Spherical vs. aspheric IOL: comparison of vision quality ...paojournal.com/archives/Vol33 No1.pdf · Spherical vs. aspheric IOL: comparison of vision quality and spherical aberration

VOL 33 NO. 1 • JANUARY - JUNE 2008A PUBLICATION OF THE PHILIPPINE ACADEMY OF OPHTHALMOLOGY • FOUNDED IN 1969

PHISSSN0031–7659

PAPI Cert. No. 291

Which viscoelastic device protects the corneal endothelium better?Spherical vs. aspheric IOL: comparison of vision quality and spherical aberrationOral diclofenac as preemptive analgesic for pterygium surgeryPreventing tube erosion with autologous scleral flap vs. donor scleral graftCan intracameral triamcinolone prevent post–cataract surgery inflammation?Effect of face-down body massage on intraocular pressureCase Reports: Rosacea, Candida endogenous endophthalmitis

PHILIPP J OPHTHALMOL VOL 33 NO. 1 JANUARY - JUNE 2008 1 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

PHILIPPINE JOURNAL OF

Ophthalmology JANUARY – JUNE 2008VOL. 33 • NO. 1

EDITOR IN CHIEF

Patricia M. Khu, MD, MSc

ASSOCIATE EDITORS

Santiago A.B. Sibayan, MD, PhD

Harvey S. Uy, MD

ASSISTANT EDITORS

Jessica Marie R. Abaño, MD

Ruben Lim Bon Siong, MD

Jocelyn L. Sy, MD

Joseph Anthony J. Tumbocon, MD

Marissa N. Valbuena, MD, MHPed

MANAGING EDITOR

Carlos G. Naval, MD

EDITORIAL BOARD

Romeo V. Fajardo, MD

FOUNDING EDITOR, PHILIPPINES

Salvador R. Salceda, MD

PHILIPPINES

Rossina Lydia A. Ramirez, MD, MHSc

PHILIPPINES

Roger W. Beuermann, PhD

SINGAPORE/USA

Donald Tan, MD, FRCS

SINGAPORE

The PHILIPPINE JOURNAL OF OPHTHALMOLOGY (PJO), the officialjournal of the Philippine Academy of Ophthalmology, aims toprovide a venue for exchange of ideas and information amongophthalmologists and other physicians. It publishes peer-reviewedreports of original clinical and laboratory investigations,epidemiological studies done in the Philippines and other countries,

major reviews of specific topics, evaluation of diagnostic and surgical techniques,treatment methods, latest updates, and controversial issues in ophthalmology.

Published biannually, Number One of Volume One is dated January–March 1969.Entered as a third-class mail matter at the Manila Post Office on February 13, 1969.

Journal International Standard Serial Number: PHISSN 0031 - 7659. Vol. 29No.1, March 2004.

Copyright 2008. All rights reserved.

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2 PHILIPP J OPHTHALMOL VOL 33 NO. 1 JANUARY - JUNE 2008 PHILIPPINE ACADEMY OF OPHTHALMOLOGY


Ophthalmology

EDITORIAL

1 What has the PhilippineGlaucoma Society achieved in thelast 10 years?Fighting glaucoma requires ateam effort, argues Dr. PatriciaKhu, and much remains to bedone.

ORIGINAL ARTICLE

22 Safety and efficacy ofintracameral triamcinolone inpostcataract inflammationM C G Coronel, MD; G N Co, MD .

ORIGINAL ARTICLE

27 The effect of body massage lyingdown on intraocular pressure innormal eyesJ E E League, MD, et al.

CASE REPORT

30 Rosacea: “Curse of the Celts”K D Jacob, MD; J U Dy Liacco, MD

CASE REPORT

33 Candida endogenousendophthalmitisA K E Lim, MD, et al.

PASSAGE

36 Dr. Liborio L. Mangubat1924–2006

VOL. 33 • NO. 1 JANUARY – JUNE 2008

ORIGINAL ARTICLE 5

Effects of two ophthalmic viscoelastic devices on the cornealendothelium after phacoemulsificationM D Lingao, MD; H S Uy, MD

The use of Discovisc resulted in less endothelial-cell loss compared withAmvisc after uncomplicated phacoemulsification in normal eyes, andprovided better protection of the corneal endothelium during cataractsurgery.

ORIGINAL ARTICLE 9

Comparing the quality of vision and spherical aberration betweenspherical and aspheric intraocular lensesR T Ang, MD, et al.

Uncorrected visual acuity and high-contrast best-corrected visual acuity at 3months were comparable between eyes implanted with IQ and Natural IOL.Mean spherical and total higher-order aberrations were significantly lower inthe IQ group.

ORIGINAL ARTICLE 13

Efficacy of oral diclofenac as preemptive analgesic for pterygiumsurgeryA F Galias, MD, et al.

The preemptive use of oral diclofenac showed a trend toward less intra- andpostoperative pain, and less need for supplemental analgesics afterpterygium surgery.

ORIGINAL ARTICLE 17

A retrospective review of autologousscleral flap versus donor scleralgraftJ Rivera, MD, et al.

The use of autologous scleral flap inAhmed glaucoma valve implantationappears to be an effective techniquein preventing transconjunctival tubeerosions. Tube exposure is a majorrisk factor for endophthalmitis.

PHILIPP J OPHTHALMOL VOL 33 NO. 1 JANUARY - JUNE 2008 3 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Global efforts to prevent glaucoma blindness



EDITORIAL

AS PART of the effort to combat one of the maincauses of blindness around the globe, the first WorldGlaucoma Day was celebrated on March 6, 2008. Thisinternational event, organized by the World GlaucomaAssociation (WGA) and the World Glaucoma PatientAssociation (WGPA), was marked by awareness andeducational activities, free screening and public servicesorganized by glaucoma institutions and societies,hospitals and clinics, and patient support groupsworldwide. Locally, the Philippine Glaucoma Society(PGS) took the lead. It organized public forums onglaucoma throughout the country, encouraged itsmembers to provide logistical support to collaboratingophthalmologists in the provinces, participated intelevision and radio talk shows regarding the diseaseand the need for early detection, disseminated printedand online information, and conducted free screeningin several institutions.

Such dedication is necessary because glaucoma isdifficult to comprehend for many. Known as the “sneakthief of sight,” the disease strikes silently and graduallythat most glaucoma sufferers may be unaware of itspresence until the late stages when there is markedconstriction in the field of vision. Like cataract, glau-coma is a chronic disease that occurs more commonlyamong the elderly. With an aging population, itsincidence is likely to increase and become a public-health problem. Like cataract, its cause is multifactorialand age is a known risk factor. Unlike cataract whereblindness is reversible, blindness from glaucoma isirreversible. Whereas treatment for cataract isstraightforward—the removal of the defective humanlens and replacement with an intraocular lens—

treatment for glaucoma is complex, ranging fromchronic use of agents to lower the intraocular pressureto filtration surgery or use of glaucoma drainage devicesto improve the outflow or drainage facility within theglaucomatous eye. Whereas the effects of cataracttreatment can be appreciated almost immediately afterthe lens replacement with improved vision, treatmentfor glaucoma is lifetime with the goal of preservingvision.

All in all, the cost of treating glaucoma, a lifelongdisease, is enormous.1-3 An individual with glauco-matous optic neuropathy will be on lifetime treatmentand monitoring that includes office visits, periodicdiagnostic tests, medications, lasers, or surgeries—allaimed at halting progression and preventing blindness.Not to treat is even more costly due to the effects ofpermanent blindness, such as loss of productivity andneed for nursing care.3

With longer life expectancy and increased incidenceof blindness from glaucoma, there is heightenedurgency to combat this devastating disease. In recentyears, there has been an upsurge in glaucoma studiesfrom different parts of the world representing thevarious facets of the disease and its effects on differentpopulations. With a plethora of information published,critical evaluation of these studies is paramount toseparate opinion from evidence. Population-basedstudies and randomized controlled clinical trials arethe 2 pillars in the paradigm shift of evidence-basedmedicine. In the era of globalization, collaboration andinterdependence in combating blindness of whatevercause are needed to produce a significant impact.Professional societies have networked with the explicitgoals of promoting glaucoma science and care throughnational and international meetings, formulating andadvocating practice guidelines with the aim ofproviding the highest standard of care, and organizingsupport groups to assist those with glaucoma in copingwith the disease.

Correspondence to

Patricia M. Khu, MD, MS

Past President 2005-2006

Philippine Glaucoma Society

Manila, Philippines

E-mail : [email protected]

What has the Philippine Glaucoma Societyachieved in the past 10 years?




The formation of the WGA set in motion a globalcollective effort to achieving excellence in glaucomacontrol and management. Composed of leadingglaucoma experts and institutions throughout the world,its overall goal is to optimize the quality of glaucomaresearch and treatment through increased communi-cation and cooperation among international glaucomasocieties, industries, and patient organizations.4 TheWGA works closely with the WGPA, an umbrellaorganization that assists glaucoma associations andnetworks worldwide by educating and supporting theirmembers so that all people with glaucoma canunderstand and better manage their disease.4

As it became increasingly evident that glaucoma isalso a major cause of blindness in the Philippines, nineglaucoma specialists met and formed the PhilippineGlaucoma Society (PGS) in November 1997. It seeksmainly to enhance the knowledge and practice ofglaucoma through continuing medical educationconsisting of roundtable discussions, symposiums,research, information and educational campaigns. Italso recognizes the importance of establishing linkageswith other professional societies locally and interna-tionally. During the congress of the Asia-Pacific Academyof Ophthalmology (APAO) hosted by the PhilippineAcademy of Ophthalmology in 1999, several glaucomaspecialists from the region met and formally convenedthe Southeast Asia Glaucoma Interest Group (SEAGIG)in Manila under the leadership of Dr. Ivan Goldberg.In 2002, the PGS hosted the second SEAGIG congressin Manila and participated in the formulation of theAsia-Pacific Glaucoma Guidelines, which were launchedin 2004. It also became a member of the WGA (formerlyAssociation of International Glaucoma Societies) andtook part in its inaugural meeting in Vienna, Austria in2005. The PGS has also participated in all the SEAGIGmeetings held every 2 years in different Asian countriesand organized symposiums and workshops in severalAPAO congresses and the WGA congress in Singapore,promoting international recognition for the society.

This year, PGS celebrated its 10th anniversary withthe holding of the first Philippine Glaucoma Congressin February that highlighted vital issues concerning thepathogenesis, diagnosis, monitoring, and treatment of

glaucoma. It assembled as core faculty a stellar groupof international experts acknowledged for theirleadership, eloquence, and expertise on the variousaspects of the science and the art of glaucoma (Welcomemessage, Norman Aquino, MD, Philippine GlaucomaCongress, February 2008). True to its mission ofbecoming an internationally recognized leader inproviding quality glaucoma care in the Philippinesthrough education, exchange of ideas, research andpublication, it has also maintained professionalenhancement, support and fellowship among itsmembers (Welcome message, Mario Aquino, MD,Philippine Glaucoma Congress, February 2008).

Certainly, the PGS has attained most of its goals inthe last 10 years. Its members and leaders haverecognized the need for a collective effort—ateamwork—to bring the highest standards of glaucomacare to the Filipino people. As a professional society, ithas brought elitism to its members. To others, it is asource of assistance and information. To those intraining, it is a teacher par excellence and a regulatorybody as well. To the patients, it is a source of hope—that blindness can ultimately be prevented. The PGSmembers should not rest on their laurels, as much moreneeds to be done where prevention of blindness isconcerned. Instead of sprinting and running out ofsteam at once, the society should look to run longdistance and accumulate small, significant gains withevery stride. Defeating glaucoma requires perseverance,and the fight is neither short nor easy.

References

1. Salm M, Belsky D, Sloan FA. Trends in cost of major eye diseases to Medicare,

1991-2000. Am J Ophthalmol 2006; 142: 976-982.

2. Peeters A, Schouten JS, Webers CA, et al. Cost-effectiveness of early detection

and treatment of ocular hypertension and primary open-angle glaucoma by the

ophthalmologist. Eye 2008; 22: 354-362.

3. Bramley T, Peeples P, Walt JG, et al. Impact of vision loss on costs and outcomes

in Medicare beneficiaries with glaucoma. Arch Ophthalmol 2008; 126: 849-856.

4. World Glaucoma Association. WGA: The Global Glaucoma Network. http://

www.worldglaucoma.org/pages/mission.htm (accessed April 2008).

PHILIPP J OPHTHALMOL VOL 33 NO. 1 JANUARY - JUNE 2008 5PHILIPPINE ACADEMY OF OPHTHALMOLOGY

ORIGINAL ARTICLE



ABSTRACTObjective

This study compared the effects of Discovisc (DV) and Amvisc Plus (AP) onthe corneal endothelium of patients after phacoemulsification cataractsurgery.

MethodsForty eyes of 36 adult patients were enrolled in this randomized, double-

masked clinical trial. They were randomly assigned to receive either DV or APduring phacoemulsification. Both the patients and the evaluators were maskedas to which viscoelastic was used during the surgery. The main outcomemeasures were endothelial-cell loss after surgery, intraocular pressures (IOP),and change in corneal thickness. Differences between the two groups wereanalyzed statistically.

ResultsThe mean endothelial-cell loss was 205.5 (9.79%) in the DV group and 450

(18.10%) in the AP group. There was significantly greater endothelial-cellloss among patients who received AP (p = 0.01). The mean postoperativecorneal thickness and IOP were similar for both groups.

ConclusionsThe use of DV resulted in less endothelial-cell loss compared with AP after

uncomplicated phacoemulsification in normal eyes. DV, therefore, providedbetter protection of the corneal endothelium during cataract surgery.

Keywords: Ophthalmic viscoelastic device, Phacoemulsification, Endothelial-cell count,Intraocular pressure, Corneal thickness

PHILIPP J OPHTHALMOL 2008; 33(1): 5-8 © PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Michelle Doronila Lingao, MD1

Harvey Siy Uy, MD1, 2

1Department of Ophthalmology and Visual SciencesUniversity of the Philippines–Philippine General HospitalManila, Philippines

2Asian Eye InstituteMakati, Philippines

Correspondence to

Michelle D. Lingao, MD

Department of Ophthalmology and Visual Sciences

University of the Philippines–Philippine General Hospital

Taft Avenue, Ermita

1000 Manila, Philippines

Telephone : +63-2-3022488

Fax : +63-2-9318706


No financial assistance was received for this study.

The authors have no proprietary or financial interest in

any product used or cited in this study.

Effects of two ophthalmicviscoelastic devices on thecorneal endothelium after

phacoemulsification


PHACOEMULSIFICATION can result in cornealendothelial damage due to localized temperature increasefrom the ultrasound energy, turbulent flow of theirrigation solution with contact of lens nuclear fragments,1

air bubbles,2 or the formation of reactive free-radicalspecies that produce oxidative damage.

