Combined cataract extraction and thermal sclerostomy versus combined cataract extraction and trabeculectomy

We performed either a combined cataract extraction and trabeculectomy or a combined cataract extraction and thermal sclerostomy on 43 eyes. All eyes had chronic open angle glaucoma or chronic angle closure glaucoma, or a combination of the two. In our cataract/trabeculectomy group, 74% had improvement in visual acuity, 91% had normalized intraocular pressure without anti-glaucoma medications, 31% had transient postoperative hyphemas. In our cataract/thermal sclerostomy group, 61% had improvement in visual acuity, 61% had normalization of intraocular pressures without antiglaucoma medications, 17% had transient postoperative hyphemas. We could not correlate any of the complications of surgery with poor intraocular pressure results in either groups. The mechanism for the higher success rate with a combined cataract extraction and trabeculectomy as compared with a combined cataract extraction and thermal sclerostomy was not obvious after analyzing these patients.     

Distressed or relieved? Psychological side effects of breast cancer screening in The Netherlands

PURPOSE: To compare three methods of combined cataract extraction and glaucoma surgery. METHODS: Retrospective review of 35 eyes of patients who had extracapsular cataract extraction and trabeculectomy using a corneoscleral incision (SAME), 54 eyes undergoing extracapsular cataract extraction and trabeculectomy using a separated corneal incision for cataract extraction and 43 eyes undergoing phacoemulsification and trabeculectomy. RESULTS: Ninety-one percent of the eyes in the SAME group, 85% of the SEPARATE group and 97% of the phacoemulsification and trabeculectomy group had an IOP < 22 mmHg at 6 months with or without medication (NS). Postoperative visual acuity and astigmatism were not significantly different between the groups. The number of eyes requiring YAG laser capsulotomy was significantly greater in the extracapsular cataract extraction and trabeculectomy (same and separated incision) as compared to the phacoemulsification and trabeculectomy group (P < 0.001). CONCLUSION: Phacoemulsification and trabeculectomy was not significantly more successful than the other methods of combined surgery. Although complication rates were similar, visual rehabilitation was faster and there was a reduced incidence of early posterior capsule opacification.     

Intraocular pressure regulation after combined glaucoma and cataract operation

BACKGROUND: The success rate of combined glaucoma and small incision cataract surgery is not yet established. PATIENTS AND METHODS: Therefore, 56 eyes of 52 patients (mean age 79.0 years) having trabeculectomy combined with phacoemul-sification and implantation of a silicone posterior chamber lens were retrospectively investigated. RESULTS: The mean follow-up was 21.6 weeks. Due to the combined surgery the mean intraocular pressure decreased significantly (p < 0.001) from 21.8 to 14.8 mmHg. Seventy-five percent of the patients did not need any antiglaucomatous medication, while 25% still had to use a local medication, but less frequently. The overall visual acuity increased significantly (p < 0.001) from a preoperative value of 0.24 to 0.52 postoperatively. CONCLUSIONS: The results of combined glaucoma and cataract surgery seem as good as those reported for two separate glaucoma and cataract procedures.     

Extracapsular cataract extraction with posterior chamber lens implantation in primary angle-closure glaucoma

PURPOSE: To evaluate long-term intraocular pressure (IOP) control after extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (IOL) implantation in patients with primary angle-closure glaucoma. SETTING: Ophthalmology Department, Groote Schuur Hospital, Cape Town, South Africa. METHODS: This retrospective study comprised 17 patients (19 eyes) with primary angle-closure glaucoma who had ECCE and posterior chamber IOL implantation. Four presented initially with acute glaucoma, 5 with subacute angle-closure glaucoma, and 8 (10 eyes) with chronic angle-closure glaucoma. In all, less than half the circumference of the angle was permanently closed. The drainage angle was evaluated preoperatively and postoperatively to monitor changes in the amount of angle closure. Intraocular pressure was measured in the early and late postoperative periods. RESULTS: On the first postoperative day, mean IOP was 17.2 mm Hg, although 5 patients (26%) had an IOP rise above 21 mm Hg despite the use of perioperative topical pilocarpine gel. After a mean follow-up of 19 months, IOP remained below 22 mm Hg without medication in 13 eyes (68%) and with topical medication in 5 eyes (26%). Mean number of glaucoma medications was reduced from 1.5/eye preoperatively to 0.5/eye postoperatively. CONCLUSION: Cataract extraction with IOL implantation resulted in good long-term IOP control in patients with primary angle-closure glaucoma, suggesting that combined cataract and trabeculectomy surgery may not be necessary to achieve long-term IOP control in these patients.     

