Mitomycin-C supplemented trabeculectomy, phacoemulsification, and foldable lens implantation

Purpose: To evaluate the outcome of combined mitomycin-C filtering surgery, phacoemulsification, and foldable intraocular lens (IOL) implantation. Setting: Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA. Methods: This retrospective study evaluated 182 eyes of 174 patients who had combined mitomycin-C trabeculectomy, phacoemulsification, and insertion of a foldable IOL through a 3.5 mm incision. Success of the combined procedure was defined as intraocular pressure (IOP) below 21 mm Hg, with or without medications, and no serious complication. Success rates were calculated using the Kaplan-Meier actuarial method. Results: Mean follow-up was 16.7 months ± 5.4 (SD). The probability of success at 6, 12, 18, and 24 months was 98.3, 95.6, 90.6, and 88.0%, respectively. When compared with preoperativety, visual acuity improved one or more lines in 148 eyes (81.3%) and worsened one or more lines in 15 (8.2%); 111 eyes (61.0%) achieved visual acuity of 20/40 or better. The most frequent complication was posterior capsule opacification requiring capsulotomy, which occurred in 22 cases (12.0%). Conclusion: The 1 year and 2 year IOP control rate of combined mitomycin-C filtering procedures and phacoemulsification in glaucoma patients was high.

The outcome of the functioning filter after subsequent cataract extraction

OBJECTIVE: To evaluate and compare the outcome of functioning filtration surgery followed by cataract surgery with posterior intraocular lens implantation by both phacoemulsification and extracapsular cataract extraction (ECCE) techniques in glaucomatous eyes. PATIENTS AND METHODS: We retrospectively evaluated the clinical course of 77 eyes (68 patients) that after successful trabeculectomy, underwent cataract surgery by either phacoemulsification or ECCE techniques. We determined the frequency of partial and absolute failure following cataract surgery by either phacoemulsification or ECCE in eyes with functioning trabeculectomies. Partial failure of intraocular pressure (IOP), control after cataract extraction was defined as the need for an increased number of antiglaucoma medications or argon laser trabeculoplasty to maintain IOP =21mm Hg. Complete failure of IOP control after cataract surgery was defined as an IOP >21 mm Hg on at least two consecutive measurements one or more weeks apart or the performance of additional filtration surgery. Failure rates were calculated using the Kaplan-Meier actuarial method. Failure rates between phacoemulsification and ECCE subgroups were compared using the log rank test. RESULTS: The probability of partial failure by the third postoperative year after cataract surgery was 39.5% in the phacoemulsification subgroup and 37.3% in the ECCE subgroup. This small difference is not statistically significant (P = 0.48). The probability of complete failure by the fourth postoperative year after cataract surgery was 12.0% in the phacoemulsification subgroup and 12.5% in the ECCE subgroup. This difference is also not statistically significant (P = 0.77). At the 6-month follow-up visit, visual acuity of both groups improved one or more lines in 87.0% of patients, and worsened one or more lines in 3.9% of patients. Sixty-one percent achieved visual acuity of 20/40 or better. The most frequent complication was posterior capsular opacification requiring laser capsulotomy that occurred in 31.2% of patients. CONCLUSION: Cataract extraction by either phacoemulsification or ECCE following trabeculectomy surgery may be associated with a partial loss of the previously functioning filter and the need for more antiglaucoma medications to control IOP.

Effect of cataract extraction on the Glaucoma Progression Index (GPI) in glaucoma patients

PURPOSE: To determine the effect of cataract extraction on the glaucoma progression index (GPI) in glaucoma patients with coexisting cataract.

PATIENTS AND METHODS: This is a retrospective noncomparative study. Consecutive eligible patients with glaucoma who underwent phacoemulsification alone or in combination with augmented trabeculectomy were included. All patients had Swedish Interactive Threshold Algorithm-standard 24-2 visual fields within 10 months of surgery. Exclusion criteria included other ocular morbidity, intraoperative complications, and perimetric reliability indices greater than 33%. Comparison was made between the immediate visual fields before and after surgery. The main outcome measure was the change in GPI. Changes in the pattern standard deviation (PSD) and mean deviation (MD) were also assessed. Comparison of means was performed with the paired t test.

