Granulomatous uveitis and congenital cataract: a rare association.

INTRODUCTION: The association of a granulomatous uveitis and congenital cataract and is rarely observed in newborn children. We describe the history of two patients presenting simultaneously with these two features in the absence of a TORCH infection. PATIENTS AND METHODS: The first patient, a boy born in 1997, presented to our hospital two days after birth with multiples Koeppe's and Busacca's nodules and bilateral cataract. The second patient, a boy born in 2006, was referred two weeks after birth. He presented with a severe unilateral granulomatous uveitis, multiples iris nodules, a high intraocular pressure of 45 mmHg and a congenital cataract. THERAPY AND OUTCOME: Lens extraction produced a rapid resolution of uveitis in these two patients. TORCH infection was ruled out in both children by history, extensive serologies performed simultaneously in mother and child or PCR of ocular fluids. CONCLUSIONS: A congenital cataract associated with a granulomatous uveitis is an extremely rare association. The removal of the lens resulted in complete resolution of the inflammation: a phacogenic mechanism could be at the origin of ocular inflammation in both cases.

Evaluation Of "Safe" Trabeculectomy Versus "Safe" Phacotrabeculectomy

Purpose: To evaluate the safety and efficacy of "safe" trabeculectomy (ST) versus "safe" phacotrabeculectomy (SPT).Methods: This study included 72 eyes with medically uncontrolled chronic glaucoma who underwent fornix based trabeculectomy with adjustable/releasable sutures and intraoperative mitomycin C ± phacoemulsification. 36 eyes underwent SPT and 36 eyes had ST. There was no difference between groups for age, intraocular pressure (IOP), diagnosis and gender. Subconjunctival antimetabolite injections and bleb needlings were administered according to bleb vascularity and IOP trends. Main outcome measures were: success rate (definition: IOP≤21mmHg and 20% IOP reduction); number of antimetabolite injections; bleb needlings; glaucoma medications and complications.Results: Mean age (SPT vs ST) was 72.7±12.1 years vs 72.3±12.9 years; p=0.44. Mean preoperative IOP was 24.5±8.8 mmHg vs 24.3±8.2 mmHg; p=0.46. Postoperative IOP was 13.1±4.5mmHg vs 12.4±3.2; p=0.24. Ninety percent of both groups required at least one suture removal. There was no statistically significant difference in success rate between groups, 80% vs 83%; number of eyes requiring antimetabolite injections was 22 eyes (mean 3.2 per eye) vs 23 eyes (mean 2.6 per eye, p=0.24); bleb needlings was performed in 16 eyes (mean 2.5 per eye) vs in 11 eyes (mean 2.0 per eye, p=0.15). The number of eyes restarting glaucoma medications was 5 vs 4. Minor complications were infrequent in both groups, 9 vs 10 eyes.Conclusions: The success and complications rates were similar between groups. The number of postoperative interventions required was slightly greater in the SPT group (not statistically significant). SPT is a safe procedure for patients with coexistent glaucoma and cataract and produces similar IOP-lowering to safe trabeculectomy.

