Safety and efficacy of ultrasound ciliary plasty as a primary intervention in glaucoma patients

AIM: To evaluate the safety and the efficacy of the ultrasound ciliary plasty(UCP) on the intraocular pressure(IOP) control in glaucomatous eyes without previous glaucoma surgery.METHODS: A retrospective study included patients with primary and secondary glaucoma who underwent UCP in Dar Al Shifa Hospital, Kuwait between January 2017 to June 2018. High-intensity focused ultrasound procedures were performed under peribulbar anesthesia using the 2^(nd) generation probe with 8 s duration of each of the 6 shots. Complete ophthalmologic examinations were scheduled pre-treatment, and at 1 d, 1 wk, 1, 3, 6 and 12 mo posttreatment. Primary outcomes were the IOP reduction and success rates at 12 mo, while the secondary outcomes were the occurrence of vision threatening complications and visual acuity.RESULTS: The records of 62 eyes of 62 patients were analyzed with mean age of 63.8 y(67.7% males). There was statistically significant reduction in the mean IOP from 35.2±8.3 mm Hg before treatment to 20.6±8.7 mm Hg at 12^(th) month(P<0.0005) with a mean percentage IOP reduction of 42.3% with significant reduction in the mean number of antiglaucomatous drugs from 3.2±0.4 before treatment to 2.1±1.02 at 12 mo(P<0.0005). Qualified success was achieved in 77.4% of eyes at 12 mo. No major intra-or posttreatment complications were reported.CONCLUSION: Second-generation UCP prove to be effective in reducing IOP in naive glaucoma patients with lower success rates in cases of neovascular and uveitic glaucomas.

Childhood glaucoma profile in Dakahelia, Egypt: a retrospective study

AIM： To analyze childhood glaucoma regarding its demographics, presentations, different causes and surgical modalities used among patients in Dakahelia and to apply the Childhood Glaucoma Research Network（CGRN） classification retrospectively to evaluate its convenience.METHODS： A retrospective study in which the medical files of all glaucoma patients 〈16 years old presented to Mansoura Ophthalmic Center, Mansoura University from 2014 to 2017, were retrieved and analyzed. Collected data included： age, gender, laterality, visual acuity（VA）, refraction, intraocular pressure（IOP）, corneal diameter, cup-disc ratio, types and number of surgeries and antiglaucomatous drugs（AGD） at the first and last visit. Prevalence of different subtypes was calculated and means of clinical features were compared.RESULTS： A total of 305 eyes of 207 patients were included classified into 6 groups： primary congenital glaucoma（PCG）, juvenile open angle glaucoma（JOAG）, glaucoma associated with systemic disease, glaucoma associated with ocular anomalies, acquired glaucoma and glaucoma following cataract surgery. PCG was the predominant type（55.1%） followed by acquired glaucoma（29.5%）. Males represented 63.8% of the whole studied patients. Glaucoma associated with ocular anomaly group showed the youngest age at diagnosis（21.9±30.0 mo）. The shortest corneal diameter was recorded in post cataract group（10.4±0.5 mm）. Highest cup-disc ratio was found in the PCG group（P〈0.0005）. Glaucoma associated with systemic disease presented with the highest baseline IOP（34.5±5.0 mm Hg）. All the cases with PCG were treated surgically with 21.8% required more than one surgery. The majority of the patients（74.2%） in the acquired group were treated medically. Combined trabeculotomy-trabeculectomy was the most frequent operation done, accounting for 34.5% of all primary surgeries. Ahmed valve implantation comprised 87% of the secondary surgeries. Acquired glaucoma group had the highest percent of eyes with good final Snellen＇s VA（69.4%）, while glaucoma associated with ocular anomaly group had poorest final VA. CONCLUSION： PCG is the most prevalent type of childhood glaucoma, followed by acquired glaucoma especially traumatic hyphema. Combined trabeculotomytrabeculectomy and Ahmed valve implantation are the most common surgical interventions. CGRN classification is found to provide a consensus skeleton and is recommended to be integrated in our routine ongoing clinical practice.

Collagen crosslinking with photoactivated riboflavin in advanced infectious keratitis with corneal melting: Electrophysiological Study

AIM: To assess the effect of photoactivated chromophore for keratitis crosslinking(PACK-CXL) in case of severe keratitis with melting on the electrophysiological function of the retina and the optic nerve.METHODS: The study included 32 eyes of 32 patients with smear positive severe infectious keratitis with corneal melting. The patients were randomly divided into two groups. Group I(control group) included 16 eyes received systemic and topical antimicrobial drugs guarded by culture and sensitivity test. Group II underwent CXL and then continued their antimicrobial treatment. Full field electroretinogram(ERG) and flash visual evoked potential(VEP) were done for each patient in both groups basically and then 1 wk, 1 and 3 mo post-treatment to assess the changes in the electrophysiological function of the retina and optic nerve.RESULTS: Healing of 10 eyes in group I in comparison to 14 eyes in group II was recorded. The mean duration of healing was 36.56±5.21 d in group I vs 20.2±4.4 d in group II(P<0.005). In group II, ERG showed an insignificant reduction of all parameters of ERG and VEP after CXL. The amplitude of scotopic rod response, oscillatory potential amplitude, flicker amplitude and photopic cone response were insignificantly decreased(P=0.4, 0.8, 0.1, and 0.3 respectively). There were insignificant prolongation of latencies of scotopic rod, oscillatory potential, flicker and photopic cone response(P=0.2, 0.7, 0.5 and 0.1). There was slight delay in latency of VEP without a significant reduction in amplitude.CONCLUSION: CXL is an effective technique in treatment of severe infectious keratitis with melting as it halts the melting process with acceptable safety on the retinal and optic nerve function.

