Topical anesthesia in phacotrabeculectomy

Purpose: To study the safety and efficacy of topical anesthesia alone, without systemic sedation, in phacotrabeculectomy for cataract and primary open-angle glaucoma. Methods: In this prospective study, topical anesthesia with 2% lidocaine hydrochloride jelly without systemic sedation was used for combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy in consecutive patients with primary open-angle glaucoma and concurrent cataract at the United Christian Hospital, Kowloon, Hong Kong, from September 2000 to May 2001. Visual analog pain score and change in vital signs were used to assess the intraoperative pain experience. Other outcome measures included postoperative visual acuity and intraocular pressure at 3 months. Results: Twenty-two eyes of 22 consecutive patients were included in the study. The mean intraoperative pain score was 0.9 (range, 0-3). Three patients reported discomfort intraoperatively. No injection of supplementary anesthetic was required in any of the eyes. None of the patients had significant increase of pulse rate or blood pressure during the whole surgical procedure. Six patients required oral analgesic for postoperative discomfort. The mean preoperative medically treated IOP was 20.3 ± 5.9 mm Hg and the mean postoperative IOP at 3 months was 14.4 ± 4.7 mm Hg. All except two patients had improved visual acuity. There was no serious intraoperative or postoperative complication. Conclusion: Topical 2% lidocaine hydrochloride jelly without systemic sedation may be a safe and effective anesthetic method in phacotrabeculectomy for patients with primary open-angle glaucoma with coexisting cataract.link_to_subscribed_fulltex

The efficacy and safety of combined phacoemulsification, intraocular lens implantation, and limited goniosynechialysis, followed by diode laser peripheral iridoplasty, in the treatment of cataract and chronic angle-closure glaucoma

Purpose: To report the efficacy and safety of combined phacoemulsification, intraocular lens implantation, and limited goniosynechialysis, followed by diode laser peripheral iridoplasty, in the treatment of cataract and chronic angle-closure glaucoma. Methods: Patients with chronic angle-closure glaucoma with total synechial angle closure and intraocular pressures higher than 21 mm Hg on maximally tolerated medications, and concurrent cataract, underwent phacoemulsification with posterior chamber intraocular lens implantation and goniosynechialysis followed by diode laser peripheral iridoplasty to the inferior half of the angle. Intraoperative complications, postoperative visual acuity, intraocular pressures, and complications were evaluated. Results: Seven eyes of seven patients received the operation, and the mean follow-up was 8.9 months (range, 2-16 months). The mean preoperative intraocular pressure was 33.0 ± 4.8 mm Hg. The mean postoperative intraocular pressure at most recent follow-up was 13.3 ± 2.9 mm Hg. The absolute success rate (intraocular pressure less than 21 mm Hg without medication) was 100%. The visual acuity of all eyes improved by more than two Snellen lines. Postoperative complications included intraocular pressure spike, hyphema, and transient corneal decompensation. Conclusion: It appears that phacoemulsification with intraocular lens implantation combined with inferior 180° goniosynechialysis followed by diode laser peripheral iridoplasty is an effective and safe surgical procedure for treating chronic angle-closure glaucoma with total synechial angle closure and cataract.link_to_subscribed_fulltex

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Comparison of postoperative refractive outcome in phacotrabeculectomy and phacoemulsification with posterior chamber intraocular lens implantation

Purpose: To compare the postoperative refractive outcomes following phacotrabeculectomy and phacoemulsification with posterior chamber intraocular lens implantation. Methods: A retrospective comparative study of 90 consecutive patients (95 eyes) with cataract with or without co-existing glaucoma who had undergone uncomplicated phacotrabeculectomy or phacoemulsification by a single surgeon. The biometry prediction error was determined for each case by the difference between the actual postoperative refraction and the preoperative predicted refractive outcome, in spherical equivalent. This was followed by a comparative analysis of the mean biometry prediction error, and the number of cases with error >0.50 D or 1.00 D. All biometry measurements were performed by one of the two qualified optometrists. Results: The mean and absolute mean biometry prediction error of the 25 eyes that received phacotrabeculectomy (+0.20 D, absolute error 0.96 D) was comparable to the 70 eyes that received phacoemulsification (-0.14 D, absolute error 0.68 D), P = 0.18 (absolute error, P = 0.12). The proportion of cases with prediction error >0.50 D or 1.00 D was 60% or 40% for phacotrabeculectomy, and 44% or 17% for phacoemulsification, respectively. Phacotrabeculectomy was more likely to have a prediction error >1.00 D (P = 0.02) and a myopic shift of >0.50 D or 1.00 D (P = 0.03 or 0.02, respectively). No significant differences were found with regard to the frequency of hyperopic shift or prediction error >0.50 D. There was no significant difference in either the mean error or the frequency of the different types of error for the different biometry operators, types of glaucoma, or postoperative intraocular pressure control success status. Conclusion: Myopically shifted prediction error was significantly more frequent following posterior chamber intraocular lens implantation with phacotrabeculectomy compared with phacoemulsification, even when surgery was uncomplicated and performed by the same surgeon. Copyright © 2006 by Lippincott Williams & Wilkins.link_to_subscribed_fulltex