Ophthalmic viscoelastic devices (OVDs) stabilize theanterior chamber and protect the corneal endothelium,thereby reducing corneal endothelial damage duringcataract surgery. Prior to their use, corneal edema wasthe most common cause of failed cataract surgery.3-4

OVDs were initially classified as either cohesive5-6 ordispersive.7-8 The cohesive, high-molecular-weight OVDsmaintain the anterior chamber and are removed moreeasily during phacoemulsification. Dispersive OVDscontaining chondroitin sulfate have lower molecularweights and provide better coating of the corneal endo-thelium, but are harder to remove from the anteriorchamber.8-11 All of these agents showed comparable resultsin their ability to protect the corneal endothelium withno difference in postoperative best-corrected visual acuity(BCVA) and percent increase in central corneal pachy-metry.8-12 Combining the use of cohesive and dispersiveagents during cataract surgery has been advocated by someauthors to maximize the benefits of both.13

The introduction of DisCoVisc (DV, Alcon Labora-tories, Fort Worth, TX, USA) led to an expansion of theclassification scheme that considers cohesion-dispersionindex (CDI) (rate of removal of the OVD during aspirationin phacoemulsification) independently from zero-shearviscosity.14 DV is the first viscous dispersive OVD containing40 mg sodium chondroitin sulfate (4%) and greater-than-17-mg sodium hyaluronate (3%). Its viscous characterfacilitates excellent space maintenance while its dispersivenature imparts tissue protection. Oshika and coworkersshowed that DV has excellent retention during phaco-emulsification and easy removal after IOL implantation.15

Amvisc Plus (AP, Bausch and Lomb Pharmaceuticals,Irvine, CA, USA) is a viscous cohesive OVD containing 16mg sodium hyaluronate (1.6%). Its high viscosity resultsin good space maintenance and tissue manipulation.Because of the high molecular weight of sodiumhyaluronate, AP exhibits high zero-shear viscosity andcohesive behavior.13 It is therefore readily removed fromthe eye.

Both DV and AP are classified under the same zero-shear viscosity range of 105 to 106; one is a viscous cohesive,the other a viscous dispersive.14 Petroll and colleagues usedin vivo confocal microscopy in quantitatively assessing 3OVDs in rabbits following phacoemulsification. Theyshowed that DV had better retention and coating of theendothelium than AP.16

This study, therefore, compared the effects of DV and

AP on the corneal endothelium of patients undergoingphacoemulsification with intraocular-lens (IOL)implantation based on the following parameters:postoperative endothelial-cell count, corneal thickness,and IOP.

METHODOLOGYForty eyes of 36 adults with cataracts scheduled to

undergo phacoemulsification surgery by one of theauthors (HSU) at the Asian Eye Institute were enrolled inthis double-masked, randomized, controlled trial. Patientswith a history of trauma, corneal pathology, cornealdecompensation, glaucoma, and uveitis were excluded.Patients with preoperative intraocular pressure (IOP) over22 mm Hg by Goldman applanation tonometry, cornealendothelial-cell counts less than 700 cells/mm2, andcorneal thickness of more than 650 µm were also excluded.

All patients underwent preoperative eye examinationthat included history taking, visual-acuity determination,IOP measurement, and biomicroscopic examination ofthe anterior and posterior segments. Manifest refractionof both eyes was also done. The following data werecollected pre- and postoperatively: BCVA using the ETDRSchart, IOP, central corneal thickness (CCT) as measuredby ultrasonic pachymetry (Pachette 2, DGH, USA), andcorneal endothelial-cell density as measured by noncontactspecular microscopy (SP1000, Topcon Corporation,Japan). A single observer, masked as to the treatmentgroup of the patients, interpreted the specular-microscopyresults and determined the endothelial-cell count. Maskedobservers measured the visual acuity and IOP, gradedcataract nuclear density according to the Lens OpacitiesClassification System II (LOCS II).17

The patients were randomly assigned by toss coin toreceive either DV or AP. All surgeries were done by a singlesurgeon (HSU), who was masked as to which OVD wasused. Phacoemulsification was performed under topicalanesthesia using proparacaine 0.5%. The techniqueincluded creating a side port with a 15-degree keratome.The assigned OVD, transferred beforehand to a 1-ccunlabeled syringe, was injected through the side port untilthe anterior chamber was filled. A clear corneal incisionwas then made using a 3.0-mm keratome. Continuouscurvilinear capsulorhexis was created, followed by hydro-dissection and hydrodelineation with balanced salinesolution (BSS). Phacoemulsification was performed usingthe same machine (Millenium Phaco Machine, Bauschand Lomb, USA) for all eyes. Nuclear disassembly wasperformed using a stop-and-chop technique. The anteriorchamber and capsular bag were filled with OVD afterremoving the remaining cortical material using anirrigation and aspiration (I/A) probe. A foldable acrylicIOL was subsequently implanted. The OVD was removed


using I/A until the anterior chamber was cleared of allvisible OVD. The phacoemulsification time, ultrasoundpower, and total operative time were recorded.

The patients were examined 1, 8, and 30 days aftersurger y. BCVA and IOP were taken and slitlampbiomicroscopy was done at each follow-up visit. Cornealpachymetry and specular microscopy of the involved eyewere performed on day 30 postoperation.

All numerical continuous data were summarized usingdescriptive statistics (percentage, frequency distribution,and measures of central tendency). Categorical variablesof the two groups were compared using chi-square andFisher’s exact test. Independent t-test was done to comparemain outcome variables. The pre- and postoperativemeans within each group were computed using the pairedt-test. Pearson’s correlation was used to correlate thesurgical parameters with the main outcomes.

The research was performed in accordance with theguidelines set by the Declaration of Helsinki. Informedconsent was obtained from all the patients after thoroughexplanation of the nature and possible risks and benefitsof the study.

RESULTSA total of 40 eyes (20 for each group) of 36 patients

were included in the study. All patients completed theprescribed number of follow-ups. The mean age of thepatients in the DV and AP groups were similar (Table 1).Surgical parameters during phacoemulsification were alsosimilar (Table 2).

There was a statistically significant difference (p = 0.01)in the mean preoperative endothelial-cell counts betweenthe 2 groups (Table 1), with higher mean cell count inthe AP group. There was no significant difference in thepostoperative endothelial-cell count between the groups.There was, however, a significantly greater endothelial-cell loss in the AP group (p = 0.01) (Table 3).

There was no difference in corneal thickness and IOPsbetween the two groups postoperatively. The average day1 postoperative IOPs were under 18 mm Hg for bothgroups.

There was a significant difference between pre- andpostoperative BCVA within each group (p = 0.000 forboth), but no significant difference between the 2 groupson day 8 postoperatively (Table 3).

There was no significant correlation between phaco-emulsification time and IOP (p = 0.20), cell count (p = 0.94),and corneal thickness (p = 0.34). Likewise, no correlationwas found between phacoemulsification power and IOP(p = 0.26), corneal endothelial-cell count (p = 0.35), andcorneal thickness (p = 0.96). There was also no correlationbetween surgical duration and IOP (p = 0.50), cell count(p = 0.76), and corneal thickness (p = 0.89).

There was no difference in the amount of postoperativeanterior-chamber reaction (cells) (p = 0.13) and cornealedema (p = 0.70) between the 2 groups.

DISCUSSIONCorneal edema is the most common complication of

cataract surgery. To prevent this, protection of the cornealendothelium during surgery is of utmost importance anda good way of ensuring this is with the use of a goodophthalmic viscoelastic. An ideal viscoelastic providesmaximum space maintenance, a property of cohesiveOVDs, and maximum protection to the cornealendothelium, a property of dispersive OVDs.

DisCoVisc (DV) has both the properties of a cohesiveas well as a dispersive viscoelastic. It belongs to the samezero-shear viscosity range 105 to 106 (hundred thousands)as Amvisc Plus (AP), but DV is more of a viscous dispersivewhile AP is a viscous cohesive. Several studies havecompared the effects of AP on the corneal endotheliumwith various viscoelastics and showed that they did notsignificantly affect the postoperative IOP, endothelial-cellcount, and corneal thickness after phacoemulsification,9-11

while a study by Holzer and coworkers showed a significantloss in the endothelial-cell count and increase in IOPpostoperatively.13

This study demonstrated a significant difference in theendothelial-cell loss between the DV and AP groups,suggesting that DV may provide additional protection tothe corneal endothelium during phacoemulsification.The dispersive nature of DV may have afforded addedprotection to the endothelium during cataract surgery.

Parameters

Age (years)

BCVA

IOP (mm Hg)

Corneal thickness (µm)

Cell count (cells/mm)

Table 1. Preoperative parameters between the 2 groups.

Discovisc

69.00 ± 10.68

0.47 ± 0.24

15.85 ± 2.56

544.15 ± 33.05

2125 ± 262.45

Amvisc Plus

68.94 ± 14.29

0.51 ± 0.20

15.90 ± 2.81

538.85 ± 50.30

2392 ± 347.16

p

0.99

0.57

0.95

0.70

0.01

Parameters

Phaco Time (minutes)

Phaco Power (%)

Surgical duration (minutes)

Table 2. Surgical parameters between the 2 groups.

Discovisc

0.64 ± 0.39

10.89 ± 5.33

15.20 ± 3.04

p

0.84

0.59

0.15

Amvisc Plus

0.62 ± 0.32

10.05 ± 4.33

13.90 ± 2.47

Table 3. Postoperative parameters between the 2 groups.

Parameters

BCVA

IOP (mm Hg)

Corneal thickness (µm)

Cell count (cells/mm)

Endothelial cell loss (%)

Discovisc

0.86 ± 0.16

17.20 ± 2.91

558.95 ± 33.26

1919.50 ± 318.94

205.5 (9.79)

Amvisc Plus

0.85 ± 0.19

16.70 ± 3.74

551.55 ± 50.44

1942.00 ± 260.60

450 (18.10)

p

0.86

0.64

0.59

0.81

(.01)


No difference in corneal thickness and IOP were seenbetween the two groups pre- and postoperatively, althougha study by Oshika et al. showed a transient rise in IOPafter DV was used, which was attributed to the difficultyin removing the OVD during irrigation and aspiration.15

No significant correlation between surgical parameters,such as phacoemulsification time, power, and surgicalduration, and endothelial-cell count, corneal thickness,and IOP were seen in this study. A decrease in theendothelial-cell count in both groups postoperatively maybe due to multiple factors, such as surgical technique andskills, and the severity of cataract.

In summary, this study demonstrated that the use ofDV resulted in less endothelial-cell loss compared withAP after uncomplicated phacoemulsification in normaleyes. DV is, therefore, more protective of the cornealendothelium and its use may result in less corneal edema,faster postoperative recovery, and better postoperativevision.

Further studies using DV in cases of decreasedendothelial-cell counts (i.e. Fuch’s endothelial dystrophy)and during long and complicated surgical procedures (i.e.phacotrabeculectomy) need to be done to elucidate if DVhas a superior protective effect on the endothelium ofcompromised corneas.

References

1. Hayashi K, Hayashi H. Risk factors for corneal endothelial injury during

phacoemulsification. J Cataract Refract Surg 1996; 22: 1079-1084.

2. Kim E, Cristol S, Geroski DH, et al. Corneal endothelial damage by air bubbles

during phacoemulsification. Arch Ophthalmol 1997; 115: 81-88.

3. Kaufman E, Katz JI. Endothelial damage from intraocular-lens insertion. Invest

Ophthalmol 1976; 15: 996-1000.

4. Roper-Hall MJ, Wilson RS. Reduction in endothelial-cell density following cataract

extraction and intraocular-lens implantation. Br J Ophthalmol 1982; 66: 516-517.

5. Roberts B, Peiffer RL Jr. Experimental evaluation of a synthetic viscoelastic material

on intraocular pressure and corneal endothelium. J Cataract Refract Surg 1989;

15: 321-326.

6. Harfstrand A, Molander N, Stenevi U, et al. Evidence of hyaluronic acid and

hyaluronic acid binding sites on human corneal endothelium. J Cataract Refract

Surg 1992; 18: 265-269.

7. Arshinoff SA. Dispersive-cohesive viscoelastic soft-shell technique. J Cataract

Refract Surg 1999; 25: 167-173.

8. Glasser DB, Osborn DC, Nordeen JF, Min Y-I. Endothelial protection and viscoelastic

retention during phacoemulsification and intraocular-lens implantation. Arch

Ophthalmol 1991; 109: 1438-1440.

9. Madsen K, Schenholm M, Jahnke G, Tengblad A. Hyaluronate binding to intact

corneas and cultured endothelial cells. Invest Ophthalmol Vis Sci 1989; 30: 2132-

2137.

10. Maar N, Graebe A, Schild G, et al. Influence of viscoelastic substances used in

cataract surgery on corneal metabolism and endothelial morphology: comparison

of Healon and Viscoat. J Cataract Refract Surg 2001; 27: 1756-1761.

11. Hutz WW, Eckhardt HB, Kohnen T. Comparison of viscoelastic substances used in

phacoemulsification. J Cataract Refract Surg 1996; 22: 955-959.

12. Koch DD, Liu JF, Glasser DB. A comparison of corneal endothelial changes after

use of Healon or Viscoat during phacoemulsification. Am J Ophthalmol 1993; 115:

188-201.

13. Holzer MP, Tetz MR, Auffart GU, et al. Effect of Healon 5 and 4 other viscoelastic

substances on intraocular pressure and endothelium after cataract surgery. J

Cataract Refract Surg 2001;27: 213-218.

14. Arshinoff S, Jafari M. New classification of ophthalmic viscosurgical devices–2005.

J Cataract Refract Surg 2005; 31: 2167-2171.

15. Oshika T, Okamoto F, Kaji Y, et al. Retention and removal of a new viscous dispersive

ophthalmic viscosurgical device during cataract surgery in animal eyes. Br J

Ophthalmol 2006; 90: 485-487.

16. Petroll WM, Jafari M, Lane SS, et al. Quantitative assessment of ophthalmic

viscosurgical device retention using in vivo confocal microscopy. J Cataract Refract

Surg 2005; 31: 2363-2368.

17. Chylack LT, Leske MC, Khu P, et al. Lens Opacities Classification System II (LOCS

II). Arch Ophthalmol 1989; 107: 991-997.


ORIGINAL ARTICLE



ABSTRACTObjective

This study compared the quality of vision and spherical aberration (SA) ineyes implanted with spherical and aspherical intraocular lenses (IOL).

MethodsTwenty-two patients (44 eyes) with bilateral cataracts were included in a

prospective, comparative, randomized clinical study to receive either AlconIQ aspheric or Natural IOL in either eye. Three-month postoperativeevaluation included uncorected (UCVA) and best-corrected visual acuity(BCVA), and contrast sensitivity under photopic and mesopic conditions.

ResultsIn the IQ group, UCVA was at least 20/20 in 45% and 20/40 in 85% of the

eyes. High-contrast BCVA was at least 20/16 in 36%, 20/20 in 95%, and 20/40in 100% of eyes. In the Natural group, UCVA was at least 20/20 in 35% and20/40 in 95% of eyes. High-contrast BCVA was 20/16 in 40%, at least 20/20in 95% and 20/25 in 100% of eyes. Mean spherical equivalent was –0.15 ± 0.6Din the IQ and –0.25 ± 0.6D in the Natural. The mean SA in the IQ wassignificantly lower than in the Natural (0.15 µm vs. 0.49 µm; p < 0.001). Meantotal higher-order aberration was significantly lower in the IQ vs. the Natural(0.58 µm vs. 0.75 µm; p = 0.03). Contrast sensitivity under photopic andmesopic conditions did not show a significant difference between the groups.

ConclusionUCVA, high-contrast BCVA, and contrast sensitivity at 3 months were

comparable between eyes implanted with IQ and Natural IOL. Mean sphericaland total higher-order aberrations were significantly lower in the IQ group.