Morgagnian cataract simulating iris neoplasia : case report

Purpose: to describe a case in which the diagnosis of Morganian cataract required clinical and instrumental differentiation from iris pathologies, including iris melanoma. Methods: a 60-years-old Caucasian man referred to our institute for worsening of vision in last few months. Clinical evaluation consisted in complete ophthalmological assessment, ultrasound examination (biomicroscopy and 20MHz), and Magnetic Resonance Imaging (MRI) completed with Susceptibility Weighted Imaging (SWI). Results: traumatic corneal wound of the left eye (LE) had occurred 5 years before, and was treated with medical therapy alone. Best-corrected visual acuity (BCVA) was 3/10 in the right eye (RE) and finger count in the LE, with intraocular pressure at 13 and 20mmHg, respectively. Chronic central serous chorioretinopathy, accounted for the low visual acuity of the RE. Slit-lamp biomicroscopy of the LE was as in Figure 1; LE fundus was not clinically observable. Despite MRI was compatible with an iris solid formation, characterized by contrast enhancement and hyperintense signal in SWI, ultrasound indicated rather a mixed solid and liquid content (moderately echogenic external layer, hyporeflective internal content). Iris root and ciliary body were not significantly altered; the lens showed inhomogeneous content. We considered Morgagnian cataract the most probable diagnosis. Surgery confirmed the presence of a hypermature cataract with prior anterior capsule fissuring; the liquefied cortex infiltrated the iris without anterior chamber seeping. Post-operative BCVA was 3/10 and fundus examination disclosed an advanced macular chronic central serous chorioretinopathy. Conclusions: In the reported case a previous perforating trauma have probably damaged the lens capsule and started cataract progression. Curiously cataract developed percolating into the iris stroma, thus simulating an iris mass. At our knowledge, Morgagnian cataract has never been included in the differential diagnosis of iris mass.

Deep sclerectomy combined with trabeculectomy in pediatric glaucoma.

PURPOSE: To evaluate the outcomes of combined deep sclerectomy and trabeculectomy (penetrating deep sclerectomy) in pediatric glaucoma. DESIGN: Retrospective, nonconsecutive, noncomparative, interventional case series. PARTICIPANTS: Children suffering from pediatric glaucoma who underwent surgery between March 1997 and October 2006 were included in this study. METHODS: A primary combined deep sclerectomy and trabeculectomy was performed in 35 eyes of 28 patients. Complete examinations were performed before surgery, postoperatively at 1 and 7 days, at 1, 2, 3, 4, 6, 9, and 12 months, and then every 6 months after surgery. MAIN OUTCOME MEASURES: Surgical outcome was assessed in terms of intraocular pressure (IOP) change, additional glaucoma medication, complication rate, need for surgical revision, as well as refractive errors, best-corrected visual acuity (BCVA), and corneal clarity and diameters. RESULTS: The mean age before surgery was 3.6+/-4.5 years, and the mean follow-up was 3.5+/-2.9 years. The mean preoperative IOP was 31.9+/-11.5 mmHg. At the end of follow-up, the mean IOP decreased by 58.3% (P<0.005), and from 14 patients with available BCVA 8 patients (57.1%) achieved 0.5 (20/40) or better, 3 (21.4%) 0.2 (20/100), and 2 (14.3%) 0.1 (20/200) in their better eye. The mean refractive error (spherical equivalent [SE]) at final follow-up visits was +0.83+/-5.4. Six patients (43%) were affected by myopia. The complete and qualified success rates, based on a cumulative survival curve, after 9 years were 52.3% and 70.6%, respectively (P<0.05). Sight-threatening complications were more common (8.6%) in refractory glaucomas. CONCLUSIONS: Combined deep sclerectomy and trabeculectomy is an operative technique developed to control IOP in congenital, secondary, and juvenile glaucomas. The intermediate results are satisfactory and promising. Previous classic glaucoma surgeries performed before this new technique had less favorable results. The number of sight-threatening complications is related to the severity of glaucoma and number of previous surgeries. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Aqueous dynamic and histological findings after deep sclerectomy with collagen implant in an animal model.