RESULTS: Thirty-three eyes of 33 patients (all Whites) were analyzed. The mean age at surgery was 77.0+/-8.7 years. Visual field tests were performed 3.3+/-3.0 months SD before surgery and 5.4+/-2.6 months after surgery. There was a statistically significant increase in the GPI after cataract surgery (from 71.5+/-18.5% to 74.6+/-17.1%; P=0.02). The improvement in MD was also statistically significant (from -11.8+/-5.3 to -10.2+/-5.3 dB; P <0.01), but the change in PSD did not reach statistical significance.

CONCLUSIONS: Uncomplicated cataract extraction resulted in a statistically significant improvement in the 24-2 Swedish Interactive Threshold Algorithm-standard GPI and MD, but not in PSD. Both the MD and the GPI may be influenced by lens opacities, which could make detection of glaucoma visual field progression more difficult for clinicians in glaucoma patients with concurrent cataract.

Surgical checklist for cataract surgery:progress with the initiative by the Royal College of Ophthalmologists to improve patient safety

PurposeThe World Health Organisation (WHO) identified patient safety in surgery as an important public health matter and advised the adoption of a universal peri-operative surgical checklist. An adapted version of the WHO checklist has been mandatory in the National Health Service since 2010. Wrong intraocular lens (IOL) implantation is a particular safety concern in ophthalmology. The Royal College of Ophthalmologists launched a bespoke checklist for cataract surgery in 2010 to reduce the likelihood of preventable errors. We sought to ascertain the use of checklists in cataract surgery in 2012.Patients and methodsA survey of members of the Royal College of Ophthalmologists seeking views on the use of checklists in cataract surgery. Four hundred and sixty-nine completed responses were received (18% response rate).ResultsRespondents worked in England (75%), Scotland (11%), Wales (5%), Northern Ireland (2%), the Republic of Ireland (1%), and overseas (6%). Ninety-four per cent of respondents support the use of a checklist for cataract surgery and 85% say that they always use a checklist before cataract surgery. Sixty-seven per cent of cataract surgeons stated they undertake a pre-operative team brief. Thirty-six per cent use a cataract surgery checklist developed locally, 18% use the college's bespoke cataract surgery checklist, 39% use a generic surgical checklist, and 4% reported that they do not use a checklist.ConclusionNinety-three per cent of cataract surgeons responding to the questionnaire report using a surgical checklist and 67% use a team brief. However, only 54% use a checklist, which addresses the selection of the correct intraocular implant. We recommend wider adoption of checklists, which address risks relevant to cataract surgery, in particular the possibility of selection of an incorrect IOL.Eye advance online publication, 24 May 2013; doi:10.1038/eye.2013.101.

Role of glycation in modification of lens crystallins in diabetic and nondiabetic senile cataracts

To assess the significance of glycation, nonenzymatic browning, and oxidation of lens crystallins in cataract formation in elderly diabetic patients, we measured three distinct products of glycation, browning, and oxidation reactions in cataractous lens crystallins from 29 diabetic patients (mean +/- SD age 72.8 +/- 8.8 yr) and 24 nondiabetic patients (age 73.5 +/- 8.3 yr). Compounds measured included 1) fructoselysine (FL), the first stable product of glycation; 2) pentosidine, a fluorescent, carbohydrate-derived protein cross-link between lysine and arginine residues formed during nonenzymatic browning; and 3) N epsilon-(carboxymethyl)lysine (CML), a product of autoxidation of sugar adducts to protein. In diabetic compared with nondiabetic patients, there were significant increases (P less than 0.001) in HbA1 (10.2 +/- 3.1 vs. 7.1 +/- 0.7%), FL (7.6 +/- 5.4 vs. 1.7 +/- 1.2 mmol/mol lysine), and pentosidine (6.3 +/- 2.8 vs. 3.8 +/- 1.9 mumol/mol lysine). The disproportionate elevation of FL compared with HbA1 suggests a breakdown in the lens barrier to glucose in diabetes, whereas the increase in pentosidine is indicative of accelerated nonenzymatic browning of diabetic lens crystallins. CML levels were similar in the two groups (7.1 +/- 2.4 vs. 6.8 +/- 3.0 mmol/mol lysine), providing no evidence for increased oxidative stress in the diabetic cataract. Thus, although the modification of lens crystallins by autoxidation reactions was not increased in diabetes, the increase in glycation and nonenzymatic browning suggests that these processes may acclerate the development of cataracts in diabetic patients.