Keywords: Intraocular lens, Cataract, Phacoemulsification, Spherical aberration, Higher-orderaberration


Robert T. Ang, MD1, 2

Gladness A. Martinez, MD2

Jesse B. Caguioa, OD1

Karen B. Reyes, MD1, 2

1Asian Eye Institute Makati City, Philippines

2Cardinal Santos Medical Center San Juan, Metro Manila, Philippines

Correspondence to

Robert T. Ang, MD

Asian Eye Institute

9/F Phinma Plaza, Rockwell Center

1200 Makati City, Philippines

Telephone : +63-2-8982020





Comparison in the quality ofvision and spherical aberrationbetween spherical and aspheric

intraocular lenses


MODERN cataract surgery has advanced extensively,its aims no longer limited to the removal of the cataractouslens but extending to the improvement of vision throughimplantation of intraocular lenses (IOLs). Studies haveshown that in a young eye without cataract, the corneaexerts a positive spherical aberration (SA) while thenatural lens exerts a negative SA.1-3 These tend to canceleach other out, producing a clear retinal image. Withincreasing age, however, the compensation afforded bythe crystalline lens is gradually lost with the developmentof cataract, leading to an increase in total ocular higher-order aberrations (HOA).

Implantation of a spherical IOL has been the standardin phacoemulsification surgery. Spherical lenses providegood vision but have been shown to induce positive SA,yielding poorer image quality by decreasing contrastsensitivity.4-5 Aspheric lenses, such as the IQ lens (AlconLaboratories, Fort Worth, TX, USA) were developed tolower spherical and total HOA of the optical system. TheAlcon IQ lens incorporates a –0.20 µm SA that is presumedto offset the +0.20 µm SA of the cornea, resulting in neutralor significantly lower SA. Correcting the cornea’s positiveSA has been shown to improve contrast sensitivity.6

This study compared the quality of vision and SA ineyes implanted with the Alcon Natural and the Alcon IQaspheric IOL.

METHODOLOGYTwenty-two patients with bilateral cataracts seen from

October 2006 to April 2007 were recruited for a pros-pective, comparative, randomized, subject-masked clinicaltrial in a single center. Included in the study were patients45 years old and above with bilateral cataracts willing toundergo phacoemulsification with IOL implantation inboth eyes. Their high-contrast best spectacle-corrected orpotential-acuity-meter-tested vision should be at least20/40 in both eyes. Patients were excluded if they hadany of the following in either eye: greater than +3brunescent cataracts, astigmatism greater than 1.50Ddetected by manifest refraction or corneal topography,increased intraocular pressure (IOP), narrow angles ordiagnosed with glaucoma, symptomatic ocular-surfacepathology such as dry eye, abnormal corneal topography(keratoconus), iris abnormalities, specular microscopycount less than 1,200 cells/mm2, unstable zonulesmanifested by phacodonesis or pseudoexfoliation, historyof traumatic eye injury, uveitis, ocular-muscle disorders,posterior-segment pathologies like diabetic retinopathy,and previous ocular or refractive surgery. Pregnant orlactating patients, those taking any form of steroids,patients with history of allergy to any medications usedduring and after phacoemulsification, those who hadadverse events intraoperatively (i.e. vitreous loss or sulcus-

placed IOL) or who developed increased IOP postope-ratively were also excluded. Depending on the contactlens used, patients were advised to discontinue use at least1 to 3 weeks before preoperative testing.

The following tests were performed 30 days preope-ratively: uncorrected and best-corrected visual acuity(UCVA and BCVA) with manifest refraction using high-contrast chart, applanation tonometry, slitlamp exami-nation, corneal topography (Orbscan version 3.14, Bauschand Lomb, Germany), pupillometry (dim-light pupil size,Zywave version 5.20, Bausch and Lomb, Germany),biometry by 2 technicians using a Quantel Axis II version1.07 A-scan (Quantel Medical, France), specularmicroscopy (SP1000, Topcon, Japan), dilated aberrometry(Zywave version 5.20, Bausch and Lomb, Germany),potential-acuity meter (Marco Technologies, USA) and adilated-retina examination.

A randomization table was used to determine whetherthe Alcon Acrysof IQ or the Natural lens would beimplanted in the first eye. The subjects were masked as towhich IOL each eye received. The choice of IOL powerwas based on the surgeon’s previous experience with adesired target of emmetropia.

Standard phacoemulsification was done by a singlesurgeon (RTA). The surgeries were performed undertopical or retrobulbar anesthesia with sedation. After theprocedure, appropriate topical antibiotic and steroid eyedrops were administered at the discretion of the surgeonat a minimum duration of two weeks postoperatively. Thesecond eye was operated within 2 weeks after the firstoperation.

The following tests were performed at 3 monthspostoperation: UCVA and BCVA with manifest refractionusing high-contrast charts, contrast-sensitivity testing(photopic/daytime -85 cd/m2 and mesopic/nighttime -3cd/m2) with and without glare using Optec 6500 (StereoOptical Inc., Chicago, USA), slitlamp examination withIOP measurement, corneal topography, pupillometry(dim-light pupil size–Zywave readings), dilatedaberrometry.

Postoperative visual perception was obtained by meansof a questionnaire with a given score for each category.Distance vision during daytime, under normal lightingcondition, and at night, including satisfaction in vision,were rated using the following scoring system: 5 = excel-lent, 4 = very good, 3 = average, 2 = poor, and 1 = bad.Symptoms of glare and haloes were rated at 5 = none,4 = mild, 3 = moderate, 2 = marked, and 1 = severe. Highermean scores implied better results whereas lower scoresimplied less satisfactory results. The mean score for eachcategory was calculated and tested for significance.

Visual acuities were reported in Snellen equivalents.Differences between groups were analyzed using paired


two-tailed t-test. A p value of <0.05 was consideredstatistically significant.

The study protocol followed the Declaration of Helsinkiand a written informed consent was obtained from eachpatient.

RESULTSForty-four eyes of 22 patients, 10 males and 12 females,

were included in the study. The mean age was 64 years(range, 55 to 82). The mean preoperative UCVA was20/60 in both groups (range, >20/200 to 20/25). Thepreoperative spherical equivalent ranged from –8.75D to+7.00D with a mean of –0.35D. Two patients were lost tofollow-up at 3 months. The mean pupil size at 3 monthswas 5.1 mm for the IQ and 5.3 mm for the Natural group.

The UCVA at 3 months was similar in both groups(Figure 1). The mean spherical equivalent in the IQ was–0.12 ± 3.25D at preoperation, –0.23 ± 0.56D at 1 month,and –0.15 ± 0.6D at 3 months. The mean sphericalequivalent in the Natural was 0.57 ± 3.0D at preoperation,–0.41 ± 0.52D at 1 month, and –0.26 ± 0.6D at 3 months.Between the two groups , the mean spherical equivalentwas similar at 3 months (Table 1).

At 3 months, high-contrast daytime BCVA without glarewas 20/16, 20/20, and 20/25 in 36%, 95%, and 100% ofeyes respectively in the IQ; and 20/16, 20/20, and 20/25in 40%,95%, and 100% of eyes respectively in the Natural.

Figure 1. Uncorrected visual acuity at 3 months.

Table 1. Mean spherical equivalent and aberration at 3 months.

Spherical equivalent (diopter)

Spherical aberration (µm)

Higher-order aberration (µm)

IQ

–0.15 ± 0.6

0.15 ± 0.17

0.57 ± 0.23

Natural

–0.26 ± 0.6

0.49 ± 0.16

0.75 ± 0.16

0.59

<0.001

0.03

p

Daytime (no glare)

IQ

Natural

p

Daytime (with glare)

IQ

Natural

p

Nighttime (no glare)

IQ

Natural

p

Nighttime (with glare)

IQ

Natural

p

1.5 cpd

108

106

0.79

108

102

0.34

97

92

0.57

79

72

0.36

3 cpd

149

155

0.50

138

138

0.97

118

113

0.72

91

85

0.56

6 cpd

180

179

0.91

168

168

0.96

143

134

0.59

91

80

0.39

18 cpd

43

42

0.83

39

35

0.39

21

16

0.18

9

9

0.77

12 cpd

100

102

0.77

98

93

0.55

64

61

0.75

33

31

0.66

Table 2. Contrast sensitivity at 3 months.

Spatial Frequency

Visual Perception

Daytime Vision

Normal Light

Nighttime Vision

Visual Satisfaction

Glare

Haloes

Satisfaction

IQ

3.9

3.8

3.3

4.0

4.4

4.6

Natural

3.8

3.7

3.2

3.9

4.3

4.3

0.49

0.43

0.43

0.72

0.33

0.33

p

Table 3. Visual-perception and satisfaction (mean scores).

100 -------------------------------------------------------------------------------------------------------------

80 -------------------------------------------------------------------------------------------------------------

60 -------------------------------------------------------------------------------------------------------------

40 -------------------------------------------------------------------------------------------------------------

20 -------------------------------------------------------------------------------------------------------------

0 --------------------------------------------------------------------------------------------------------------20/16 20/20 20/30 20/35 20/40 >20/40

I | | I I I I

Perc

en

t o

f P

ati

en

ts

510

45

70

95

75

Natural IQ

35

70

95

85

100 100

Contrast-sensitivity results showed that in both photopicand mesopic studies, the mean scores at spatial frequenciesof 1.5, 3, 6, 12, and 18 did not show significant differencesbetween the groups (Table 2). Contrast-sensitivity scoresunder mesopic study with and without glare were higherin the IQ than in the Natural in all spatial frequencies,but the differences did not reach statistical significance.

The mean scores for postoperative visual perceptionfor daytime, normal-light, and nighttime vision at 3months were similar for both groups (Table 3). Symptomsof glare and haloes were similar. Satisfaction scoresbetween the two groups were also equivalent (Table 3).

At 3 months, the mean SA was 0.15 ± 0.17 µm in the IQand 0.49 ± 0.16 µm in the Natural; this difference wasstatistically significant (Table 1). The mean HOA of0.57 ± 0.23 µm in the IQ differed significantly from the0.75 ± 0.16 µm in the Natural (Table 1).

DISCUSSIONThe mean UCVA, BCVA, and spherical equivalent were

similar in the IQ and Natural groups in this study. MeanSA and HOA were, however, significantly lower in the IQthan in the Natural. Other studies have shown similarresults, with a decrease in SA and HOA in aspheric lensesand improving the optical quality in pseudophakicpatients.4-5, 7 Contrast sensitivity was reportedly improved inboth photopic and mesopic conditions.6-7 In this study,


although the contrast-sensitivity scores under mesopicconditions with and without glare were higher in the IQ,the difference was not statistically significant. Clinically,the distance-vision perception of the patients underdifferent lighting conditions and the visual-disturbances(glare, haloes) scores at 3 months were similar for bothgroups.

In summary, eyes implanted with the IQ aspheric IOLhave a significantly lower spherical and total higher-orderaberration compared to eyes implanted with the sphericalNatural lens. This could benefit patients who requirebetter nighttime vision or who may have large pupils indim-light situations. Increasing the study population mayalso make the results, particularly contrast-sensitivitystudies, more statistically significant.

References

1. Artal P, Berrrio E, Guirao A. Contribution of cornea and internal surfaces to the

change of ocular aberrations with age. J Opt Soc Am 2002; 19: 137-143.

2. Artal P, Guirao A, Berrio E. Williams DR. Compensation of corneal aberrations by

the internal optics of the eye. J Vision 2001; 1: 1-8.

3. Barbero S, Marcos S, Merayo-Lloves J. Corneal and total optical aberrations in a

unilateral aphakic eye. J Cataract Refract Surg 2002; 28: 1594-1600.

4. Holladay JT, Piers PA, Koranyi G, et al. A new intraocular lens design to reduce

spherical aberration of pseudophakic eyes. J Refract Surg 2002; 18: 683-691.

5. Mester U, Dillinger P, Anterist N. Impact of a modified optic design on visual function:

clinical comparative study. J Cataract Refract Surg 2003; 29: 652-660.

6. Marcos S, Barbero S, Jimenez-Alfaro I. Optical quality and depth of field of eyes

implanted with spherical and aspheric intraocular lenses. J Refract Surg 2005; 21:

223-235.

7. Caporossi A, Martone G, Caspirini F, Rapisarda L. Prospective randomized study of

clinical importance of 3 aspheric and 2 spherical intraocular lenses in 250 eyes. J

Refract Surg 2007; 23: 639-648.


ORIGINAL ARTICLE



ABSTRACTObjective

To determine the efficacy of oral diclofenac as preemptive analgesic forpterygium excision.

MethodsA prospective, randomized, controlled, double-blind clinical trial was carried

out involving 30 patients diagnosed with pterygium. They were randomlyassigned to receive either placebo or oral diclofenac. A single surgeonperformed the same technique of pterygium excision. Pain scores weredetermined using visual-analog-scale (VAS) questionnaires handed out toparticipants 30 minutes and 24 hours after surgery. Collected data wereanalyzed using two-tailed t-test, chi-square, and Fisher’s exact test.

ResultsThere was no statistical difference between VAS pain scores in both groups

in the intra- (p = 0.33) and postoperative periods (p = 0.46). No statisticallysignificant difference was noted on the intake (p = 0.68) and dose (0.18) ofsupplemental analgesia. There appeared to be a trend for lower pain scoresin the intraoperative (VAS = 2.00 ± 1.89 for diclofenac vs. 2.73 ± 2.22 for control)and postoperative (VAS = 3.86 ± 2.92 for diclofenac vs. 4.60 ± 2.44 for control)periods with intake of diclofenac. This group also took less supplementalanalgesics.

ConclusionThe preemptive use of oral diclofenac showed a trend toward less intra-

and postoperative pain, and less need for supplemental analgesics after ptery-gium surgery.

Keywords: Oral diclofenac, Preemptive analgesia, Pterygium surgery, Surgical pain


Anabelle F. Galias, MDTeofilo R. Bulosan, MDDanilo Q. Reyno, MDAmiel N. Rodriguez, MDRosalina T. Babao

Department of OphthalmologyEast Avenue Medical CenterQuezon City, Philippines

Correspondence to

Anabelle F. Galias, MD

Department of Ophthalmology

East Avenue Medical Center

East Avenue, Diliman

Quezon City, Philippines





Efficacy of oral diclofenacas preemptive analgesicfor pterygium surgery


POSTOPERATIVE pain is a concern of both patientsand surgeons. It is generally managed by pain relieversgiven intra- or postoperatively. Pain in ocular surgery isthe result of nociceptive injury to peripheral neuralstructures. The use of local anesthesia during ocularsurgery is primarily aimed at controlling intraoperativepain.

The concept of preemptive analgesia to reduce postope-rative pain was founded on a series of successful animalexperimental studies.1 Preemptive analgesia stems fromthe importance of pain modulation through peripheralor central inhibition of nociception. It is the pharma-cologic management producing effective analgesia priorto surgical trauma using central neural block, localanesthetic infiltration, opioids, nonsteroidal antiinflam-matory drugs (NSAIDs), or ketamine.

The use of preemptive analgesics in ocular surgery isnot well established. Weinberger used topical sodiumdiclofenac as a preemptive analgesic for retinal laserphotocoagulation.2 Kristin showed that preoperativeperibulbar bupivacaine effectively reduced postoperativepain for vitrectomy surgery. 3 Fekrat demonstrated thatintraoperative intravenous ketorolac tromethamineeffectively controlled postoperative pain after vitreoretinalsurgery.4 A metaanalysis by Ong (2005) on preemptiveanalgesia, covering the period January 1987 to October2003, however, showed equivocal effectiveness amongvarious forms of preemptive analgesics for a variety ofsurgical procedures.5

Pain is still a concern in intra- and postoperative periodsin minor ocular surgeries, such as pterygium excisionwhere topical and local anesthetics are used. This is usuallyaddressed by giving analgesics after surgery. However,patients’ apprehension of pain and their actual painperception may be markedly reduced if the pain relieveris given preoperatively. Diclofenac, a common painreliever given postoperatively, is a nonselective cyclooxy-genase inhibitor rapidly absorbed by the body followingoral intake. It has a half-life of 1 to 2 hours, with an onsetof action an hour after intake. Its duration of action lastsfor approximately 12 hours and is, therefore, suitable forrelieving postoperative pain.