AIM: The use of an animal model to study the aqueous dynamic and the histological findings after deep sclerectomy with (DSCI) and without collagen implant. METHODS: Deep sclerectomy was performed on rabbits' eyes. Eyes were randomly assigned to receive collagen implants. Measurements of intraocular pressure (IOP) and aqueous outflow facility using the constant pressure method through cannulation of the anterior chamber were performed. The system was filled with BSS and cationised ferritin. Histological assessment of the operative site was performed. Sections were stained with haematoxylin and eosin and with Prussian blue. Aqueous drainage vessels were identified by the reaction between ferritin and Prussian blue. All eyes were coded so that the investigator was blind to the type of surgery until the evaluation was completed. RESULTS: A significant decrease in IOP (p<0.05) was observed during the first 6 weeks after DSCI (mean IOP was 13.07 (2.95) mm Hg preoperatively and 9.08 (2.25) mm Hg at 6 weeks); DS without collagen implant revealed a significant decrease in IOP at weeks 4 and 8 after surgery (mean IOP 12.57 (3.52) mm Hg preoperatively, 9.45 (3.38) mm Hg at 4 weeks, and 9.22 (3.39) mm Hg at 8 weeks). Outflow facility was significantly increased throughout the 9 months of follow up in both DSCI and DS groups (p<0.05). The preoperative outflow facility (OF) was 0.15 (0.02) micro l/min/mm Hg. At 9 months, OF was 0.52 (0.28) microl/min/mm Hg and 0.46 (0.07) micro l/min/mm Hg for DSCI and DS respectively. Light microscopy studies showed the appearance of new aqueous drainage vessels in the sclera adjacent to the dissection site in DSCI and DS and the apparition of spindle cells lining the collagen implant in DSCI after 2 months. CONCLUSION: A significant IOP decrease was observed during the first weeks after DSCI and DS. DS with or without collagen implant provided a significant increase in outflow facility throughout the 9 months of follow up. This might be partly explained by new drainage vessels in the sclera surrounding the operated site. Microscopic studies revealed the appearance of spindle cells lining the collagen implant in DSCI after 2 months.

Evaluation of an intravitreal fluocinolone acetonide implant versus standard systemic therapy in noninfectious posterior uveitis.

PURPOSE: To evaluate the safety and efficacy of an intravitreal fluocinolone acetonide (FA) implant compared with standard therapy in subjects with noninfectious posterior uveitis (NIPU). DESIGN: Randomized, controlled, phase 2b/3, open-label, multicenter superiority trial. PARTICIPANTS: Subjects with unilateral or bilateral NIPU. METHODS: One hundred forty subjects received either a 0.59-mg FA intravitreal implant (n = 66) or standard of care (SOC; n = 74) with either systemic prednisolone or equivalent corticosteroid as monotherapy (> or =0.2 mg/kg daily) or, if judged necessary by the investigator, combination therapy with an immunosuppressive agent plus a lower dose of prednisolone or equivalent corticosteroid (> or =0.1 mg/kg daily). MAIN OUTCOME MEASURES: Time to first recurrence of uveitis. RESULTS: Eyes that received the FA intravitreal implant experienced delayed onset of observed recurrence of uveitis (P<0.01) and a lower rate of recurrence of uveitis (18.2% vs. 63.5%; P< or =0.01) compared with SOC study eyes. Adverse events frequently observed in implanted eyes included elevated intraocular pressure (IOP) requiring IOP-lowering surgery (occurring in 21.2% of implanted eyes) and cataracts requiring extraction (occurring in 87.8% of phakic implanted eyes). No treatment-related nonocular adverse events were observed in the implant group, whereas such events occurred in 25.7% of subjects in the SOC group. CONCLUSIONS: The FA intravitreal implant provided better control of inflammation in patients with uveitis compared with systemic therapy. Intraocular pressure and lens clarity of implanted eyes need close monitoring in patients receiving the FA intravitreal implant.

Autophagy induction does not protect retina against apoptosis in ischemia/reperfusion model.

The role played by autophagy after ischemia/reperfusion (I/R) in the retina remains unknown. Our study investigated whether ischemic injury in the retina, which causes an energy crisis, would induce autophagy. Retinal ischemia was induced by elevation of the intraocular pressure and modulation of autophagic markers was analyzed at the protein levels in an early and late phase of recovery. Following retinal ischemia an increase in LC3BII was first observed in the early phase of recovery but did not stay until the late phase of recovery. Post-ischemic induction of autophagy by intravitreal rapamycin administration did not provide protection against the lesion induced by the ischemic stress. On the contrary, an increase in the number of apoptotic cells was observed following I/R in the rapamycin treated retinas.