Comparative results of combined procedures for glaucoma and cataract: II. Limbus-based versus fornix-based conjunctival flaps

BACKGROUND AND OBJECTIVE: One of the variables to be considered in a combined procedure for glaucoma and cataract is the type of conjunctival flap to be used. The objective of this study was to compare the effects of limbus-based and fornix-based conjunctival flaps on postoperative long-term intraocular pressure (IOP) control and visual acuity after combined trabeculectomy with phacoemulsification. PATIENTS AND METHODS: The authors retrospectively reviewed the charts of 189 patients (215 eyes) who underwent combined trabeculectomy with phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and intraoperative mitomycin-C administration and who had a minimum follow-up of 12 months. The results of the limbus-based (151 eyes) versus fornix-based (64 eyes) conjunctival incisions used in these combined procedures were compared. RESULTS: In the limbus-based conjunctival flap group, 146 eyes (97%) achieved an IOP of less than 20 mm Hg, with or without medication; 62 eyes (97%) of the fornix-based conjunctival flap group (P > .05) achieved this result. A visual acuity of 20/40 or better was noted in 106 eyes (70%) in the limbus-based conjunctival flap group and in 45 eyes (70%) in the fornix-based conjunctival flap group (P > .05) at the last examination. Early wound leakage was observed more frequently in the fornix-based conjunctival flap group (8% vs 1%) (P = .014); however, it was not a serious clinical problem, as only 1 eye required surgical repair. Posterior capsular opacification was found more often in the limbus-based conjunctival flap group (25% vs 14%) (P = .072) and required more frequent laser capsulotomy (22% vs 9%) (P = 0.03). CONCLUSION: Limbus-based and fornix-based conjunctival flaps appear to be comparable with respect to postoperative IOP control and visual acuity after a combined trabeculectomy with phacoemulsification and posterior chamber IOL implantation in cases supplemented by intraoperative mitomycin-C.     

Secondary intraocular lens implantation after cataract surgery in children

PURPOSE: To report results of secondary intraocular lens implantation after cataract surgery in children. METHODS: We reviewed clinical records for a 5-year period of patients who had cataract surgery in childhood and received a secondary intraocular lens implant. We studied indications for secondary intraocular lens placement; surgical procedures for intraocular lens implantation; preoperative and postoperative visual acuity, refractive error, and binocular status; and complications of the procedure. RESULTS: A secondary intraocular lens was placed in 28 eyes of 25 patients who had cataract surgery in childhood. In 20 eyes, the lenses were placed in the ciliary sulcus. The other eight eyes had insufficient capsular support for an intraocular lens; in two, the intraocular lens was placed in the anterior chamber and, in six, in the posterior chamber with suture fixation to the sclera. Twenty of 28 eyes (71%) had measurable improvement in visual acuity; only one eye had a decrease in visual acuity of 2 lines. Fifteen patients (54%) had a final refraction within 1.50 diopters of the fellow eye; 21 (75%) were within 3.00 diopters. During follow-up, two eyes developed glaucoma. One had transient pressure elevation; one required two filtration procedures. Three patients required Nd:YAG capsulotomy. Six patients demonstrated Worth fusion at distance and near; three demonstrated 200 seconds of arc or better stereo visual acuity. CONCLUSION: Secondary placement of an intraocular lens in the posterior chamber appears to be a safe, effective alternative for correction of aphakia in the contact lens- or spectacles-intolerant child or young adult.     