This study determined the efficacy of oral diclofenacas a preemptive analgesic among patients undergoingpterygium excision. Intra- and postoperative-pain scoreswere determined including the need for supplementalanalgesic within 24 hours after the procedure.

METHODOLOGYWe conducted a prospective, randomized, double-blind

clinical trial involving patients from the outpatient clinics ofthe Department of Ophthalmology, East Avenue MedicalCenter. Patients were invited to participate in the study if

they met the following inclusion criteria: at least 21 yearsold, diagnosed with pterygium at least >2 mm from thelimbus, scheduled for pterygium excision under localanesthesia, and undergoing minor ocular surgery for thefirst time. Excluded were patients who have undergoneprevious ocular surgery, those taking other oral painmedication or other modes of analgesic therapy for othermedical conditions, and those with diagnosed renal or liverfailure. Informed consent was obtained from all participants.

Patients were asked to report 2 hours before theirscheduled surgery and advised to have their lunch priorto oral intake of oral diclofenac to reduce the incidenceof gastric irritation.

The participants were randomly assigned by toss cointo one of two groups: placebo or diclofenac. One hourprior to the scheduled surgery, the study participants weregiven one tablet of either 50-mg diclofenac or 100-mgascorbic acid (control).

A single surgeon, blinded as to the status of preemptiveanalgesia, performed the pterygium excision under localanesthesia using the standard bare-sclera technique. 0.2%mitomycin C was applied over the bare sclera. The surgeonalso gave the postoperative instructions, including the useof postoperative analgesic.

The primary outcome is the determination of the painscore within 30 minutes and 24 hours after surgery usingthe visual analog scale (VAS). The VAS pain-scoring systemis a scale that ranks the level of pain from zero (no pain feltat all) to 10 (being the most painful or intolerable type ofpain). The secondary outcome was the use of postoperativeanalgesic by the patient. The same investigator, blinded asto the medication received by the patient, conducted thepain survey within 30 minutes after the surgery and askedthe participant to indicate the pain score felt during theprocedure. She also retook the pain score at postoperativeday 1 and noted whether additional analgesic was taken.

The sample size was computed based on the result ofthe study by Reuben6 that showed a standard deviation of0.7 for the control and a mean difference of 1.3 betweenthe treatment and control groups. The sample size wascalculated based on an α-error level of significance of 95%and a β-error level of significance of 90%. Each studygroup, therefore, had a minimum sample size of 15.

The data were entered in SPSS version11 and analyzedusing the t-test comparing the mean between the controland treatment groups. Chi-square and the Fisher’s exacttests were used to compare nominal data.

RESULTSThe study population consisted of 30 subjects, 15 in

the placebo and 15 in the diclofenac groups. There wasno significant difference in mean age and sex distribution(Table 1).


The mean VAS scores were not significantly differentbetween the two groups for both the intra- (p = 0.33) andpostoperative (p = 0.46) periods (Table 2). Relative riskwas computed for VAS scores of zero as having nointraoperative pain and VAS scores above 1 as havingsignificant postoperative pain. The relative risk for intra-operative pain was slightly less for the diclofenac group(RR = 0.73) but it was not significantly different (p = 0.09).It was also less in the postoperative period (RR = 0.73)but not significantly different from the control group(p = 0.09) (Table 3).

The need for postoperative supplemental analgesic waslesser for the diclofenac group (RR = 0.84) but thedifference was not significant (p = 0.68) (Table 3). Themost commonly used postoperative analgesic for bothgroups was mefenamic acid. The number of postoperativesupplemental doses of analgesic was also lesser for thediclofenac group (RR = 1.20) but the difference was notsignificant (p = 0.18) (Table 2).

DISCUSSIONPain intensity following induction of surgical trauma

can be controlled not only by local wound infiltrate ofanesthesia that blocks peripheral nerves, but also by anti-inflammatory medications. The amount of pain sensationis related to the amount of inflammation induced duringsurgery. Thus, blocking pain sensation by reducing post-operative inflammation is a logical option to reduce painintra- and postoperatively.

Diclofenac is an NSAID that inhibits both peripheraland central pain. As a cyclooxygenase inhibitor, it reducesthe release of inflammatory mediators in the cyclooxy-genase pathway, resulting in reduction of inflammationand pain sensation.

Many surgeons still prescribe postoperative analgesicson “as needed” basis depending on the patient’s level ofpain tolerance. With better understanding of surgical

Characteristics

Age (years)

Mean

20 – 30

31 – 40

41 – 50

51 – 60

61 – 70

Sex

Male

Female

1Computed by t-test2Computed by Fisher’s exact test

Table 1. Demographic characteristics of the study population.

Control

(n = 15)

41.00 ± 9.64

3 (20.0%)

2 (13.3%)

8 (53.3%)

2 (13.3%)

0

9 (60.0%)

6 (40.0%)

Diclofenac

(n = 15)

42.93 ± 13.96

4 (26.7%)

2 (13.3%)

3 (20.0%)

5 (33.3%)

1 (6.7%)

12 (80.0%)

3 (20.0%)

p

0.661

0.422

Parameter

VAS scores

Intraoperative

0

1

2

3

4

5

6

8

Mean

24 hours postoperative

0

1

2

3

4

5

6

7

8

9

Mean

Supplemental analgesic

0

1

2

3

4

Mean

Table 2. Mean VAS scores and number of supplemental analgesic taken.

Control

(n = 15)

0

7 (46.7%)

2 (13.3%)

1 (6.7%)

2 (13.3%)

1 (6.7%)

1 (6.7%)

1 (6.7%)

2.73 ± 2.22

0

0

5 (33.3%)

1 (6.7%)

2 (13.3%)

1 (6.7%)

2 (13.3%)

2 (13.3%)

1 (6.7%)

1 (6.7%)

4.60 ± 2.44

3 (20.0%)

1 (6.7%)

6 (40.0%)

4 (26.7%)

1 (6.7%)

1.93 ± 1.22

Diclofenac

(n = 15)

4 (26.7%)

4 (26.7%)

2 (13.3%)

0

3 (20.0%)

2 (13.3%)

0

0

2.00 ± 1.89

2 (13.3%)

2 (13.3%)

3 (20.0%)

0

1 (6.7%)

1 (6.7%)

4 (26.7%)

0

1 (6.7%)

1 (6.7%)

3.86 ± 2.92

5 (33.3%)

3 (20.0%)

4 (26.7%)

3 (20.0%)

0

1.33 ± 1.18

p1

0.33

0.46

0.18

1Computed by t-test

trauma and resultant inflammation, there is growinginterest in giving analgesics much earlier to minimize painduring and after surgery. The concept of preemptiveanalgesia is to minimize intra- and postoperative pain bygiving analgesic before pain occurs and before localanesthesia wears off. Such intervention may lead to bettermanagement of postoperative pain.

Our study found diclofenac to be an insufficientpreemptive analgesic following pterygium excision.Although there was a trend toward greater reduction inthe VAS pain scores in the diclofenac group, meaning thata surgeon would only need to treat 1 out of 4 patients toget a reduction in the intra- and postoperative-painscores—a 25% pain reduction—this was not statisticallysignificant. The need for supplemental analgesic,mefenamic acid in this study, was also less in the diclofenacgroup, but the trend was not statistically significant. Oneexplanation for diclofenac’s insufficiency as a preemptiveanalgesic may be its half-life of 1 to 2 hours, which is rather


short compared with 50 hours forother oral pain medications. Themore ideal analgesic is one that ispotent enough that the patient willno longer have to take any form ofsupplemental therapy postope-ratively. It is noteworthy that eventhough the mean pain scores weregenerally low in both the control anddiclofenac groups during the intra-and postoperative periods, theparticipants still had to take someform of supplemental analgesicpostoperatively.

Newer NSAIDs, such as rofecoxiband piroxicam, were used in arthros-copic knee surgery6 and laparoscopicsurgery7 respectively and found to besignificantly effective in reducingpostoperative pain as measured byVAS scores (p = 0.005 and p < 0.05

respectively). Intake of supplementalanalgesic was also found to besignificantly less in these studies(p = 0.0001 and p < 0.04 respectively).

Rofecoxib, a cyclooxygenase-IIinhibitor, has been withdrawn fromthe market due to its side effects whilepiroxicam is still available. It has alonger half-life of approximately 57hours,8 permitting once-daily dosing.It is rapidly absorbed in the body, withpeak plasma concentration withinan hour following intake. Piroxicamcan, therefore, be a more suitablepreemptive analgesic.

Although diclofenac failed todemonstrate conclusively its useful-ness as a preemptive analgesic inpterygium excision, this study islimited by its small sample size. Largersample using stronger NSAIDs may be

Outcome

Intraoperative

No pain (VAS = 0)

With pain (VAS > 0)

Postoperative

No pain (VAS = 0)

With pain (VAS > 0)

Supplemental analgesic

No intake

With intake

1Confidence interval2Computed by Fisher’s exact test

Table 3. Presence or absence of intra- and postoperative pain and intake of supplemental

analgesic.

Control

(n = 15)

0

15

0

15

3

12

Diclofenac

(n = 15)

4

11

4

11

5

10

p2

0.09

0.09

0.68

RR

0.73

0.73

0.84

95% CI1

0.54–1.00

0.54–1.00

0.34–1.18

NNT

3.7

3.7

7.8

more appropriate in demonstratingthe utility of preemptive analgesia inocular surgery.

In summary, the preemptive use oforal diclofenac showed a trend towardless intra- and postoperative pain andless need for supplemental analgesicafter pterygium surgery.

Acknowledgement

The authors acknowledge the assistance of Drs.

Alejandro de Leon, Rudolfo Chuanico, Debbie Yap,

Gerald Maceda, Grandyll Oca, and Ms. Grace Rosales.

References

1. Woolf CJ, Chong MS. Preemptive analgesia: treating

postoperative pain by preventing the establishment

of central sensitization. Anesth Analg 1993; 77: 362-

379.

2. Weinberger D, Ron Y, Lichter H, et al. Analgesic effect

of topical sodium diclofenac 0.1% drops during retinal

laser photocoagulation. Br J Ophthalmol 2000;

84:135-137.

3. Kristin N, Schönfeld CL, Bechmann M, et al.

Vitreoretinal surgery: preemptive analgesia. Br J

Ophthalmol 2001; 85: 1328-1331.

4. Fekrat S, Marsh MJ, Elsing SH, et al. Intraoperative

ketorolac and eye pain after vitreoretinal surgery: a

prospective, randomized, placebo-controlled study.

Retina 2003; 23: 8-13.

5. Ong C, Lirk P, Seymour R, Jenkins B. The efficacy of

preemptive analgesia for acute postoperative pain

management: a metaanalysis. Anesth Analg 2005;

100: 757-773.

6. Reuben SS, Bhopatkar S, Maciolek H, et al. The

preemptive analgesic effect of rofecoxib after

ambulatory arthroscopic knee surgery. Anesth Analg

2002; 94: 55-59.

7. O’Hanlon JJ, Muldoon T. Lowry D. McCleane G.

Improved postoperative analgesia with preoperative

piroxicam. Can J Anaesth 1996; 43: 97-101.

8. Katzung, BG. Basic and Clinical Pharmacology, 7th

ed. Connecticut: Appleton and Lange, 1998; 578-600.

PHILIPP J OPHTHALMOL VOL. 33 NO. 1 JANUARY - JUNE 2008 17PHILIPPINE ACADEMY OF OPHTHALMOLOGY

ORIGINAL ARTICLE


Ophthalmology JANUARY - JUNE 2008VOL. 33 • NO. 1

Jonathan Rivera, MD1

Edgar Leuenberger, MD1, 2

Ma. Imelda Yap-Veloso, MD2

1University of the East Ramon Magsaysay Memorial Medical CenterQuezon City, Philippines


A retrospective review ofautologous scleral flap versus

donor scleral graft

Correspondence to

Jonathan Rivera, MD

University of the East Ramon Magsaysay Memorial

Medical Center

Aurora Boulevard


Telephone : +63-2-7150861 ext. 354

Email : [email protected]




ABSTRACTObjective

This study determined the rates of tube erosion and associated complicationsamong patients implanted with the Ahmed glaucoma valve (AGV) usingautologous scleral flap versus donor scleral graft.

MethodsThe clinical records of consecutive patients who underwent AGV implan-

tation using either autologous scleral flap or donor scleral graft between August2001 and April 2006 with a minimum follow-up of four months were reviewed.Data were collected using a standardized form and subjected to statisticalanalyses.

ResultsA total of 25 eyes of 25 consecutive patients who underwent AGV implanta-

tion were included. Fourteen received donor scleral grafts and 11 autologousscleral flaps. There were no tube erosions in the autologous scleral group.Transconjunctival erosion was seen in 71% of eyes in the donor scleral group,half of them occurring during the first 3 months postoperatively. Two eyeswith erosion developed endophthalmitis.

ConclusionThe use of autologous scleral flap in AGV implantation appears to be an

effective technique in preventing transconjunctival tube erosions. Exposureof the tube is a major risk factor in the development of endophthalmitis.

Keywords: Glaucoma drainage device, Ahmed glaucoma valve, Autologous scleral flap, Donorscleral patch, Glaucoma


Ahmed glaucoma valve tube erosion

18 PHILIPP J OPHTHALMOL VOL. 33 NO. 1 JANUARY - JUNE 2008 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

GLAUCOMA drainage devices (GDD), such as theAhmed glaucoma valve (AGV) (New World Medical,Rancho Cucamonga, CA, USA), play an important rolein the treatment of certain types of glaucoma wheretrabeculectomy is likely to fail. These include neovascularglaucoma, uveitic glaucoma, aphakic and pseudophakicglaucoma, and in scarred conjunctiva after failed filteringprocedures or multiple intraocular surgeries.

A silicone tube connects the anterior or posteriorchamber to the equatorial region of the globe where theAGV plate is implanted. Aqueous is shunted in a unidi-rectional manner through the valve mechanism and poolsin the space between the valve plate and the posterior blebencapsulation. The aqueous humor then penetrates theposterior bleb encapsulation and is eventually absorbed byorbital tissues and capillaries. Wilcox and colleaguesdemonstrated movement of latex microspheres as large as0.2 µm passing freely through the capsular wall.1, 2

Upon implantation of the AGV, the subconjunctival andsub-Tenon’s portions of the tube are covered with a graftof donor sclera or human allograft tissue (gammasterilized pericardium, dura mater, fascia lata, or tectoniccorneal graft). Alternatively, one could use a limbal-basedscleral lamellar flap similar to scleral flaps employed intrabeculectomy procedures.3

Although studies have shown the efficacy of the AGVin the treatment of complicated glaucomas, severalcomplications have also been reported. These includehypotony,4 tube blockage or valve failure,5 loss of visualacuity,6 strabismus and diplopia,7 epithelial downgrowth5

calcification of the implant,8 transconjunctival tubeerosion,9 transconjunctival plate erosion, plate extrusion,and associated endophthalmitis.9

Retrospective studies have shown that endophthalmitisis a rare complication after glaucoma drainage devices.9

In a retrospective review of 542 eyes implanted with theAGV, endophthalmitis developed in 9 (1.7%) eyes.9 It wassuggested that a Seidel positive transconjunctival AGV tubeerosion in a younger patient represents a major risk factorfor the development of endophthalmitis. In all of thesurgeries, the tube was covered with either sclera, dura,or pericardial graft. Autologous scleral flap was not usedin any of the procedures.