Changes in AC angle width and depth after IOL implantation in eyes with glaucoma

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Incisional surgery for angle closure glaucoma

Angle closure glaucoma remains a major challenge for ophthalmologists. The three main challenges in the treatment of angle closure glaucoma are, firstly, to achieve rapid reduction of intraocular pressure in acute angle closure glaucoma, secondly, to prevent progression to chronic angle closure glaucoma, and thirdly, to manage established chronic angle closure glaucoma. Incisional surgery for angle closure glaucoma is typically required when laser surgery and/or medical therapy fail to control the intraocular pressure or control progressive synechial closure. The role for surgical iridectomy and emergency trabeculectomy in the modern management of acute angle closure glaucoma is diminishing. Trabeculectomy, goniosynechialysis, cyclodestructive procedures, and glaucoma implant are effective surgical options for chronic angle closure glaucoma, but none of them have been shown to be more effective than the others with proper comparative clinical trials. Trabeculectomy and goniosynechialysis are often combined with cataract extraction, which appears to offer additional pressure-control benefits to patients with chronic angle closure glaucoma.link_to_subscribed_fulltex

Limited argon laser peripheral iridoplasty as immediate treatment for an acute attack of primary angle closure glaucoma: A preliminary study

Purpose. To study the efficacy and safety of limited (180°) argon laser peripheral iridoplasty (ALPI) as a first-line treatment for acute primary angle closure glaucoma (PACG) without the use of systemic anti-glaucomatous medications. Methods. Ten consecutive patients with PACG were recruited into the study. Each patient received topical pilocarpine (4%) and timolol (0.5%), and immediate limited ALPI as primary treatment. The intraocular pressures at 15, 30 and 60 min after ALPI were documented by Goldmann applanation tonometry. Results. The mean intraocular pressure (IOP) of this group of patients was reduced from 57.9 ± 10.6 mmHg to 39.0 ± 10.9 mmHg at 15 min, 28.3 ± 9.1 mmHg at 30 min and 20.4 ± 9.0 mmHg at 60 min after ALPI. No complications were encountered. In 8 of the 10 patients the corneal oedema cleared 1 h after ALPI. In the remaining 2 patients the corneal oedema cleared 2 h after ALPI. Conclusion. Immediate limited ALPI, without adjunctive systemic anti-glaucomatous medications, appeared to be effective and safe in controlling the IOP in treating acute PACG with a duration of attack ≤ 48 h. It may be as effective as 360°ALPI, and therefore has a role in those patients in whom 360°treatment is not possible.link_to_subscribed_fulltex

Intracameral lidocaine in trabeculectomy. A preliminary safety and efficacy study

Purpose: To study the safety and efficacy of intracameral lidocaine as anaesthesia in trabeculectomy for primary open-angle glaucoma. Methods: Trabeculectomy under intracameral anaesthesia using 1% preservative-free lidocaine was performed in 10 patients with primary open-angle glaucoma. Intraoperative pain score, postoperative intraocular pressure (IOP) and endothelial cell count at 3 months were recorded. Results: The mean pain score was 1.70 ± 1.34. The mean IOP was lowered from 24.60 ± 8.28 mmHg preoperatively to 14.1 ± 3.11 mm Hg postoperatively. There was no significant decrease in the mean endothelial cell count 3 months after the surgery (P = 0.375). Conclusion: Intracameral lidocaine may be a safe and effective alternative anaesthesia method in trabeculectomy for uncomplicated primary open-angle glaucoma.link_to_OA_fulltex

Immediate argon laser peripheral iridoplasty as treatment for acute attack of primary angle-closure glaucoma: A preliminary study

Objective: This study aimed to examine the intraocular pressure (IOP)- lowering effects and safety of immediate argon laser peripheral iridoplasty (ALPI) as a first-line treatment for acute primary angle-closure glaucoma (PACG). Design: A prospective cohort study. Participants: Ten consecutive patients with their first attack of PACG, with IOP of 40 mmHg or greater, were recruited into the study. Intervention: On presentation, each patient received topical pilocarpine (4%) and timolol (0.5%) and immediate ALPI as primary treatment. The IOPs at 15, 30, and 60 minutes after ALPI were documented by applanation tonometry. When the corneal edema had settled, laser peripheral iridotomy was performed as a definitive treatment. Main Outcome Measures: The IOP, corneal edema, and complications from ALPI were measured. Results: The mean IOP of this group of patients was reduced from 59.5 ± 10.4 mmHg to 28.7 ± 14.9 mmHg at 15 minutes, 21.7 ± 13.1 mmHg at 30 minutes, and 16.0 ± 9.4 mmHg at 60 minutes after ALPI. No complications from the laser procedure were encountered during the study period. In nine of the ten patients, the corneal edema cleared up 1 hour after ALPI. In the remaining patient, the cornea cleared up 2 hours after ALPI. Conclusion: From this preliminary study, immediate ALPI, without adjunctive systemic antiglaucoma treatment, appeared to be very effective in controlling the IOP and returning corneal clarity in acute PACG. Its safety also appeared reassuring and did not have the risks associated with conventional systemic therapies.link_to_subscribed_fulltex

Immediate argon laser peripheral iridoplasty for acute attack of PACG (addendum to previous report)

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