Results of bilateral cataract extraction with posterior chamber intraocular lens implantation in children

OBJECTIVE: A retrospective study was undertaken to evaluate long-term anatomic and visual outcomes in eyes of children who underwent bilateral intraocular lens implantation. DESIGN: The study design was a review of medical records of 24 children operated on for bilateral cataracts and posterior chamber-intraocular lenses. PARTICIPANTS: Twenty-four children operated on for bilateral cataracts by 1 surgeon between February 1980 and February 1995 were studied. INTERVENTION: Cataract extraction with bilateral posterior chamber-intraocular lens implantation was performed. MAIN OUTCOME MEASURES: Best-corrected visual acuity, visual acuity without correction, intraocular pressure, manifest refraction, and any intraoperative or postoperative complications were measured. RESULTS: At last follow-up (mean follow-up, 50.8 months; range, 10-149 months), the intraocular lens was in good position and the intraocular pressure was normal without medication in all eyes. Four years after surgery, 79.2% (19 of 24) of first eyes achieved a best-corrected visual acuity of 20/40 or better compared to 66.7% (16 of 24) of second eyes. No eye had any loss in best-corrected visual acuity. In first eyes of 3- to 8-year olds at the time of surgery, 73.3% (11 of 15) achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery compared to 80% of second eyes. In the 9- to 18-year-old group, 88.9% (8 of 9) of first eyes and 100% of second eyes achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery. Intraoperative and postoperative complications were minimal. CONCLUSIONS: Long-term anatomic and visual results have been gratifying in this series of patients with bilateral implants.     

Topical plus subconjunctival anesthesia for phacotrabeculectomy: one year follow-up

PURPOSE: To evaluate the results of topical plus subconjunctival anesthesia for phacotrabeculectomy surgery and postoperative glaucoma control over 1 year. SETTING: Pacific Eye Center, Brisbane, Australia. METHODS: In this retrospective study of consecutive patients with glaucoma and cataract, topical plus subconjunctival anesthesia was used for combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy). Patients with proliferative diabetic retinopathy or neovascular glaucoma were excluded. RESULTS: Thirty-eight eyes had phacotrabeculectomy using topical plus subconjunctival anesthesia over 2 years. Patients reported no discomfort intraoperatively or postoperatively, and none required intravenous sedation. Eighty-one percent of patients achieved a best corrected visual acuity of 20/40 or better 6 months after surgery. Mean drop in intraocular pressure (IOP) was 5.91 mm Hg at 3 months and 5.86 mm Hg at 12 months, at which time IOP was controlled without additional medication in 72% of patients. There were no serious complications postoperatively. CONCLUSION: In this series, no patient reported intraoperative or postoperative discomfort and surgical results were excellent in terms of visual outcome and IOP control.     

Phacoemulsification and silicone oil removal through a single corneal incision

OBJECTIVE: Cataracts are a frequent complication after silicone oil infusion for the repair of complicated retinal detachments, occurring in up to 100% of eyes retaining silicone oil for 6 months or more. The authors devised a combined procedure for cataract and silicone oil removal with intraocular lens (IOL) implantation through a single corneal incision and evaluated their results. DESIGN: A prospective, noncomparative case series. PARTICIPANTS: Thirty-four eyes of 34 consecutive patients with a history of retinal detachment repair requiring silicone oil placement in whom a clinically significant cataract subsequently developed were identified when removal of silicone oil was scheduled. INTERVENTION: All 34 eyes were prospectively entered into a study to evaluate the efficacy and potential complications of a combined procedure for cataract and silicone oil removal with posterior chamber lens implantation. All patients underwent uncomplicated phacoemulsification removal of cataract followed by removal of silicone oil and placement of an IOL through a single corneal incision. MAIN OUTCOME MEASURE: Recurrent retinal detachment and IOL-related complications were measured. RESULTS: Ten eyes had recurrent retinal detachments develop. Final visual acuity ranged from 6/12 to hand movements with 25 eyes (74%) showing stabilized or improved vision. Pre-existing macular pathology and recurrent retinal detachment generally were responsible for poor visual outcome. CONCLUSIONS: Combined phacoemulsification, IOL implant with silicone oil removal is a useful procedure in these complicated eyes. Visual outcome generally is good with improvement in visual acuity, even with recurrent retinal detachment or pre-existing macular pathology or both.     