Launching a paradigm for first and redo-surgery in primary congenital glaucoma: institutional experience

AIM: To evaluate the outcome of the initial and the redo-surgeries for primary congenital glaucoma(PCG) correlated to its degree of severity. METHODS: A retrospective study involved patients with PCG presented between 2010 and 2018. Medical records were reviewed to assess the degree of the preoperative severity according to the intraocular pressure(IOP), corneal diameter and corneal edema. Success and failure rates were calculated for both first and redo-surgeries at 6 and 12 mo respectively then correlated to the severity of the cases. RESULTS: Complete records were retrieved for 272 eyes(153 patients) with PCG: 43 eyes were mild, 136 moderate and 93 severe. Combined trabeculotomy and trabeculectomy(CTT) had the highest success rate in moderate(96.4%) and severe cases(59.3%) while trabeculotomy had the highest success rate in mild cases(96.3%). Medical records of 88 eyes(63 patients) with recurrent PCG were analyzed, most with severe presentation(59 eyes). Ahmed glaucoma valve(AGV) was used in 67(76%) eyes and augmented trabeculectomy in 21(24%) eyes. At 12 mo, there was no statistically significant difference between both surgeries in total success rate(P=0.256). For mild cases, success rate was 100% for both surgeries. Severe cases had higher success rates following AGV(87%) than augmented trabeculectomy(20%). Preoperative severity of the disease was an independent factor affecting the failure rate in secondary trabeculectomy but not in AGV. Patients younger than 24 mo had higher probabilities of failure following both redo-surgeries with hazard ratio =1.325 and 0.37 for augmented trabeculectomy and AGV respectively. CONCLUSION: Preoperative assessment of the severity of eyes with PCG helps in the selecting the optimal primary and secondary surgery. For first surgery, trabeculotomy is more effective in mild cases whereas; CTT and augmented subscleral trabeculectomy(SST) are appropriate for moderate and severe cases. AGV proved to be superior to augmented SST in severe recurrent cases.

Efficacy of topical dorzolamide 2% in diabetic cystoid macular edema

AIM:To study the effect of topical dorzolamide 2%on macular thickness reduction in diabetic cystoid macular edema(CME).METHODS:This was a prospective,non-randomized,open study including eyes with diabetic macular edema(DME).All eyes received topical dorzolamide 2%three times daily for one month.Changes in best-corrected visual acuity(BCVA),and central macular thickness(CMT)by optical coherence tomography were evaluated at 1 wk,1,and 3 mo post-treatment.RESULTS:Ninety-three eyes(84 patients)were included.Mean±SD(log MAR)BCVA improved significantly from 1.08±0.26 pretreatment to 0.66±0.24 at 1 mo and 0.87±0.26 at 3 mo post-treatment(P<0.001 both).The mean±SD CMT was significantly reduced from 535.27±97.4μm at baseline to 357.43±125.8μm at 1 mo and 376.23±114.5μm at 3 mo post-treatment(P<0.001 both).No significant ocular or systemic side effects were recorded.CONCLUSION:Topical dorzolamide 2%results in significant improvement of mean BCVA and reduction of mean CMT at 3 mo post-treatment.It can be used as an effective,affordable,and safe therapy for treatment of nonrefractory diabetic CME.

An Ex-Press implant versus trabeculectomy in a fibrotic bleb with late failure after previous trabeculectomy

AIM: To compare the outcome of an Ex-Press implant and subscleral trabeculectomy(SST) in the management of glaucoma after previous trabeculectomy on a fibrotic bleb.METHODS: This randomized prospective study included 28 eyes from 28 patients(age range: 42-55 y) with primary open angle glaucoma(POAG) presented with elevated intraocular pressure(IOP) with fibrotic bleb despite previous SST for more than 4 mo. The eyes enrolled in the study were divided into two groups: group I(subjected to Ex-Press implant surgery) and group II [subjected to SST with mitomycin C(MMC)]. The follow-up continued one year after surgery to evaluate IOP, visual acuity(VA), visual field(VF), and postoperative complications. RESULTS: A significant decrease in IOP was found in both groups with a higher reduction in Ex-Press implant surgery with the mean IOP of 14.50 mm Hg(P=0.001), while the SST group recorded the mean IOP of 16.50 mm Hg(P=0.001) after one year. However, the difference between the two groups in terms of the decrease in IOP was insignificant. Fewer postoperative complications were recorded in the Ex-Press implant surgery and more cases requiring further anti-glaucomatous medications were seen in the SST group. Both groups showed stability in terms of VA and VF.CONCLUSION: Ex-Press implant surgery and SST with MMC are two surgical alternatives for controlling IOP in late failure that occurs more than 4 mo after previous SST with a fibrotic bleb. However, Ex-Press shunt is a safer surgery with fewer complications.