In a retrospective study by Aslanides involving 17 eyeswith a mean follow-up of 14.8 months (range 6 to 62months) using a variety of glaucoma drainage devices andautologous scleral flap, all eyes showed no clinical evidenceof tube erosion, or graft-related intraocular compli-cations.3 Smith reported that no tube-covering materialwas superior than the other.10

We hypothesize that the use of autologous scleral flap,which is easily available, is an effective, safe, and inexpen-sive alternative to donor scleral graft. It offers the

advantage of minimizing the risk of transmitting infectiousdiseases3, 11-13 and is effective in preventing transcon-junctival tube erosion. This study compared the rates oftransconjunctival tube erosions between autologous scleralflap and donor scleral graft in AGV implantation and theirassociated compli-cations and management.

METHODOLOGYThe clinical records of consecutive patients who

underwent AGV implantation using either autologousscleral flap or donor scleral graft at the Asian Eye Institutebetween August 2001 and April 2006 were reviewed.Included were those with a minimum follow-up of fourmonths from the date of implantation, with regularslitlamp biomicroscopy. Photos were taken as needed.

Data collected using a standardized form includeddemographic characteristics, preoperative indications forsurgery, visual acuity (VA), intraocular pressure (IOP),type of glaucoma, operative techniques of AGVimplantation, manner of preparing the donor sclera,postoperative VA and IOP, and presence of tube erosion.Transconjunctival tube erosion was defined as any part ofthe AGV tube exposed through the conjunctiva visible bybiomicroscopic examination. The time to appearance oftube erosion postoperatively was noted, plus any associatedcomplications and subsequent interventions.

Surgical ProcedureTwo surgeons performed the AGV implant procedures.

All patients received intraoperative sedation. One surgeonused topical anesthestic with supplemental subconjunc-tival lidocaine, while the other surgeon used retrobulbarblock. One surgeon used donor scleral graft in all proce-dures while the other surgeon initially used donor scleralgraft followed by autologous scleral flap consecutively.General anesthesia was used for a 9-year-old patient withcongenital aniridia. Both surgeons utilized the sameoperative technique of AGV implantation.

After administration of the anesthetic, a limbal corneal6 or 7-0 silk traction suture was applied. A 3-clock-hoursuperotemporal fornix-based conjunctival flap wascreated. Spring tenotomy scissors were used to carry thedissection posteriorly toward the equator to create apocket between the superior and lateral recti muscles.Bleeding was controlled with bipolar cautery. The AGVwas primed with balanced salt solution (BSS) using a 27G cannula and the plate inserted into the posterior pocketwith the anterior border approximately 8 mm away fromthe limbus. The plate was anchored to the underlyingsclera with 2 interrupted 9-0 nylon sutures. Viscoelasticsolution was injected into the anterior chamber (AC)through a paracentesis. The site of tube insertion into


the AC was initially created with a 23 G needle at thelimbus, followed by trimming of the tube to adequatelength and its subsequent insertion into the AC. The bodyof the tube was anchored to the sclera with interrupted 9-0 nylon sutures.

A donor graft soaked in BSS for 30 minutes was cut tosize and used to cover the body of the tube near the limbus.9-0 sutures anchored the donor sclera to the host sclera.Alternatively, a 7 mm x 7 mm limbal-based lamellar-scleralflap was constructed with a crescent knife and the tubeinserted through a limbal sclerostomy under the flapanchored with 9-0 nylon sutures. The conjunctiva wasreattached to the limbus with interrupted 10-0 nylonsutures.

Statistical AnalysisThe following variables were evaluated: age and sex of

patients, indications for AGV implantation, number andtype of previous conjunctival surgeries, type of glaucoma,time from implantation of the AGV to recorded transcon-junctival erosion, complications associated with erosions,and interventions after erosions were noted.

Descriptive statistics consisted of measures of centraltendency (mean and standard deviation) for continuousnumerical data and percentage-frequency distribution forcategorical variables. Chi-square test was used forcomparison of categorical data and Mann-Whitney U testfor continuous numerical data. Comparison of proportionof subjects with tube erosion in both groups was facilitatedusing z-test of two proportions.

All tests of significance were carried out at 0.05 alphalevel of significance using Statistica version 1999 (StatsoftInc., Tulsa, OK, USA).

RESULTSA total of 41 AGV implantations were performed

between August 2001 and April 2006. Sixteen eyes wereexcluded because of insufficient data or failure to meetthe criteria of minimum 4 months of follow-uppostoperatively. Four patients in the donor group werelost to follow-up but completed the minimum follow-upperiod, while none in the autologous group was lost tofollow-up. Out of the 25 eyes included in this study, 21received the AGV model S2 (polypropylene plate) while2 in the donor sclera graft and 2 in the autologous scleraflap received the AGV model FP7 (silicone plate).

Eleven (44%) underwent implantation using autolo-gous scleral flap, while 14 (56%) had donor scleral graft(Table 1). The mean age was 51 ± 3 years (range, 9 to 84).There were more males (72%) in this series. The righteye was more commonly involved(68%). Baselinedemographic variables did not show any significantdifference between the 2 groups (Table 1).

No tube erosions were observed among those who hadautologous scleral flap (Table 2). Seventy-one percent(71%) of those who received donor scleral graft had tubeerosion, half of which occurred during the first 3 monthspostoperatively, the earliest at 1 month and the latestbetween 37 and 39 months (Tables 2 and 3). Thedifference in proportions between the 2 groups was,however, not statistically significant (p = 0.29). This maybe attributed to the small samples of the study groups.

The number of previous conjunctival surgeries did notdiffer statistically between the 2 groups (Table 1). Previousconjunctival procedures accounted for most of theindications for AGV implantation, with a greaterproportion seen in the donor group than the autologousgroup. Neovascular glaucoma was the second mostfrequent indication for both the donor and the autologousgroups (Table 1).

Two eyes developed endophthalmitis (Table 4) asso-ciated with transconjunctival tube erosion that requiredexplantation of the AGV. In one eye, tube culture studiesyielded Staphylococcus sp (Figure 1). Both eyes underwent

*Significant difference if p is <.05aComputed using Mann-Whitney U testbComputed using Chi-square1Visual acuity2Intraocular pressure3Extracapsular cataract extraction4Open-angle glaucoma5Retinal detachment6Chronic angle-closure glaucoma

Table 1. Demographic and clinical characteristics of the study population

(n = 25).

Characteristics

Age (years)

Mean

Range

Sex

Male

Female

Affected Eye

Right

Left

Preoperative VA1

Mean

Range

Preoperative IOP2

Mean

Range

Types of Glaucoma

Post ECCE3 OAG4

Post RD5 surgery OAG

Post filter CACG6

Neovascular glaucoma

Uveitic

Previous Ocular Surgeries

p*

0.28a

0.06b

0.22b

0.37a

0.57b

0.69b

0.79b

0.42b

0.41b

0.85b

0.38b

Autologous

Scleral Flap

(n = 11)

48 ± 25

9–77

6 (54%)

5 (46%)

8 (73%)

3 (27%)

1.87 ± 0.93

0.54–3.0

36.2 ± 9

22–49

1 (9%)

2 (18%)

3 (27%)

4 (36%)

1 (9%)

6 (55%)

Donor Scleral

Graft

(n = 14)

58 ± 21

18–86

12 (86%)

2 (14%)

9 (64%)

5 (36%)

2.22 ± 0.74

1.3–3.0

35.5 ± 14

19–68

2 (14%)

2 (14%)

6 (43%)

3 (21%)

1 (7%)

10 (71%)

20 PHILIPP J OPHTHALMOL VOL. 33 NO. 1 JANUARY - JUNE 2008 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

diode cycloablation for subsequent IOP control. Threeeyes with tube erosions had “sterile hypopyon;” two ofthese underwent amputation of the exposed tube, leavingbehind a short tube stump and the AGV plate untouched.The limbal sclerostomy and conjunctival defects wereclosed and trabeculectomy with mitomycin C wasperformed in adjacent area where the conjunctiva wasdeemed mobile. The other eye had the AGV explantedand replaced with a new AGV using a donor scleral graft.No new erosion was seen during the follow-up period.Resolution of the hypopyon occurred within the first weekof the intervention.

Three eyes with tube erosions showed no intraocularsequelae for more than 36 months from the time theerosion was noted. They were Seidel negative and weremaintained on rotating third- and fourth-generationtopical antibiotics once a day.

Patients who received donor scleral graft were followedup for a period of 36 to 70 months whereas those whohad autologous scleral flap were seen over a period of 4to 36 months.

DISCUSSIONOccurrence of tube erosion ranged from 0 to 3 in GDD

implantation14 and about 3% in AGV.15 In this study, theincidence was 40%, which is rather high compared to therates in other reports. And all erosions occurred with thedonor scleral group and none in the autologous scleralgroup. Other studies reported that no tube coverage inglaucoma drainage implant was more prone to melting.16

Several factors may contribute to transconjunctivalerosion of the AGV tube in the donor scleral group. Forinstance, small amounts of absolute alcohol retained inthe donor sclera can be toxic to ocular tissues.17 Using gas

Table 2. Outcomes of AGV implantation with donor scleral graft versus

autologous scleral flap.

Table 4. Complications and interventions for tube erosions.

Complication Intervention

1 – Valve explanted, vitrectomy, infective

agent unknown

1 – Valve explanted, Staphylococcus sp.

on tube culture, diode transcleral

cycloablation done

2 – Tube amputated, valve plate retained,

trabeculectomy with mitomycin done

1 – Tube amputated, valve plate retained,

new AGV implanted inferiorly

1 – AGV explanted, new AGV implanted,

no erosion

1 – 36 months since eroded*



Endophthalmitis

Sterile hypopyon (anterior

uveitis)

Erosion with no intraocular

sequelae

Eroded with no intraocular

complication so far

*Seidel negative; maintained on third- or fourth-generation fluoroquinolone drops once

a day.

Figure 1. Tube erosion with exudates (Staphylococcus sp.) seen 3 months after AGV

implantation with donor scleral graft. Patient developed endophthalmitis , underwent AGV

explantation and vitrectomy. Diode transcleral cycloablation was done to control IOP.

Table 3. Occurrence of tube erosion (months) in patients with donor

scleral graft.

Interval in Months at

which Erosion Occurred

Tube Erosion Rate

Number Percent

0-3

7-9

16-18

19-21

25-27

37-39

Total

5

1

1

1

1

1

10

50

10

10

10

10

10

100

aComputed using Mann-Whitney U testbComputed using Chi-squarecComputed using Z-test of two proportions

Characteristics

Postoperative VA

Mean

Range

Postoperative IOP

Mean

Range

Duration of follow-up

Mean (months)

Range

Tube Erosion

Present

Time to appearance

Mean

Range

Absent

Number of previous

surgeries

Mean

Range

Complications

p*

0.62a

0.40a

0.03a

0.03c

0.45a

0.43b

Autologous

Scleral Flap

(N = 11)

1.73 ± 1.1

0–3

13.4 ± 3.5

10–20

20 ± 1

4–36

0 (0%)

–

–

11 (100%)

1

1–3

6 (54%)

Donor Scleral

Graft

(N = 14)

2.58 ± 0.74

0.70–3.0

12.1 ± 2.8

8–18

53 ± 3

36–70

10 (71%)

5.6 ± 1

0–39

4 (29%)

3

1–4

10 (71%)


References

1. Coleman AL, Wilson MR, Tan M, et al. Initial clinical experience with the Ahmed

glaucoma valve implant. Am J Ophthalmol 1995; 120: 23-31. Erratum in Am J

Ophthalmol 1995; 120: 684.

2. Minckler DS, Shammas A, Wilcox M, Ogden TE. Experimental studies of aqueous

filtration using the Molteno implants. Trans Am Ophthalmol Soc 1987; 85: 368-392.

3. Aslanides IM, Spaeth GL, Schmidt CM, et al. Autologous patch graft in tube shunt

surgery. J Glaucoma 1999; 8: 306-309.

4. Sayyad FE, El-Meghraby A, Helal M, Amayen A. The use of releasable sutures in

Molteno glaucoma implant procedures to reduce postoperative hypotony. Ophthalmic

Surg 1991; 22: 82-84.

5. Sidoti PA, Mincker DS, Baerveldt, et al. Epithelial ingrowth and glaucoma drainage

implants. Ophthalmology 1994; 101: 1036-1043.

6. Law SK, Kalenak JW, Mieler WF, et al. Retinal complications after aqueous shunt

surgical procedures for glaucoma. Arch Ophthalmol 1996; 114: 1473-1480.

7. Prata JA, Minckler DS. Pseudobrown syndrome as a complication of glaucoma

drainage surgery. Ophthalmic Surg 1993; 24: 608-611.

8. Fellenbaum PS, Baerveldt G, Minckler DS. Calcification of a Molteno glaucoma

implant. J Glaucoma 1994; 3: 81-83.

9. Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, et al. Endophthalmitis associated with

the Ahmed glaucoma valve implant. Br J Ophthalmol 2005; 89: 454-458.

10. Smith MF, Doyle JW, Ticmey JW. A comparison of glaucoma drainage implant tube

coverage. J Glaucoma 2002; 11: 143-147.

11. Duffy L, Wolf J, Collins G. Letter: Possible person-to-person transmission of

Creutzfeldt-Jakob Disease. N Engl J Med 1974; 290: 692-693.

12. Herzberg L. Creutzfeldt-Jakob disease and corneal grafts. Med J Aust 1979; 1:

248.

13. Centers for Disease Control. Update: Creutzfeldt-Jakob disease in a second patient

who received a cadaveric dura matter graft. MMWR 1989; 38: 37-38.

14. Lim KS, Allan BDS, Lloyd AW, et al. Glaucoma drainage devices: past, present, and

future. Br J Ophthalmol 1998; 82: 1083-1089.

15. Huang MC, Netland PA, Coleman AL, et al. Intermediate-term clinical experience

with the Ahmed glaucoma valve implant. Am J Ophthalmol 1999; 127: 27-33.

16. Smith MF, Doyle JW, Ticrney JW Jr. A comparison of glaucoma drainage implant

tube coverage. J Glaucoma 2002; 11:143-47.

17. Perkins TW, Kumar A. Corneal decompensation following bleb revision with absolute

alcohol: clinical pathologic correlation. Arch Ophthalmol 2006; 124:738-741.

18. Enzenauer RW, Sieck EA, Vavra DE, et al. Residual ethanol content of donor sclera

after storage in 95% ethanol and saline rinse of various durations. Am J Ophthalmol

1999; 128: 522-524.

19. Heuer DK, Budenz D, Coleman A. Aqueous shunt tube erosion. J Glaucoma 2001;

10: 493-496.

20. Newell F. Ophthalmology: Principles and Concepts, 8th ed. St.Louis: Mosby, 1996;

6.

21. Gedde SJ, Scott I, Tabandeh H, et al. Late endophthalmitis associated with glaucoma

implants. Ophthalmology 2001; 108: 1323-1327.

chromatography studies, Enzenauer showed that forscleras preserved in 95% alcohol, soaking in BSS for 20minutes or longer leached only 98% of the alcohol, while2% remained in the sclera.18 Thus there was no certaintythat soaking the donor sclera in BSS for 30 minutes duringthe surgeries was enough to leach out the absolute alcoholthat the local eye bank used as preservative.