Prothrombin gene G20210-->A transition is a risk factor for cerebral venous thrombosis

OBJECTIVE: The objective of the study was to determine the long-term outcome of patients with uveitis who underwent extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PCIOL) implantation. DESIGN: Retrospective review. PARTICIPANTS: Twenty-eight patients (36 eyes). INTERVENTION: Extracapsular cataract extraction and PCIOL implantation. MAIN OUTCOME MEASURES: Level of best-corrected Snellen visual acuity, change in visual acuity, length of follow-up, long-term findings, and complications. RESULTS: In long-term follow-up (mean, 81.4 months), 94% of eyes had visual acuity improvement compared with preoperative levels. Average change in visual acuity for all eyes was an improvement of 6.4 Snellen lines; 75% of eyes were 20/40 or better. The prevalences of cystoid macular edema (CME), epiretinal membrane (ERM), and posterior capsule opacification (PCO) were 56%, 56%, and 58%, respectively. CONCLUSIONS: Patients with uveitis who are treated with ECCE with PCIOL implantation can have successful visual results in long-term follow-up despite the prevalence of PCO or macular abnormalities such as CME and ERM.     

Elschnig pearl formation along the posterior capsulotomy margin after neodymium:YAG capsulotomy

PURPOSE: To determine the incidence of Elschnig pearl formation along the capsulotomy margin (string of pearls) after neodymium:YAG (Nd:YAG) laser posterior capsulotomy and to elucidate its clinical features, predisposing factors, effect on visual function, and association with additional capsulotomy. SETTING: Keio University Hospital, Tokyo, Japan. METHODS: The records of 418 eyes that had had Nd:YAG posterior capsulotomy after cataract surgery were retrospectively reviewed. Of those, 315 were excluded for short follow-up (fewer than 12 months) or insufficient clinical examination data. In the remaining 103 eyes, the incidence of string of pearls was calculated, and its clinical features, predisposing factors, effect on visual function, and correlation with additional capsulotomy were evaluated. RESULTS: String of pearls was identified in 49 eyes (47.6%); 37 (75.5%) developed pearls within 1 year after Nd:YAG capsulotomy. The incidence was significantly higher in patients having intraocular lens implantation and continuous curvilinear capsulorhexis (CCC) than in those without (95.9 versus 61.1% and 97.9 versus 55.6%, respectively). No significant differences were found in patient age and sex, total Nd:YAG energy, and the presence of diabetes mellitus or high myopia. String of pearls caused visual disturbances in 17 eyes (34.7%). The rate of repeat capsulotomy was higher in patients with string of pearls than in those without (36.7 and 9.3%, respectively). CONCLUSIONS: String of pearls formation was a common and significant complication after Nd:YAG posterior capsulotomy. Intraocular lens implantation and CCC may promote its formation.     

The role of early trabeculectomy in the control of chronic simple glaucoma

Seventy patients of bilateral chronic simple glaucoma with a mean age of 59.7 years, an intra-ocular pressure over 25 mmg Hg, optic disc cupping, and without visual field loss were selected. The eye with higher intra-ocular pressure or the larger optic disc cup was treated by early trabeculectomy while the other eye of the same patient was subjected to medical therapy with topical beta blockers for 3 years (without any surgical treatment). Both the eyes of 70 patients were compared after 3 years. Eyes which had undergone trabeculectomy had a mean intra-ocular pressure of 11.7 mm Hg against 18 mm Hg in the medically treated eyes. Surgically treated eyes had decrease in the mean cup : disc ratio (from 0.54 : 1 to 0.48 : 1) whereas medically treated eyes showed an increase from 0.41:1 to 0.51: 1. Visual field loss occurred in 3/70 operated eyes and in 27/70 medically treated eyes. Twenty-one of 70 treated eyes developed cataract and 12 of these required cataract surgery. Only 18/70 medically treated eyes developed cataracts but none of these required cataract surgery. Early trabeculectomy in cases of chronic simple glaucoma resulted in a large reduction of intra-ocular pressure and consequently reduced the size of optic disc cup and the chances of visual field loss.     