Retinal embolisation with localised retinal detachment following retrobulbar anaesthesia.

BACKGROUND: The aim of this communication is to describe an unusual and serious complication of retrobulbar anaesthesia for cataract surgery. HISTORY AND SIGNS: A 78-year-old female was referred for visual loss (light perception) 24 hours after apparently uneventful cataract surgery with retrobulbar anaesthesia in her left eye. Fundus examination revealed multiple arterial emboli and a localised retinal detachment. MRI revealed a retrobulbar hypersignal of the optic nerve associated with perineuritis. The cardiovascular examination was normal. We assumed this condition resulted from injection of the anaesthetic mixture into the optic nerve. THERAPY AND OUTCOME: In order to improve retinal circulation and oxygenation, the intraocular pressure was maximally lowered and anticalcic therapy administered, expecting optimal arterial dilatation. Methylprednisolone (1 g/day 3 days i. v., then rapidly tapered) was also added. The retina slowly reattached but visual acuity remained unchanged. CONCLUSIONS: Retrobulbar anaesthesia is routinely used for ocular surgery. Serious complications may still happen, however. This case adds to the previously reported spectrum of complications from retrobulbar anaesthesia.

Ten years follow-up after deep sclerectomy with collagen implant.

PURPOSE: To evaluate the long-term success rate and complications of nonpenetrating deep sclerectomy with collagen implant in open-angle glaucoma. PATIENTS AND METHODS: Clinical, prospective, monocentric, nonrandomized, unmasked study on 105 patients with medically uncontrolled glaucoma. A standard procedure deep sclerectomy with collagen implant was performed. Complete examinations were performed before surgery and postoperatively at 1 and 7 days; 1, 2, 3, 6, 9, and 12 months and then every 6 months during the 10 following years. RESULTS: The mean follow-up was 101.5+/-43.1 (3 to 144) months [mean+/-SD, (range)]. The preoperative intraocular pressure (IOP) was 26.8+/-7.7 (14 to 52) mm Hg and the best-corrected visual acuity 0.71+/-0.33 (0.02 to 1.5). Ten years after surgery IOP was 12.2+/-4.7 (6 to 20) mm Hg and best-corrected visual acuity 0.63+/-0.34 (0.01 to 1.2) (number of remaining patients=52). The mean number of medications per patient went from 2.3+/-0.7 (1 to 4) down to 1.3+/-1.1 (0 to 3). An IOP <or=21 mm Hg without medication was achieved in 47.7% patients and in 89% with or without treatment. One major complication was reported. Goniopuncture was performed in 61 eyes (59.8%), 5-fluorouracil treatment given to 25 patients postoperatively and included needling (n=5). CONCLUSIONS: On the basis of a 10-year follow-up deep sclerectomy with collagen implant demonstrated its efficacy in controlling IOP with few postoperative complications.

Biocompatibility of an x-shaped zirconium implant in deep sclerectomy in rabbits

ABSTRACT : Background : The aim of this study was to evaluate the midterm biocompatibility of a new x-shaped implant made of zirconium in an animal model of glaucoma surgery. Methods : Preoperatively, ultrasound biomicroscopy (UBM), intraocular pressure (IOP) and outflow facility (OF) data were acquired. Upon surgery, one eye was chosen randomly to receive an implant, while the other received none. Ten rabbits went through a 1-, 2-, 3-, 4- and 6-month follow-up. [OP was measured regularly, UBM performed at 1, 3 and 6 months after surgery. At the end of the follow-up, OF was again measured. Histology sections were analyzed. Results : For both groups IOP control was satisfactory, while OF initially increased at month 1 to resume preoperative values thereafter. Eyes with implants had larger filtration blebs which decreased faster than in eyes without the implant. Drainage vessel density, inflammatory cell number and fibrosis were higher in tissues near the implant. Conclusions : The zirconium implant initially promoted the positive effects of the surgery (IOP control, OF increase). Nevertheless, after several months, foreign body reactions and fibrosis had occurred on some implants that restrained the early benefit of such a procedure. Modifications of the zirconium implant geometry could enhance the overall success rate.

