of two first-generation stents compared to one, irrespective of phacoemulsification status (p < 0.001). Additionally, there was a significantly greater IOP reduction following iStent alone relative to phaco-iStent for the first-generation iStent (p < 0.001) and the iStent inject (p < 0.001). For the first generation stent, combined phaco-iStent provided a greater level of IOP reduction (p < 0.001) and reduction in the number of medication classes relative to phacoemulsification alone (p < 0.001). In total, 22.5% of eyes that received iStent implantation sustained some type of adverse event. The most common adverse events were intraocular pressure elevation, stent blockage or obstruction, stent malposition and hyphema.
Conclusion and Clinical Significance: Statistically significant differences in efficacy outcomes exist between different numbers of stents and the presence or absence of concurrent phacoemulsification.
Tageldin M Othman,
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Elbably A, Othman TM, Mousa A, Elridy M, Badawy W, Elbably M. Deep Sclerectomy with Porous Collagen in Open-angle Glaucoma, Short-term Study. J Curr Glaucoma Pract 2018; 12 (2):85-89.
Aim: To assess the role of porous collagen in deep sclerectomy (DS), with and without trabeculo-Descemet membrane (TDM) rupture.
Patients and methods: Forty-six eyes with different types of open-angle glaucoma and medically uncontrolled intraocular pressure (IOP) were selected. DS was performed in all cases. Ologen was implanted as a single large piece in the scleral lake and subconjunctival space in all cases with and without TDM rupture.
Results: A total sample of 46 open-angle glaucoma patients were included in the study. The mean ± standard deviation (SD) IOP was 25.6 mm Hg ± 10.6 (range 12–58 mm Hg) preoperatively. On follow-up, the mean ± SD IOP was 6.1 mm Hg ± 3.7 (range 2–20 mm Hg) 1 day postoperatively and 9.3 mm Hg ± 4.0 (range 4–23 mm Hg) after 1 month of follow-up, at 12 months the IOP was at 12.1 mm Hg ± 3 (range 8–18 mm Hg). The overall mean ± SD IOP reduction percentage was 48.3% ± 21.3 (range 0.0–86.2).
Comparing mean IOP reductions at last follow-up between TDM rupture cases and non-TDM cases (Mann–Whitney test), the mean ± SD IOP reduction in TDM rupture patients was 12.1 ± 8.0 mm Hg (range 2-27) meanwhile, in non-TDM rupture patients it was 14.3 ± 11.4 mm Hg (range 0–50). However, the difference in IOP reduction between the two groups was not significant. (p = 0.689)
Conclusion: Porous collagen can enhance the results of DS; also, it helps to proceed with DS in cases of TDM rupture without converting to trabeculectomy.
How to cite this article:
Shah S, Rana M, Pandey P, Masood I. Endoscopic Goniosynechialysis for Acute Angle Closure Glaucoma Following Descemet\'s Stripping Automated Endothelial Keratoplasty. J Curr Glaucoma Pract 2018; 12 (2):90-93.
We describe a new modified technique to release the peripheral iridocorneal adhesions that formed after Descemet stripping automated endothelial keratoplasty. The usual technique of goniosynechialysis was modified and performed using endoscopic fiber-optic light and camera probe to aid visualization of the adherent iris tissue and carry out uneventful 270 degrees release of adhesions. The iris tissue was gently pulled away using micro forceps. The modified technique was conceptualized, as the view from the cornea was very poor due to recent lamellar surgery and corneal oedema secondary to poorly controlled intraocular pressure. The blocked trabecular meshwork system was successfully recanalized, which allowed an adequate control of intraocular pressure. The graft survived the insult and cornea gained complete clarity giving the patient the desired vision and improved quality of life.
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Singh K, Mutreja A, Bhattacharyya M, Dangda S, Jaisingh K. Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins. J Curr Glaucoma Pract 2018; 12 (2):94-98.
Aim: To report a case of bilateral phacomatosis pigmentovascularis (PPV), in a young male, presenting with developmental glaucoma and high myopia along with systemic features of klippel trenanauy weber (KTW) syndrome.
Background: The co-existence of oculodermal melanocytosis (ODM)and port-wine stain was termed PPV by Ota. Port-wine stain presents as part of Sturge-Weber syndrome (SWS). KTW presents with varicose veins and tissue hypertrophy alongwith port-wine stain.
Case Description: A 22-year-old male presented with decreased vision owing to high myopia and advanced glaucoma. Incidental findings noted were pigmentary naevi along with facial port-wine stain, which collectively comprises PPV. Also noted were bilateral varicose veins which are usually seen in association with KTW. In view of advanced visual field damage and inability to control intraocular pressures (IOP) on topical medications, he underwent Glaucoma filtration surgery in both eyes. Intra-operatively care was taken to avoid sudden decompression by controlled anterior chamber paracentesis, and scleral flap closure with releasable sutures was done to prevent hypotony related complications in the immediate postoperative period. Such precautions lead to an uneventful postoperative recovery, and even at 3 years’ follow-up, the patient is maintaining IOP in early teens along with a stable visual acuity and visual fields.
Conclusion: This case highlights the overlapping features of congenital conditions like oculodermal melanocystosis (ODM), SWS, KTW; presenting in a young male. Systemic features reported less frequently with PPV, included palatal pigmentation and palatal vascular malformations.
Clinical Significance: This case re-emphasizes a common origin of these entities, PPV and KTW, from the neural crest cells. Early recognition of the systemic features and timely surgical intervention under appropriate precautions, can be vision salvaging in such cases of developmental glaucoma.