Effect of diabetes and aging on carboxymethyllysine levels in human urine

Carboxymethyllysine (CML) has been identified as a modified amino acid that accumulates with age in human lens proteins and collagen. CML may be formed by oxidation of fructoselysine (FL), the Amadori adduct formed on nonenzymatic glycosylation of lysine residues in protein, or by reaction of ascorbate with protein under autoxidizing conditions. We proposed that measurements of tissue and urinary CML may be useful as indices of oxidative stress or damage to proteins in vivo. To determine the extent to which oxidation of nonenzymatically glycosylated proteins contributes to urinary CML, we measured the urinary concentrations of FL and CML in diabetic (n = 26) and control (n = 28) patients. The urinary concentration of FL correlated strongly with HbA1 measurements and was significantly higher in diabetic compared with control samples (9.2 +/- 6.5 and 4.0 +/- 2.8 micrograms/mg creatinine, respectively; P less than 0.0001). There was also a strong correlation between the concentrations of CML and FL in both diabetic and control urine (r = 0.67, P less than 0.0001) but only a weakly significant increase in the CML concentration in diabetic compared with control urine (1.2 +/- 0.5 and 1.0 +/- 0.3 micrograms/mg creatinine, respectively; P = 0.05). The molar ratio of CML to FL was significantly lower in diabetic compared with control patients (0.25 +/- 0.12 and 0.43 +/- 0.16, respectively; P less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence and rate of rhegmatogenous retinal detachment seven years after cataract surgery in patients with high myopia

Background: Cataract extraction is the most commonly performed surgery in the National Health Service. Myopia increases the risk of postoperative rhegmatogenous retinal detachment (RRD). The aim of this study was to determine the incidence and rate of RRD seven years after cataract extraction in highly myopic eyes. Methods: Retrospective review was performed of notes of all high myopes (axial length 26.0 mm or more) who underwent cataract extraction during the study period in one centre. Results: 84 eyes met the study criteria. Follow-up time from surgery was 93 to 147 months (median 127 months). The average axial length was 28.72 mm (sd 1.37). Two eyes developed post-operative RRD; the incidence was 2.4% and the rate one RRD per 441.6 person-years. The results of 15 other studies on the incidence of RRD after cataract extraction in high myopia were pooled and combined with our estimate. Conclusion: Both patients in our study who developed RRD had risk factors for this complication as well as high myopia. Risk factors are discussed in the light of our results and the pooled estimate. Our follow-up time is longer than most. Future case series should calculate rates to allow meaningful comparison of case series. © The Ulster Medical Society, 2009.

OPTIMIZATION OF THE SLOW-MODE PLASMON POLARITON IN LIGHT-EMITTING TUNNEL-JUNCTIONS

Light emitted from metal/oxide/metal tunnel junctions can originate from the slow-mode surface plasmon polariton supported in the oxide interface region. The effective radiative decay of this mode is constrained by competition with heavy intrinsic damping and by the need to scatter from very small scale surface roughness; the latter requirement arises from the mode's low phase velocity and the usual momentum conservation condition in the scattering process. Computational analysis of conventional devices shows that the desirable goals of decreased intrinsic damping and increased phase velocity are influenced, in order of priority, by the thickness and dielectric function of the oxide layer, the type of metal chosen for each conducting electrode, and temperature. Realizable devices supporting an optimized slow-mode plasmon polariton are suggested. Essentially these consist of thin metal electrodes separated by a dielectric layer which acts as a very thin (a few nm) electron tunneling barrier but a relatively thick (several 10's of nm) optically lossless region. (C) 1995 American Institute of Physics.