Assessing the Glaucoma Quality of Life-15 (GCL-15) Questionnaire, Goldmann Tonometry and Moorfields Motion Displacement Test in Glaucoma Case Finding

Purpose: To compare the performance Glaucoma Quality of Life-15 (GQL-15) Questionnaire, intraocular pressure measurement (IOP Goldmann tonometry) and a measure of visual field loss using Moorfields Motion Displacement Test (MDT) in detecting glaucomatous eyes from a self referred population. Methods: The GQL-15 has been suggested to correlate with visual disability and psychophysical measures of visual function in glaucoma patients. The Moorfields MDT is a multi location perimetry test with 32 white line stimuli presented on a grey background on a standard laptop computer. Each stimulus is displaced between computer frames to give the illusion of "apparent motion". Participants (N=312, 90% older than 45 years; 20.5% family history of glaucoma) self referred to an advertised World Glaucoma Day (March 2009) Jules Gonin Eye Hospital, Lausanne Switzerland. Participants underwent a clinical exam (IOP, slit lamp, angle and disc examination by a general ophthalmologist), 90% completed a GQL-15 questionnaire and over 50% completed a MDT test in both eyes. Those who were classified as abnormal on one or more of the following (IOP >21 mmHg/ GQL-15 score >20/ MDT score >2/ clinical exam) underwent a follow up clinical examination by a glaucoma specialist including imaging and threshold perimetry. After the second examination subjects were classified as "healthy"(H), "glaucoma suspect" (GS) (ocular hypertension and/or suspicious disc, angle closure with SD) or "glaucomatous" (G). Results: One hundred and ten subjects completed all 4 initial examinations; of these 69 were referred to complete the 2nd examination and were classified as; 8 G, 24 GS, and 37 H. MDT detected 7/8 G, and 7/24 GS, with false referral rate of 3.8%. IOP detected 2/8 G and 8/24 GS, with false referral rate of 8.9%. GQL-15 detected 4/8 G, 16/24 GS with a false referral rate of 42%. Conclusions: In this sample of participants attending a self referral glaucoma detection event, the MDT performed significantly better than the GQL-15 and IOP in discriminating glaucomatous patients from healthy subjects. Further studies are required to assess the potential of the MDT as a glaucoma screening tool.

Free conjunctival autologous graft for bleb repair and bleb reduction after trabeculectomy and nonpenetrating filtering surgery.

PURPOSE: To describe methods and outcomes of excisional revision of a filtering bleb (bleb revision) using free conjunctival autologous graft either for bleb repair or for bleb reduction after trabeculectomy and deep sclerectomy with an implant. METHODS: Retrospective medical records were reviewed for a consecutive non-comparative case series comprising patients who underwent excisional revision of a filtering bleb between May 1998-January 2001. Excisional revision using free conjunctival autologous graft (bleb revision) was performed either for bleb repair, to treat early and late leaks and hypotony with maculopathy, or for bleb reduction, to improve ocular pain, discomfort, burning, foreign body sensation, tearing, and fluctuations of visual acuity. The revision consisted of bleb excision and free conjunctival autologous graft. The bleb histopathology was analyzed in patients who underwent bleb repair. RESULTS: Sixteen patients were included in the study, consisting of nine patients who had a trabeculectomy and seven patients who had a deep sclerectomy with an implant. Bleb revision was necessary in 14 patients due to leaking filtering bleb (bleb repair), and in 2 patients due to bleb dysesthesia (bleb reduction). After a follow-up of 15.1 +/- 8.4 months, the mean intraocular pressure (IOP) rose from 7.8 +/- 6.3 mm Hg to 14.3 +/- 6.5 mm Hg, and the visual acuity from 0.4 +/- 0.3 to 0.7 +/- 0.3, with a P value of 0.008 and 0.03, respectively. The complete success rate at 32 months, according to the Kaplan-Meier survival curve, was 38.3%, and the qualified success rate was 83.3%. Four patients (25%) required additional suturing for persistent bleb leak. To control IOP, antiglaucoma medical therapy was needed for six patients (37.5%) and repeated glaucoma surgery was needed for one patient. CONCLUSION: Free conjunctival autologous graft is a safe and successful procedure for bleb repair and bleb reduction. However, patients should be aware of the postoperative possibility of requiring medical or surgical intervention for IOP control after revision.