Progression of diabetic retinopathy after cataract extraction

A prospective study of the effect of cataract extraction with intraocular lens implantation on the course of diabetic retinopathy (DR) in 44 patients (59 eyes) was carried out. It showed that in the 1-3 years following surgery, there was progression of DR (including development of newly formed retinopathy) in 35% of the patients (28.8% of eyes). Progression was more marked in patients with pre-operative bilateral DR compared to those without bilateral DR (77% and 16% respectively). Insulin dependence did not play a role in progression. Final visual acuity was better in patients without pre-operative DR, as well as in eyes without progressive retinopathy.     

Impact of genetics on disease resistance

PURPOSE: To evaluate the safety and efficacy of phacoemulsification, primary posterior capsulorhexis (PCCC), and primary intraocular lens (IOL) implantation for uveitic cataracts. SETTING: Institutional practice. METHODS: Fifteen consecutive eyes of 13 patients with various causes of uveitis received anterior capsulorhexis, phacoemulsification, PCCC, and in-the-bag implantation of a heparin-surface-modified IOL for visually disabling cataract. The safety and efficacy of the combined operation were studied prospectively. RESULTS: At a mean follow-up of 16.9 months (range 8 to 30 months), all eyes had a clear central visual area. Fourteen of 15 eyes (93.3%) had good visual improvement after surgery. Eight eyes (53%) achieved a best corrected visual acuity (BCVA) of 20/30 or better and 6 (40%), 20/20 or better. Seventy-three percent of eyes attained a BCVA of 20/80 or better. The mean improvement in visual acuity was 5.2 Snellen lines (range 0 to 11 lines). No cases of uveitis flare-up or other major complications related to the cataract surgery occurred. CONCLUSIONS: The study's preliminary results are encouraging and indicate that phacoemulsification, PCCC, and IOL implantation can be considered in patients with visually disabling uveitic cataract.     

Use of Naclof in combined intervention for cataract and glaucoma

Two aspects of using eye drops of a nonsteroid antiinflammatory drug Naclof (sodium diclofenac) are analyzed: maintenance of mydriasis during an intervention (extracapsular cataract extraction with implantation of an intraocular lens and trabeculectomy and arrest of postoperative inflammation. The study was carried out in 40 patients, 20 of which were controls. In the naclof group the diameter of the pupil during the intervention was reliably larger, exudative inflammatory reactions were rarer, and the postoperative vision acuity higher. Hence, naclof is effective in combined interventions for cataract and glaucoma.     

Combined cataract and glaucoma procedures using temporal cataract surgery

PURPOSE: To evaluate whether separating the procedures in a combined procedure by performing a temporal cataract incision and superior trabeculectomy induces the lower astigmatism of a temporal cataract incision without sacrificing intraocular pressure (IOP) control. SETTING: EyeSight Associates, Warner Robins, Georgia. METHODS: This study evaluated 50 consecutive eyes receiving a superior cataract incision with a superonasal trabeculectomy and 65 eyes receiving a temporal cataract incision with a superonasal trabeculectomy. RESULTS: After 3 months, a substantially greater proportion of temporal incision cases had controlled IOP without medication. A substantially higher proportion in the superior incision group had uncontrolled IOP at each time period. Mean surgically induced cylinder was higher in the superior incision group at every time period. The superior group had early with-the-rule mean induced cylinder that decayed to against-the-rule, with a mean induced cylinder with keratometry at the final available visit (more than 3 months) of -1.01 diopter (D). The temporal group started with a negligible induced cylinder (-0.13 D) that drifted slightly with the rule to a final mean induced cylinder of +0.49 D. At the last visit, 31% in the superior incision group and 57% in the temporal incision group had an uncorrected visual acuity of 20/40 or better, and 72% and 94%, respectively, had a best corrected acuity of 20/40 or better. CONCLUSION: Separating the cataract and glaucoma procedures frees the surgeon to use newer astigmatically neutral techniques for the cataract incision.     