Mechanical friction, such as constant rubbing of theeyelids against the conjunctiva and scleral graft, may alsocontribute to tube erosion, but the exact mechanism isunclear.19 Heuer et al. suggested that burying the tubeunder an autologous lamellar scleral flap would reducethe overall height of the tube and the graft, therebysubjecting the overlying conjunctiva to less tension andmechanical friction. This may be even more significant ineyes with preexisting scarred conjunctivae resulting frommultiple surgeries, as were most of the cases in this study.A thick donor sclera may result in more mechanicalfriction against the eyelids, and lead to early tube erosion.The area of the donor sclera immediately posterior to theinsertion of the rectus muscle may be more ideal to use asa patch graft as this is anatomically thinner (0.3 mm versus1.0 mm in the region surrounding the optic nerve).20

The high occurrence of transconjunctival erosionsobserved among the patients who received donor scleralgraft prompted a shift by one surgeon to an alternatetechnique involving the use of autologous scleral flap,explaining the shorter follow-up period of the lattergroup. Moreover, surgeon’s experience in AGV implant-ation may also have contributed to the occurrence oftube erosion. Most of the tube erosions occurred in theearly years of the 2 surgeons who performed thesurgeries. Since the 2 techniques were not performedsimultaneously, but rather the autologous scleral flap wasdone much later in the surgical experience of onesurgeon, modifications in surgical technique, includingmuch gentle handling of tissues and familiarity with theprocedure could affect this comparison. This limitationshould be addressed in future studies.

Complications related to tube exposure includedendophthalmitis which developed in 2 eyes(8%). Earlytreatment given to 3 patients with erosion and hypopyonmay have helped avoid this devastating complication. Foureyes with erosion remained Seidel negative with nointraocular signs of inflammation after 36 to 48 months(Table 4). They were maintained on once-a-day topicalantibiotic and followed up closely. Some authors suggestedthat exposed glaucoma-device implant tubes may beobserved in the absence of a leak (Seidel-negative test) orocular irritation.21 It is not clear whether maintainingthese eyes on prophylactic topical antibiotics may be of

any clinical benefit.In summary, the use of autologous scleral flap in AGV

implantation showed significantly better outcomes thanthe use of donor scleral graft in this study. To validate theresults, a prospective randomized trial involving compa-rison of the 2 groups with standardized surgical techniqueand similar follow-up periods should be conductedsimultaneously to eliminate surgeon’s experience as aconfounding factor. Furthermore, collateral studieslooking into the proper technique of preparing the donorsclera prior to its use may help determine the amount ofresidual alcohol in the graft. A comparison of the differentsolutions used in rinsing the alcohol may also beundertaken. To investigate the effect of mechanicalfriction on the conjunctiva overlying the patch graft,ultrabiomicroscopic studies measuring graft heights mayprovide valuable information.


ORIGINAL ARTICLE



ABSTRACTObjective

To evaluate the efficacy and safety of intracameral triamcinolone on post-cataract surgery inflammation compared with topical 1% prednisolone acetate.

MethodsEighteen eyes of 18 patients underwent phacoemulsification with

intraocular-lens implantation. They were randomly assigned to 2 treatmentgroups: the control group received 1% prednisolone acetate postoperativelyfor 1 month; the triamcinolone group received 0.4 mg in 0.1 ml solution oftriamcinolone acetonide intraoperatively. Main outcome measures wereanterior-chamber (AC) cells, conjunctival hyperemia, corneal edema, andintraocular pressure (IOP).

ResultsSignificant difference in preoperative and postoperative AC cells in both

the control (p < 0.001) and triamcinolone (p = 0.001) groups was seen, but nodifference postoperatively between the 2 groups (0.98 vs. 0.94 respectively).No difference in postoperative conjunctival hyperemia or increase in IOP wasseen in both groups. Snow-globe effect and pseudohypopyon were transientlyobserved in the triamcinolone group.

ConclusionIntracameral triamcinolone is a safe alternative to topical 1% prednisolone

acetate in controlling postoperative inflammation.

Keywords: Triamcinolone, Postoperative inflammation, Intracameral, Cataract surgery, Steroids


Ma. Catherina G. Coronel, MDGeorge N. Co, MD

Department of OphthalmologyUniversity of Santo Tomas HospitalManila, Philippines

Correspondence to

Ma. Catherina G. Coronel, MD

35 Bernardo Street, San Francisco del Monte


Telephone : +63-2-4113361

Mobile Phone : +63-917-8871024





Safety and efficacy ofintracameral triamcinolone in

postcataract inflammation


THE ADVENT of new phacoemulsification techniques,small-incision cataract surgery, and foldable intraocularlenses (IOLs) has not only shortened surgery time butreduced ocular trauma, as well. Patients, however,continue to experience significant postoperative inflam-mation. Corticosteroids, which reduce inflammatoryexudation and inhibit the formation of fibroblasts andgranulation tissue, have been the mainstay in controllingocular inflammation. The use of topical steroids, whichhave been shown effective in controlling postoperativeinflammation, has been the standard practice, althoughpatient compliance remains an issue. Intravitreal,subtenon, and intracameral administration of steroidshave also been employed, each with its own indications,advantages, and disadvantages.

The use of triamcinolone acetonide has been gainingpopularity in ophthalmic practice. This insoluble form ofcortisone stays longer in intraocular fluids, like the vitreousand aqueous humor, making it ideal for controlling theinflammatory process if used intravitreally, intracamerally,or via subtenon’s injection. Some studies have reportedtraces of triamcinolone in the anterior chamber (AC) foras long as 6 months after intravitreal injection.1

Triamcinolone has been used in the treatment ofvarious ophthalmic conditions, such as cystoid macularedema, age-related macular degeneration (ARMD), andpersistent uveitis. It has also been given subtenon’s tocontrol postoperative inflammation. However, rarecomplications like scleral melt at the injection site andglobe perforation have been reported.2 Alternatively,triamcinolone has been injected intracamerally at the endof surger y to avoid these complications.3 Othercomplications reported were increased intraocularpressure (IOP), development of cataract, endophthal-mitis, and pseudoendophthalmitis. Problems of increasedIOP postinjection have been recognized but are reportedlytransient.4 Snow-globe effect causing pseudoendoph-thalmitis can be a problem, but is said to be dose-relatedand is distinguishable from AC inflammation.3

Intracameral administration of triamcinolone duringsurgery can help address patient-compliance problems asonly antibiotic eye drops need to be given postoperatively.This study, therefore, evaluated the safety and efficacy ofintracameral triamcinolone in controlling postoperativeinflammation compared with topical steroid (1%prednisolone acetate). Complications and side effectswere also evaluated.

METHODOLOGY

Eighteen eyes of 18 patients who underwent electivephacoemulsification with IOL implantation using 5.0 mmrigid polymethylmetacrylate (PMMA) lens (Alcon)between June 2006 and August 2006 at the University of

Santo Tomas Hospital and Quezon Institute were includedin the study. Informed consent was obtained from allpatients. Excluded were patients with glaucoma orpreoperative IOP >22 mm Hg, those with history of ocularinfection or inflammation or diabetes, those taking anyoral or topical nonsteroidal antiinflammatory drugs(NSAIDs), and those who have had previous ocularsurgery. Preoperative evaluation included visual-acuitytesting, external-eye examination, slitlamp biomicroscopy,tonometry, and dilated-fundus examination.

Patients were randomly assigned to 2 groups by drawinglots. The treatment group was injected with 0.4 mg triam-cinolone in 0.1 ml solution and the control group with0.1 ml of balanced salt solution (BSS) after removal ofthe ophthalmic viscosurgical device (OVD). The triamci-nolone group was prescribed only topical antibiotic (0.3%ofloxacin) 1 drop every 2 hours for the first postoperativeday, then 1 drop every 4 hours for 1 week, and 1 drop 4times a day until 1 month. If inflammation remainedsignificant 1 week postoperatively, topical steroid (1%prednisolone acetate) was given with the dosagedepending on the degree of inflammation. Treatmentfailure of the triamcinolone group was defined asincreasing amount of or nonimprovement of AC cells andflares and significant conjunctival hyperemia for at least2 consecutive visits. The control group received 0.3%ofloxacin and 1% prednisolone acetate eye drops at 1 dropeach every 2 hours for the first day, 1 drop every 4 hoursfor 1 week, and 1 drop 4 times a day for 1 month.

All surgeries were done by the same surgeon usingeither the Millenium (Bausch and Lomb Storz) or theLegacy (Alcon Surgicals) phacoemulsification machines.Eyes were dilated with1% tropicamide prior to surgeryand 2.5% phenylephrine every 15 minutes during surgery.Surgery was performed under topical anesthesia (0.5%proparacaine) and intracameral 1% lidocaine. Allsurgeries were performed in 2.75 mm clear corneaincision using phaco chop technique. Rigid 5.0 mmPMMA IOLs were used on all patients. After removal ofthe OVD, 0.4 mg in 0.1 ml solution of triamcinoloneacetonide was injected intracamerally for the treatmentgroup while 0.1 ml of BSS was injected intracamerally forthe control group.

Postoperative inflammation was graded according tothe amount of AC cells, conjunctival hyperemia, clarity ofcornea, and perception of symptoms of ocular inflam-mation, such as foreign-body sensation, photophobia,tearing, and eye pain. Patients were evaluated at baselineand in subsequent follow-up visits using slitlampbiomicroscopy without dilating the pupil. AC cells weregraded as follows: 0 = no cells, 1 = 1 to 5 cells, 2 = 6 to 15cells, 3 = 16 to 30 cells, 4 = >30 cells. Conjunctivalhyperemia and corneal clarity were graded from 1 (mild)


to 4 (very severe).Visual-acuity testing, applanation tonometry, slitlamp

biomicroscopy, and ophthalmoscopy were done at eachfollow-up visit. Clinical assessment of ocular inflammationwas conducted by a masked investigator and data wereanalyzed by a masked statistician.

An intent-to-treat analysis was carried out. The MannWhitney U Test was used to analyze variables with ordered-response categories and continuous responses compar-ing the 2 treatment groups while the Friedman outputwas used to evaluate differences among repeated measuresper treatment group. Significant difference was set at pvalue ≤0.05.

RESULTSOf the 18 patients, 5 were males and 13 were females

with a mean age of 64.6 ± 9.16 years (range, 32 to 73).Preoperative visual acuities ranged from 20/70 to handmovement while preoperative IOPs of both groupsranged from 10 to 18 mm Hg with a mean of 13.44 mmHg. The demographic comparison between the 2 groupsare shown in Table 1.

There was a significant difference between preopera-tive and postoperative VA in the control (p < 0.001) (Table

2). There was a significant difference in VA preopera-tively and on the first day postoperatively (p = 0.01) inthe triamcinolone group, but not in the succeeding weeks(p = 0.15).

Significant difference in preoperative and postopera-tive AC cells in both the control (p <0.001) and triamci-nolone (p = 0.001) groups was seen (Table 2), but nosignificant difference postoperatively between the 2groups (0.98 vs 0.94 respectively) (Figure 1).

There was a significant difference in conjunctivalhyperemia preoperatively and postoperatively in thecontrol (p = 0.02) and triamcinolone (p = 0.008) groups(Table 2). Between the 2 groups, a significant differencein the conjunctival hyperemia from day 1 to day 3 in thecontrol and triamcinolone (p = 0.02) (Table 3) groupswas seen. However, there was no significant differencebetween the groups on the succeeding postoperative days(Figure 2).

There was no significant difference in the corneal claritypreoperatively and postoperatively in both groups norbetween the two treatment groups (Tables 2 and 3).

There was a significant difference in the preoperative(13.77 mm Hg) and postoperative (13.21 mm Hg) IOP inthe control (p = 0.03) but not in the triamcinolone (13.11mm Hg and 12.93 mm Hg) (p = 0.15). Between the twogroups, however, there was no significant difference in

Table 3. Mean efficacy and outcome measure scores.

Outcome Measures

Anterior-chamber cells

Conjunctival hyperemia

Corneal clarity

Intraocular pressure

Group

Control

Triamcinolone

Control

Triamcinolone

Control

Triamcinolone

Control

Triamcinolone

Preoperative

0

0

0

0

0

0

13.77 (12-16)

13.11 (10-18)

Day 1

2.11 (2-3)

2.22 (2-3)

0.67 (0-2)

0.89 (0-2)

0

0.33 (0-2)

13 (10-18)

13.77 (8-19)

Week 1

1.11 (0-3)

1.22 (0-3)

0.33 (0-1)

0.33 (0-2)

0

0

13.62 (10-16)

13.25 (10-16)

Day 3

1.78 (1-4)

1.55 (1-2)

0.78 (0-2)

0.11 (0-1)

0

0.22 (0-1)

14.11 (10-18)

12.66 (8-16)

Week 2

0.67 (0-2)

0.44 (0-1)

0.33 (0-1)

0.11 (0-1)

0

0

13 (10-16)

13.14 (10-16)

Week 3

0.22 (0-1)

0.22 (0-1)

0.11 (0-1)

0.22 (0-1)

0

0

12.5 (10-16)

11.83 (10-14)

Week 4

0

0

0

0

0

0

13 (12-14)

12.95

Table 2. Comparison between pre- and postoperative outcomes in each

treatment group.

.Variable

Visual acuity

Intraocular pressure

(mm Hg)

Hyperemia

Corneal clarity

Anterior-chamber cells

Control

(p value)

27.50

(<0.001)

12.61

(0.03)

11.27

(0.02)

0.0

(1.000)

24.62

(<0.001)

Triamcinolone

(p value)

8.07

(0.15)

12.93

(0.15)

12.84

(0.008)

0.0

(1.000)

17.90

(0.001)

Postoperative

Table 1. Demographic characteristics of the study population.

Characteristics

Age

Mean

Range

Preoperative visual acuity

Mean

Range

Preoperative IOP (mm Hg)

Mean

Range

Number of eyes with

Surgical complications

Prolonged surgery

Maculopathy/Retinal problems

Control

(n = 9)

61.6

32-73

20/100

20/70 to CF

13.77

12-16

0

0

0

Triamcinolone

(n = 9)

67.4

62-72

5/200

20/100 to HM

13.11

10-18

0

0

0


Figure 1. Mean AC cells scores over time between control and triamcinolone groups.

control

triamcinolone

2.5

2

1.5

1

0.5

0

AC

Ce

lls

Sc

ore

Postoperative time

d1 d3 w1 w2 w3 w4

Figure 2. Mean conjunctival hyperemia grading over time between control and

triamcinolone groups.

1

0.8

0.6

0.4

0.2

0Co

nju

nc

tiv

al

Hy

pe

rem

ia G

rad

ing

d1 d3 w1 w2 w3 w4

control

triamcinolone

Postoperative time

IOP preoperatively and throughout the postoperative days(Table 3).

DISCUSSIONThe use of topical steroids as postoperative medication

to control inflammation has been the standard practicein most ocular surgeries. Generally, this entailed instil-lation of drops several times a day plus other concomitanteye drops. Uncontrolled ocular inflammation can affectnot only visual recovery but also the surgical outcome.The need for frequent instillation of eye drops can alsoaffect compliance with postoperative treatment. Intraca-meral injection of triamcinolone at the close of surgery isaimed at reducing postoperative medications.

Several techniques of delivering steroids intraocularlyhave been reported in the literature.2 Subtenon’s injectionof triamcinolone for severe uveitis is an acceptable alterna-tive and is also used in post-cataract surgery. Paganelliand coworkers found that subtenon’s injection of triamci-nolone was not significantly different from topical 1%prednisolone acetate.5 Complications of subtenon’sinjection included globe perforation, subconjunctivalhemorrhage, scleral melt, inadvertent injection into theretinal or choroidal circulation, central-retinal-arteryocclusion, blepharoptosis, proptosis, orbital fat atrophy,strabismus, chemosis, and infection.2

Intracameral triamcinolone to control post-cataract-surgery inflammation was studied by Gills and associates.6

The study showed that as the dosage of triamcinoloneacetonide was increased, fewer eyes required topicalsteroids postoperatively (from 45% at the lowest dose toonly 2% at the 1.8- to 2.1-mg level). None of the eyes thatreceived 2.8 mg or more required additional steroidtreatment. There was also a decrease in the rate of clinicalCME as the dose of triamcinolone acetonide increased.