Unilateral optic disc edema following trabeculectomy.

Two cases of a benign form of optic disc edema after successful trabeculectomy are reported. In both patients, optic disc edema was noted 2 to 4 weeks after trabeculectomy. The edema occurred without loss of visual acuity or field. The absolute intraocular pressure and intracranial pressure were normal--that is, the edema was not a syndrome of hypotony or pseudotumor cerebri. However, both patients had intracranial pressure in the high-normal range. The decrease in intraocular pressure into the low normal range after trabeculectomy may have altered the intracranial pressure:intraocular pressure ratio at the lamina cribrosa enough to produce optic disc edema.

Retinal vessel oxygen saturation and its correlation with structural changes in retinitis pigmentosa.

PURPOSE: To study the influence of retinal structural changes on oxygen saturation in retinitis pigmentosa (RP) patients. METHODS: Oximetry measurements were performed on 21 eyes of 11 RP patients and compared to 24 eyes of 12 controls. Retinal oxygen saturation was measured in all major retinal arterioles (A-SO₂) and venules (V-SO₂) with an oximetry unit of the retinal vessel analyser (IMEDOS Systems UG, Jena, Germany). Oximetry data were compared with morphological changes measured by Cirrus optical coherence tomography (OCT) (Carl Zeiss Meditec, Dublin, CA, USA, macular thickness protocol). RESULTS: In RP patients, the retinal A-SO₂ and V-SO₂ levels were higher at 99.3% (p = 0.001, anova based on mixed-effects model) and 66.8% (p < 0.001), respectively, and the difference between the two (A-V SO₂) was lower at 32.5% (p < 0.001), when compared to the control group (92.4%; 54.0%; 38.4%, respectively). With the RP group, the A-V SO₂ correlated positively, not only with central macular thickness, but also with retinal thickness, in zones 2 and 3 (p = 0.006, p = 0.007, p = 0.014). CONCLUSION: These data indicate that oxygen metabolism was altered in RP patients. Based on our preliminary results, retinal vessel saturation correlated with structural alterations in RP. This method could be valuable in monitoring disease progression and evaluating a potential therapeutic response.

Visualization of aqueous shunt position and patency using anterior segment optical coherence tomography.

PURPOSE: To describe the use of anterior segment optical coherence tomography (AS-OCT) to clarify the position and patency of aqueous shunt devices in the anterior chamber of eyes where corneal edema or tube position does not permit a satisfactory view. DESIGN: Noncomparative observational case series. METHODS: Four cases are reported in which aqueous shunt malposition or obstruction was suspected but the shunt could not be seen on clinical examination. The patients underwent AS-OCT to identify the position and patency of the shunt tip. RESULTS: In each case, AS-OCT provided data regarding tube position and/or patency that could not be obtained by slit-lamp examination or by gonioscopy that influenced management. CONCLUSIONS: AS-OCT can be used to visualize anterior chamber tubes in the presence of corneal edema that precludes an adequate view or in cases where the tube is retracted into the cornea. In such cases, AS-OCT is useful in identifying shunt patency and position, which helps guide clinical decision making.