INTERPLAY OF CAF2 SUBSTRATE ROUGHENING AND FILM DEPOSITION RATE ON RADIATIVE SCATTERING OF SURFACE-PLASMON POLARITONS FROM AG FILMS

The radiative decay of surface plasmon polaritons has been investigated in an attempt to characterize the surface roughness of Ag films prepared under different conditions. The polaritons were excited by the method of attenuated total reflection of light. The films were deposited on the face of a 60-degrees BK-7 glass prism at a rate that was deliberately fixed in two different ranges (centred on 0.1 and 10 nm s-1) and in some cases a CaF2 underlayer was used to roughen the film surfaces. The intensity of the scattered light emitted from the opposite face of the films was measured as a function of direction for each using the same sensitivity scale and was correlated with the preparation of the film. It was found that on nominally smooth substrates fast-deposited thinner films give out more light and are deduced to have greater short wavelength (300-600 nm) roughness amplitude. There is also evidence for long wavelenth (7 mum) periodic roughness due to the prism substrate itself. On CaF2 roughened surfaces the light output from the films is further increased and the peak intensity is backward directed with respect to the exciting laser beam direction. Here roughness on a lateral scale of 350 nm is responsible. Also, elastic scattering of surface plasmon polaritons at grain boundaries reduces the light output from fast deposited, small grain, films on CaF2 roughened surfaces. Overall, a consistent picture of roughness induced radiative polariton decay emerges for all cases studied.

DEPENDENCE OF LIGHT OUTPUT FROM NOMINALLY SMOOTH AL-OX-AU TUNNEL-JUNCTIONS ON ELECTRODE MORPHOLOGY

The light output from nominally smooth Al-Ox-Au tunnel junctions is observed to be substantially independent of the deposition rate of the Au film electrode. Films deposited quickly (2 nm s-1) and those deposited slowly (0.16 nm s-1) have similar spectral dependences and intensities. (This is in contrast to roughened films where those deposited quickly give out less light, especially towards the blue end of the spectrum.) The behaviour can be interpreted in terms of the ratio l(ph)/l(em) where l(ph) and l(em) are the mean free paths of surface plasmons between external photon emissions and internal electromagnetic absorptions respectively. Once l(ph)/l(em) exceeds 100, as it does on smooth films, grain size has little further effect on the spectral shape of the light output. In fast-deposited films there are two compensating effects on the output intensity: grain boundary scattering decreases it and greater surface roughness increases it.

Investigating the dynamics of laser induced sparks in atmospheric helium using Rayleigh and Thomson scattering

We have used optical Rayleigh and Thomson scattering to investigate the expansion dynamics of laser induced plasma in atmospheric helium and to map its electron parameters both in time and space. The plasma is created using 9 ns duration, 140 mJ pulses from a Nd:YAG laser operating at 1064 nm, focused with a 10 cm focal length lens, and probed with 7 ns, 80 mJ, and 532 nm Nd:YAG laser pulses. Between 0.4 μs and 22.5 μs after breakdown, the electron density decreases from 3.3 × 1017 cm−3 to 9 × 1013 cm−3, while the temperature drops from 3.2 eV to 0.1 eV. Spatially resolved Thomson scattering data recorded up to 17.5 μs reveal that during this time the laser induced plasma expands at a rate given by R ∼ t0.4 consistent with a non-radiative spherical blast wave. This data also indicate the development of a toroidal structure in the lateral profile of both electron temperature and density. Rayleigh scattering data show that the gas density decreases in the center of the expanding plasma with a central scattering peak reemerging after about 12 μs. We have utilized a zero dimensional kinetic global model to identify the dominant particle species versus delay time and this indicates that metastable helium and the He2 + molecular ion play an important role.

Measurement of The Dynamic Response of Compressed Hydrogen by Inelastic X-Ray Scattering

Measurement of the dynamic properties of hydrogen and helium under extreme pressures is a key to understanding the physics of planetary interiors. The inelastic scattering signal from statically compressed hydrogen inside diamond anvil cells at 2.8 GPa and 6.4 GPa was measured at the Diamond Light Source synchrotron facility in the UK. The first direct measurement of the local field correction to the Coulomb interactions in degenerate plasmas was obtained from spectral shifts in the scattering data and compared to predictions by the Utsumi-Ichimaru theory for degenerate electron liquids.