Possible complications from intracameral injectionincluded toxic anterior-segment syndrome (TASS),7

microstructural damage to corneal endothelium,8 andsnow-globe effect in the AC, sometimes leading to pseudo-endophthalmitis.3 These side effects can be prevented byproper preparation of the triamcinolone solution injected.In this study, particles adherent to the IOL were seen insome of the eyes, which eventually lessened. One patienthad pseudohypopyon on postoperative day 1 that resolvedon the third postoperative day. Others reported anincrease in IOP after steroid injection,5 which was not seenin this study. There were no IOPs >18 mm Hg in both thecontrol and triamcinolone groups. Endophthalmitis wasalso not observed in this study.

Overall, there was no significant difference in thescoring of AC cells, conjunctival hyperemia, and cornealclarity between the control and triamcinolone groups. Insome patients, the conjunctival hyperemia may be less inthe first 3 days postoperatively in the triamcinolonecompared with the control group; in others, persistentinflammation requiring the use of topical 1% predni-solone acetate occurred. One had increased AC reactionduring the first postoperative week and the other hadciliary flush during the third postoperative week. Only 1from the control group had similar increase in post-operative inflammation that needed an increase in thefrequency of prednisolone acetate.

Intracameral injection of triamcinolone can gain accessto the vitreous cavity by flowing through the zonules. Thiscan be an advantage in complicated surgeries, in thosewith posterior-capsular rupture to prevent cystoid macularedema, and in diabetic patients to reduce the risk ofneovascularization and macular edema.

In summary, intracameral triamcinolone is comparablewith topical steroids (1% prednisolone acetate) in


controlling postoperative inflammation after cataractsurgery. Posttreatment increase in IOP was not observedin this study. It can be a safe alternative to topical steroidsas postoperative medication, reducing noncomplianceand other problems like macular edema.

References

1. Jonas JB. Concentration of intravitreally injected triamcinolone acetonide in aqueous

humour. Br J Ophthalmol 2002; 86: 1066.

2. Moshfeghi AA, Flynn HW. Complications of IVTA injection. Rev Ophthalmol 2004;

11: 12.

3. Gills JP. Avoiding complications with intraocular medications. Cataract and Refractive

Surgery Today April 2005; 87-89.

4. Burk SE, Da Mata AP, Osher RH, et al. Triamcinolone-assisted anterior vitrectomy.

Cataract and Refractive Surgery Today April 2005; 61-63.

5. Paganelli F, Cardillo JA, Melo LAS, et al. A single intraoperative sub-tenon’s capsule

triamcinolone acetonide injection for the treatment of post-cataract surgery

inflammation. Ophthalmology 2004; 111: 2102-2108.

6. Gills JP, Gills P. Effect of intracameral triamcinolone to control inflammation following

cataract surgery. J Cataract Refract Surg 2005; 31: 1670–1671.

7. Beware potential complications with intracameral medications. Noor Vision

Correction Center Ophthalmology Review. Daily Notes in Ophthalmology. October

28, 2005.

8. Oh JY, Wee WR, Lee JH, et al. Short-term effect of intracameral triamcinolone

acetonide on corneal endothelium using the rabbit model. Eye 2006; 10: 1036.


ORIGINAL ARTICLE



ABSTRACT

ObjectiveThis study determined changes in intraocular pressure (IOP) of normal

eyes during face-down body massage.

MethodsForty-six participants were recruited and underwent detailed ophthalmic

examination including gonioscopy, corneal pachymetry, and visual-fieldexamination. IOP was recorded using a pneumatonometer before the massage,immediately after resuming the sitting position, and every 5 minutes thereafteruntil the IOP returned to baseline.

ResultsA mean rise in IOP of 5.39 mm Hg was noted in 43 participants. There was

a significant difference between baseline sitting IOP and immediately afterthe face-down massage (p < 0.001) and 5 minutes after the massage (p = 0.001),but not between IOP at baseline and 10 minutes after the massage (p = 0.09).

ConclusionChange in body positiion, such as in face-down body massage, can lead to

transient IOP rise with a mean of 5.39 mm Hg.

Keywords: Intraocular pressure, Glaucoma, Massage


Jose E.E. League, MD1

Jonathan A. Rivera, MD2

Edgar U. Leuenberger, MD 1,2


2University of the East Ramon MagsaysayMemorial Medical CenterQuezon City, Philippines

Correspondence toJose E. E. League, MD

Asian Eye Institute

9/F Phinma Plaza, Rockwell Center

1200 Makati City, Philippines

Telephone : +63-2-8982020





The effect of body massage lyingface down on intraocularpressure in normal eyes


GLAUCOMA is associated with various risk factors,foremost of which is elevated intraocular pressure (IOP).Understanding aqueous-humor dynamics, which regulateIOP, is key to understanding glaucoma, as IOP is currentlythe only factor that can be modified to prevent progressiveoptic neuropathy.

Several factors have been associated with raised IOP,including diurnal variation, postural variation, and exertion.1

IOP can increase when changing from sitting to supineor prone position. The reported IOP changes due topostural effects ranged from 0.3 to 6.0 mm Hg.2-6 Othersreported increase in IOP twice from baseline duringposture changes.7 The postural influence on IOP wasgreater in eyes with glaucoma and persisted even after asuccessful filtering surgery.8-10

Straining, associated with valsalva’s maneuver, has alsobeen linked with raised IOP. The likely mechanism forthis phenomenon included elevated episcleral venouspressure.11-13

Massage is the practice of applying structured orunstructured pressure, tension, motion, or vibration—manually or with mechanical aids—to the soft tissues ofthe body to achieve a beneficial response. Massage isusually performed on a person while lying on a massagetable, sitting upright in a massage chair, or lying on a padon the floor. The therapy usually lasts about an hour.

Two important facets associated with increase in IOPare present when a person undergoes a body massage inprone position—postural effect and exertion due tovalsalva’s. Depending on the type of massage performed,the subjects usually exert some form of straining andvalsalva’s, both of which can cause an increase in IOPindependently. Several studies related Sirsasana or headstand exercise and yoga to IOP,7-8 but none on face-downmassage.

With the proliferation of wellness clinics and spas, face-down body massage is becoming more popular. We,therefore, determined the IOP changes during face-downbody massage in normal eyes. The information obtainedfrom this study can help guide clinicians on how to advisepatients, espcially those with glaucoma, regarding activitiesthat can cause transient raised IOP.

METHODOLOGYForty-six volunteers recruited to have massage in prone

position for 30 minutes were included in the study. Afterinformed consent was obtained, the participants under-went a complete eye evaluation with normal findings.Excluded were those with severe eye disorders andconditions precluding prone position, such as backdisorders (scoliosis, slipped disc, osteoartritis).

Ophthalmic examination included best-corrected visualacuity, slitlamp examination, gonioscopy, funduscopy,

ultrasound pachymetry for central corneal thickness, andvisual-field examination.

A professional masseuse performed a 30- minute backmassage (combination of Swedish and shiatsu) on eachof the subjects lying face down.

The IOPs were measured in both eyes using a pneuma-tonometer (Medtronic Solan Model 30, Medtronic,Jacksonville, FL, USA) after application of 1% propa-racaine (Alcaine) eye drops. The IOP was taken beforethe massage, immediately after the volunteer resumed thesitting position, then every 5 minutes thereafter until theIOP returned to baseline. Data were analyzed using pairedt-test.

The study was conducted in accordance with the tenetsof the Declaration of Helsinski and approved by theInstitutional Review Board of the Asian Eye Institute.

RESULTSA total of 46 subjects, 21 males and 25 females, with a

mean age of 29.11 ± 6.28 years (range, 21 to 43),participated in the study. All had essentially normal eyefindings. All had open angles (Table 1). The centralcorneal thickness was similar for both eyes. Visual-fieldexamination was normal for all participants.

The mean baseline IOP prior to massage was 14.54 ±2.18 mm Hg. The IOP uniformly increased in 43 of the46 participants immediately after the massage. One hadIOP lower than the baseline while no changes were notedin 2 subjects.

The highest IOP attained was 28 mm Hg. The IOP ofall participants returned to near baseline level 10 minutesafter resuming the sitting position.

The mean IOP immediately after the massage was 19.93mm Hg, a difference of 5.39 mm Hg from baseline. Themean IOP 5 and 10 minutes after the massage was 15.72mm Hg and 14.15 mm Hg respectively (Table 2). Therewas a significant difference between IOP at baseline andimmediately after the massage and between baseline and5 minutes after the massage (Table 2). There was,however, no significant difference between IOP at baselineand 10 minutes after the massage.

None of the participants developed any ocular orsystemic adverse effects during the study period.

DISCUSSIONIt is well recognized that a change in body position alters

IOP. Several authors have reported an average rise of 2 to3 mm Hg in IOP when body position is changed fromsitting to supine.4, 15-17 Others reported changes as high as6 mm Hg,18-19 with several authors reporting twofoldincrease when changing position from sitting to lying facedown.7

The rise in IOP in this study is similar to those in other


studies dealing with changes in body position. The IOPuniformly increased in all but 3 participants whosepressures were taken immediately after the massage. Therise in IOPs may have been higher had the pressures beenmeasured while lying face down during the massage. Dueto technical difficulties, IOPs were not obtained in theoriginal position but in sitting position immediately afterthe massage. Elevated episcleral venous pressure as a resultof the face-down lying position is one possible mechanismof IOP rise. Further studies, such as anterior-segmentoptical coherence tomography or ultrasound biomicros-copy, are needed to document specific changes in the eye.

This study also did not demonstrate a significant IOPdifference (much higher IOP elevation) when the twofactors (postural effect and valsalva’s) were presentcompared with other studies wherein there was significantIOP rise with change in body position alone. But it

1Computed by t-test

References

1. Allingham RR, Damji K, Freedman S, Moroi S, Shafranov G. Shields’ Textbook of

Glaucoma. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2005; 38-39.

2. Chiquet C, Custaud MA, Le Traun AP, et al. Changes in intraocular pressure during

prolonged seven-day head-down tilt bed rest. J Glaucoma 2003; 12: 204-208.

3. Linder BJ, Trick GL. Simulation of spaceflight with whole body head-down tilt:

influence on intraocular pressure and retinocortical processing. Aviat Space Environ

Med 1987; 58: A139-142.

4. Krieglstein GK, Waller WK, Leydhecker W. The vascular basis of the positional

influence of the intraocular pressure. Albecht Von Graefes Arch Klin Exp Ophthalmol

1978; 206: 99-106.

5. Rice R, Allen RC. Yoga in glaucoma. Am J Ophthalmol 1985; 100: 738-739.

6. Fahmy JA, Fledelius H. Yoga-induced attacks of acute glaucoma: a case report.

Acta Ophthalmol 1973; 51: 80-84.

7. Baskaran M, Raman K, Ramani K, et al. Intraocular pressure changes and ocular

biometry during Sirsasana in Yoga practitioners. Ophthalmology 2006; 113: 1327-

1332.

8. Anderson DR, Grant WM. The influence of position on intraocular pressure. Invest

Ophthalmol Vis Sci 1973; 12: 204-212.

9. Jain MR, Marmion VJ. Rapid pneumatic and Mackay-Marg applanation tonometry

to evaluate the postural effect on intraocular pressure. Br J Ophthalmol 1976; 60:

687-693.

10. Parsley J, Powell RG, Keightley SJ, Elkington AR. Postural response of intraocular

pressure in chronic open-angle glaucoma following trabeculectomy. Br J Ophthalmol

1987; 71: 494-496.

11. Rafuse PE, Mills DW, Hooper PL, et al. Effects of Valsalva’s manoeuvre on intraocular

pressure. Can J Ophthalmol 1994; 29: 73-76.

12. Epstein HM, Fagman W, Bruce DL, et al. Intraocular pressure changes during

anesthesia for electroshock therapy. Anesth Analg 1975; 54: 479-481.

13. Schuman JS, Masicotte EC, Connolly S, et al. Increased intraocular pressure and

visual-field defects in high-resistance wind instrument players. Ophthalmology 2000;

107: 127-133.

14. Lafaut AS, Van Malderen L, Zeyen T. Is pulse synchronized pneumotonometry more

reproducible than routine pneumotonometry and more in agreement with Goldmann

applanation tonometry? Eur J Ophthalmol 2007; 17: 178-182.

15. Jain MR, Marmion VJ. Rapid pneumatic and Mackay-Marg applanation tonometry

to evaluate the postural effect on intraocular pressure. Br J Ophthalmol 1976; 60:

687-693.

16. Galin MA, McIvor JW, Brock Magruden G. Influence of position on intraocular

pressure. Am J Ophthalmol 1963; 55: 720-723.

17. Wuthrich UW. Postural change and intraocular pressure in glaucomatous eyes. Br

J Ophthalmol 1976; 60: 111-114.

18. Weber AK, Price J. Pressure differential of intraocular pressure measured between

supine and sitting position. Ann Ophthalmol 1981; 13: 323-326.

19. Trew DR, Smith SE. Postural studies in pulsatile ocular blood flsow: I. Ocular

hypertension and normotension. Br J Ophthalmol 1991; 75: 66-70.

Table 1. Baseline demographic and clinical profile of subjects.

Parameters

Age (years)

Mean

Range

Sex

Male

Female

Gonioscopy

Open angle

To scleral spur

To ciliary body band

Vertical cup-to-disc ratio (mean)

Central corneal thickness (µm)

Right eye (OD)

Left eye (OS)

Results

29.11 ± 6.28

21 – 43

21 (45.66%)

25 (54.34%)

46 (100%)

8 (17.39%)

38 (82.61%)

0.45 ± 0.23

550.92 ± 36.23

550.67 ± 37.42

551.18 ± 35.42

reinforced the view that patients with glaucoma aresusceptible to pressure spikes when they assume the proneposition. Glaucomatous eyes, especially those withadvanced damage, may not be able to withstand thetransient but significant increase in IOP that occurs afterassuming a face-down position.

Time

Baseline

Immediately after

After 5 minutes

After 10 minutes

Table 2. Mean intraocular pressure at baseline and after face-down

massage.

Mean IOP

(mm Hg)

14.54

19.93

15.72

14.15

p1

<0.001

0.001

0.089


CASE REPORT



Karlo D. Jacob, MD1

Jacinto U. Dy Liacco, MD1, 2

1Department of Ophthalmology and VisualSciencesUniversity of the Philippines–PhilippineGeneral Hospital

2Institute of OphthalmologyUniversity of the Philippines Manila

Rosacea

ABSTRACT

ObjectiveTo report an interesting case of rosacea in a 16-year-old Filipino female.

MethodsThis is a case report.

ResultsA 16-year-old Filipino female consulted for recurrent bilateral eye and facial

redness. Ocular findings included swollen lids, matting of the lashes, lid-marginerythema and crusting, blocked meibomian glands, diffuse papillaryconjunctival reaction, extensive corneal scar with peripheral neovascularizationinvolving the inferior two-thirds of the cornea in both eyes. Skin lesionsincluded papules and pustules on the forehead, cheek, and chin, and bulbouscharacteristic of the nose. Incision biopsy on the left cheek revealedhistopathologic findings consistent with rosacea.

Treatment included doxycycline 100 mg BID, metronidazole 0.75% gelapplied to the face twice daily, and tobramycin + dexamethasone lid scrubHS.

ConclusionIncreased awareness of cutaneous lesions associated with ocular findings

leads to earlier diagnosis and treatment of rosacea and prevents permanenteye impairment.