Fatal outcome after propofol sedation in children

This study was conducted to determine how phaco-emulsification combined with trabeculectomy influenced intraocular pressure and need for glaucoma medication postoperatively. A retrospective analysis was undertaken of results relating to 243 eyes of 195 patients who had undergone phaco-emulsification combined with trabeculectomy. Pre-operative intraocular pressure decreased from a mean of 22.0 mmHg to 12.5 mmHg one week postoperatively with an average change of 9.5 mmHg. One month postoperatively, 70% of patients were without glaucoma medication. Visual acuity had improved in 80% of eyes. Phaco-emulsification combined with trabeculectomy resulted in excellent glaucoma control, good visual recovery and a need for fewer glaucoma drugs.     

Evaluation of latex agglutination for detecting chlamydial antibody activity in psittacine bird sera by comparison with direct complement fixation

Two patients presented with unilateral ciliary block angle closure glaucoma and bilateral pseudoexfoliation (PSX) syndrome and were treated successfully with posterior sclerotomy (one case), extracapsular cataract extraction and posterior chamber lens implantation. None of the eyes had undergone previous ocular surgery except Nd: YAG-laser iridotomy. Axial lengths as measured with A-scan ultrasonography were 22.48 mm and 24.30 mm. During follow-up of 5 and 12 months, intraocular pressure was well controlled without antiglaucoma medication in both patients. We suspect that the well-known changes of the zonula origin at the ciliary epithelium in PSX syndrome lead to anterior subluxation of the lens with consecutive ciliary block angle closure glaucoma. Ciliary block angle closure glaucoma seems to be another serious complication in PSX syndrome. Therefore, miotics should probably be used with care in PSX eyes with signs of zonular alterations because they may trigger this mechanism.     

Pseudoexfoliation syndrome and secondary cataract

AIM/BACKGROUND: The pseudoexfoliation (PEX) syndrome is frequently associated with impairment of the blood-aqueous barrier. This study analysed if this might stimulate secondary cataract following cataract extraction. METHODS: This historical cohort study included 197 eyes of 197 patients (99 with and 98 without PEX) that underwent extracapsular cataract extraction with posterior chamber lens implantation (PMMA optic) between 1985 and 1991. Secondary cataract was defined as opacification of the axial posterior capsule and decrease of visual acuity by two or more lines. Mean follow up was 23.8 months. For statistical analysis, the Kaplan-Meier method and multivariate Cox regression analysis were used. RESULTS: Secondary cataract was observed within 24 months in 35% (SD 7%) of all eyes, and was significantly more frequent in eyes with PEX (45 (11)%) than in eyes without PEX (24 (9)%, p < 0.03). Eyes with diabetes mellitus (n = 32) showed a significantly lower frequency of secondary cataract (11 (11)%) than eyes without diabetes mellitus (39 (8)%, p < 0.01). The influences of sex, open angle glaucoma, type of cataract, surgeon, positioning of IOL, and phacoemulsification versus nuclear expression on secondary cataract did not reach statistical significance. CONCLUSION: The higher frequency of secondary cataract could be considered as another potential complication of cataract surgery in eyes with PEX.     

Microsurgical reconstruction of the Achilles tendon with a fascia lata flap

MATERIAL AND METHODS: During ten years, 890 operations of cataract with anterior chamber intraocular lens implantation were performed. TWO GROUPS OF EYES WERE OBSERVED: Eyes after planned intracapsular cataract surgery and eyes in which intraoperative complications occurred making impossible to apply posterior IOL. PURPOSE: To evaluate late complications and functional status of the eye. RESULTS: Our results indicate that anterior chamber intraocular lens implantation yields in many cases good visual acuity and, although not free of complications, is a safe procedure.