Keywords: Rosacea, Skin disease, Meibomian-gland dysfunction, Keratitis


Correspondence to

Karlo D. Jacob, MD

Department of Ophthalmology and Visual Sciences

University of the Philippines–Philippine General Hospital

Taft Avenue, Ermita

1000 Manila, Philippines

Telephone : +63-2-3022491; +63-2-5211360





“Curse of the Celts”


ROSACEA is a chronic, persistent, progressive, andpotentially life-disruptive skin disease that affects thecheeks, nose, eyes, chin, and forehead.1 It is characterizedby recurrent episodes of flushing, papules, and pustulesthat occur in the central region of the face against a lividerythematous background with telangiectasias. Later,there may occur diffuse hyperplasia of connective tissuewith enlarged sebaceous glands.2, 3 The disease usuallyaffects individuals between 30 and 50 years of age.4 It is arelatively common disease, especially in fair-skinnedpeople of Celtic or northern European heritage, hencethe term “Curse of the Celts.” The disease is estimated toaffect at least 5 percent of Americans or some 13 millionpeople.5 Although it is said that women are more oftenaffected than men in earlier stages (3:1 ratio), mendevelop the tissue and sebaceous-gland hyperplasialeading to rhinophyma much more frequently.

CASE REPORTA 16-year-old Filipino female with fair complexion

consulted at the outpatient clinic of the Department ofOphthalmology and Visual Sciences, University of thePhilippines–Philippine General Hospital (UP–PGH)forrecurrent bilateral eye redness accompanied by burningsensation, whitish corneal opacities, and blurring of vision.Seven years prior, she started experiencing episodes ofbilateral eye redness, pruritus, lid puffiness, and frequentstyes that resolved spontaneously. Two years later, she againexperienced eye redness, discharge, and tearing in botheyes (OU) associated with episodes of facial redness inhot environment or during consumption of spicy foods.Consultation at UP–PGH was made when the symptomsbecame more severe, associated with foreign-bodysensation, photophobia, and periorbital edema. Initialdiagnosis was staphylococcal blepharo-keratoconjunctivitis,which was managed with regular lid scrubs andantibacterial/antiinflammatory eye drops. During thesame year, she started to develop “pimples” over her face.When the symptoms recurred two years later, sheconsulted a general ophthalmologist and was diagnosedto have “sore eyes” and prescribed eye drops.

At consultation, visual acuity was 5/60 with noimprovement on pinhole (NIPH) in OD and 3/60 NIPHin OS. Intraocular pressures were 11 and 12 mm Hgrespectively. Both eyelids were swollen with matting of thelashes, erythematous and crusted margins, blockedmeibomian glands, hyperemic conjunctivae with diffusepapillary reaction, bilateral whitish corneal opacities, andperipheral neovascularization involving the inferior two-thirds of the cornea in OU (Figure 1). Facial rash was alsopresent. Initial consideration was atopic kerato-conjunctivitis. The presence of papules and pustules onthe cheek, chin, forehead, and their concentration on the

nose giving a bulbous characteristic, led to a reviseddiagnosis of rosacea blepharo-keratoconjunctivitis.Incision biopsy of the left cheek revealed histopathologicfindings (Figure 2) consistent with rosacea.

DISCUSSIONThe diagnosis of rosacea is largely dependent on the

clinical findings, particularly the skin manifestations.There are no histological, serological, or other diagnostictests specific for rosacea. Ocular manifestations alone arenonspecific, leading to frequent misdiagnosis. Browningand colleagues observed that the problem of under-diagnosis can be attributed in part to the failure of ophthal-mologists to inspect the entire face.6 Twenty percent ofpatients can present with nonspecific ocular problems ofrosacea prior to the development of the skin lesions. Thereare no criteria for making a definitive diagnosis.

Rosacea is known for its chronic and persistent course.Differential diagnosis includes herpes simplex, whichpresents as epithelial or stromal keratitis with neovas-cularization, but is usually unilateral, and cutaneouslesions present as clear vesicles on an erythematous base.Other differential diagnoses for cutaneous manifestationsare seborrheic dermatitis, systemic lupus erythematosis,and acne vulgaris.

The precise etiology of rosacea is still unknown. Keycausative factors identified are abnormalities of smallblood vessels and an abnormal inflammatory response. Areview by van Zuuren et al.7 enumerated the followingpossible contributing factors:

• association with gastrointestinal tract diseases• infestation with Demodex folliculorum• exposure to heat and sunlight• alcoholic beverages• personality disorders/emotional stress• hot drinks (esp. coffee and tea) and spicy foods• pilosebaceous abnormalities

Figure 1. Ocular findings included mattling of the eyelashes, blocked meibomian glands,

collarettes, hyperemic conjunctiva, opacities with peripheral neovascularization involving

the inferior two-thirds of the cornea.


• free oxygen radicals• bacterial protein production at

different temperatures• hormonal influences• follicular involvement• staphylococcal infection and

type IV hypersensitivity reactionChronic meibomian-gland inflam-

mation and blood-vessel dysfunctionwere cited as possible etiologicalfactors with increased bacteria alongthe eyelid margin.8 These bacteriabreak down lipid secretions from themeibomian glands into inflammatoryby-products that may irritate theocular surface. Allergic reactions canalso affect the external eye and eyelidby causing vascular flushing andtriggering mast-cell activation. Thesecan cause ocular irritation, hyper-irritability, itching, burning, andswelling of the eyelid.

Keratitis is the most commoncomplication of ocular rosacea.9 Itmay be secondary to a delayedstaphylococcal hypersensitivity or adirect invasion of the cornea by theorganism. There is damage to theblood vessels of the lids associatedwith swelling and meibomian-glanddysfunction with resultant tear-filminstability and ocular-surfaceproblems.

There is no cure for rosacea. It canonly be controlled by long-termtreatment. Patient compliance isimportant. Management includeslifestyle modifications (avoidingtriggers, use of sunblock) andconventional therapies like lidhygiene and warm compress. Topicalmetronidazole (0.75 and 1% gel,applied once or twice daily) is themain therapy for rosacea. It is mostactive for inflammatory lesions and itmay have some effect on erythema.10

Tetracyclines are the most commonlyprescribed oral medications forrosacea to control inflammation.Typically, treatment is started at ahigher dose and lowered as thedisease quiets. Combination therapywith oral and topical medications

Figure 2. Histopathologic findings included dilated and

thickened veins surrounded by lymphohistiocytic infiltrates

(A); presence of giant cells on high-power field (B); large,

irregular sebaceous lobules (C).

References

1. Jansen T, Plewig G. Rosacea: classification and

treatment. J R Soc Med 1997; 90: 144-150.

2. Bjerke R, Fyrand O, Graupe K. Double-blind

comparison of azelaic acid 20% cream and its vehicle

in treatment of papulo-pustular rosacea. Acta Derm

Venereol 1999; 79: 456.

3. Jorizzo JL, Lebwohl M, Tobey RE. The efficacy of

metronidazole 1% cream once daily compared with

metronidazole 1% cream twice daily and their

vehicles in rosacea: a double-blind clinical trial. Am

Acad Dermatol 1998; 39: 502-504.

4. Mondino BJ. Clinical immunologic diseases. In:

Smolin G, Toft R. The Cornea, 3rd ed. Boston: Little,

Brown and Company, 1994; chap. 12

5. Plewig G, Jansen T. Rosacea. In: Fitzpatrick’s

Dermatology in General Medicine. 6th ed. Columbus:

McGraw Hill, 2003; v. I. chap. 74.

6. Browning DJ, Proia A. Ocular Rosacea. Surv

Opthalmol 1986; 3: 145-158.

7. Van Zuuren EJ, Graber MA, Hollis S, et al.

Interventions for rosacea. Cochrane Database of

Systematic Reviews 2005, Issue 3. Art. No.:

CD003262. DOI: 10.1002/14651858.CD003262.

pub3.

8. Ghanem V, Mehra N, Wong S, Mannis M. The

prevalence of ocular signs in acne rosacea. Cornea

2003; 22: 230-233.

9. Borrie P. Rosacea with special reference to its ocular

manifestations. Br J Dermatol 1953; 65: 458-463.

10. Webster GF. Rosacea and related disorders. In:

Bologria, Jorizzo and Rapini. Dermatology. Toronto:

Mosby 2003; chap. 39.

A

B

C

often gives the best results. In casesof severe rosacea, telangiectasias andpersistent erythema are effectivelytreated with pulsed dye laser andfibrotic rhinophyma can be managedsurgically using CO2 laser or hot-looprecontouring method.

The patient was started onmetronidazole (Robaz) 0.75% gelapplied to her face twice daily,doxycycline (Doxin) 100 mg BID, andtobramycin + dexamethasone(Tobradex) lid scrub HS. After two

months, the dose of oral medicationwas halved and subsequently reduced.A few months later, the corneal lesiondiminished in size and visual acuityimproved to 6/12 OD and 6/7.5 OS.Ocular symptoms and skin lesionsalso resolved.

In conclusion, increased awarenessof cutaneous lesions associated withocular findings by the clinician leadsto earlier diagnosis and treatment ofrosacea and prevents permanent eyeimpairment.


CASE REPORT



Andrew Keat Eu Lim, FRCS, MMedSoo Ken Tan, MDYu Ming Ong, MBBS

Ophthalmology DepartmentPenang HospitalPenang, Malaysia

Candida endogenousendophthalmitis

ABSTRACT

ObjectiveTo report an uncommon case of bilateral candida endogenous

endophthalmitis that presented as a diagnostic dilemma because of negativevitreous cultures.

MethodsThis is a case report.

ResultsA 47-year-old Indian with poorly controlled type 2 diabetes mellitus was

referred with complaints of blurred vision for a week. Visual acuity was bilateralhand movement. Examination revealed bilateral panuveitis, with fine keraticprecipitates and pigment deposits on the lens surface. Posterior-segmentfindings included severe vitritis, vitreous “cotton balls,” multifocal retinalexudates, and fluffy chorioretinitis.

The patient was treated with oral fluconazole and intravitreal amphotericinwith no clinical improvement. A pars plana vitrectomy was performed resultingin improvement in vision.

ConclusionPanuveitis in patients with uncontrolled diabetes mellitus should raise the

suspicion of endogenous endophthalmitis with Candida being the mostimportant differential. Blood and vitreous cultures for fungi will increase themicrobiological yield. Prompt treatment with suitable intravitreal and systemicantifungal agents plus vitrectomy may prevent blindness.

Keywords: Candida, Endogenous, Endophthalmitis, Uveitis


Correspondence to

Andrew Keat Eu Lim, MD

Ophthalmology Department

Penang Hospital

Jalan Residensi

10990 Penang, Malaysia


Presented as a poster at the annual meeting of the Asia-

Pacific Academy of Ophthalmology, 2006, Singapore.





CANDIDEMIA is associated with significant mortality.Risk factors include chemotherapy and immunosuppresion,prolonged indwelling catheters, recent gastrointestinalsurgery, intensive-care admission, intravenous drug use,and debilitating diseases, such as uncontrolled diabetesmellitus, chronic renal failure, and malignancies.1,2,3

Candidemia can lead to endophthalmitis if not treatedearly and this eye infection often ends with a poor visualoutcome.4 It is recommended that patients with candi-demia be screened with funduscopy for intraocularseeding.5 The risk of endophthalmitis is virtuallynonexistent if the infection can be identified and treatedwithout delay with systemic antifungal agents. Unfor-tunately, the diagnosis of candidemia is difficult, with only15 to 40% diagnosed early enough for appropriate treat-ment. The identification of this infection is difficult becauseof the low microbiologic sensitivity. Candida infectionshould be suspected in patients with diabetes or immuno-suppresion who continue to have low-grade fever in spiteof repeated broad-spectrum antibiotics.

We report an uncommon case of bilateral endogenousendophthalmitis that presented as a diagnostic dilemmabecause of negative vitreous cultures.

CASE REPORTA 47-year-old Indian with poorly controlled type 2

diabetes mellitus was referred to the OphthalmologyDepartment of Penang Hospital with complaints ofblurred vision for a week. He had loin pain, low-gradefever, and was generally feeling unwell. He had beentreated with various intravenous antibiotics in threehospitals with no improvement over a period of threeweeks.

At consultation, his visual acuity was bilateral handmovement. There was no eye redness. Examination,however, revealed bilateral panuveitis (severe inflam-mation in both eyes). There were fine keratic precipitatesand pigment deposits on the lens surface (Figure 1). Theanterior segment had 3+ cells. There were no iris nodules.The intraocular pressures were 6 mm Hg bilaterally.Posterior-segment findings included severe vitritis, vitreous“cotton balls” (Figure 2), multifocal retinal exudates, andfluffy chorioretinitis. The initial uveitis work-up wasunremarkable. Differential diagnoses considered wereinfection with human-immunodeficiency virus and herpes,endogenous endophthalmitis, tuberculosis, syphilis,toxoplasmosis, and malignancy. No septic focus was foundand blood cultures were negative. Because of the poordiabetic control and the presence of vitreous “cottonballs,” a fungal infection was suspected and vitreous tapswere taken. Intravitreal vancomycin, ceftazidime, andamphotericin were also injected. The taps did not showany evidence of fungi or bacteria on staining and culture.

Figure 2. Funduscopy showing fungal balls.

Figure 3. Gram stain microscopy of blood smear at 100x magnification showing Candida

in yeast and pseudohyphae forms.

Figure 1. Slitlamp examination showing pigment deposits on the anterior lens surface.


A second set of blood cultures was done. These grewCandida albicans (Figure 3).

The patient was immediately started on oralfluconazole. A repeat vitreous tap taken prior to thesecond intravitreal amphotericin did not show anyevidence of Candida on staining and culture. There was,however, no clinical improvement and the patientsubsequently underwent pars plana vitrectomy, whichresulted in improvement in vision to 6/24 in the right eyeand counting fingers in the left. The vision did not recovercompletely because of premacular gliosis.

DISCUSSIONThe focus of infection in this case study was probably

the urinary tract in view of the patient’s complaint of loinpain. The urine cultures did not show any significantfindings, illustrating the low microbiologic sensitivity forCandida. Epidemiology of candidemia suggested that themost likely source was the urinary-tract infection.4

Fungal endogenous endophthalmitis is an uncommoncondition but occurs more frequently than bacterial endo-genous endophthalmitis. Fungal blood cultures shouldalways be requested when investigating the etiology.Candida albicans is the most common fungal pathogenfollowed by Aspergillus spp.4 Empirical treatment ofendogenous endophthalmitis should hence cover thecommon causative fungi. Empirical treatment is importantas the diagnosis of fungal endogenous endophthalmitisis often based on a strong clinical suspicion. Vitreouscultures are positive in only 50 to 70% of samples.3-4 Bila-teral panuveitis with a history of uncontrolled diabetesmellitus should trigger a high index of suspicion for fungalendogenous endophthalmitis. Unfortunately, half of thecases of endogenous endophthalmitis are missed initiallyby ophthalmologists.4 One should always be suspicious ifcharacteristic fungal balls are seen in the fundus. Vitrec-tomy and specific fungal vitreous and blood cultures maybe necessary as vitreous tap and blood cultures frequentlyshow no growth.4

There is much debate as to the ideal treatment ofcandidemia. Amphotericin B 0.6-1.0 mg/kg/day used asfirst-line treatment for many years is effective but hassignificant side effects(50%).3 Recently, fluconazole given400 mg daily has been shown to be as effective withoutthe side-effect problems, making this a more attractiveoption.3 In the future, the new antifungal caspofungin 50mg daily, which has been shown to be highly efficacious,may overtake both amphotericin and fluconazole as thedrug of choice for candidemia.5 The use of this new drug,however, is limited by its price.

The utility of vitrectomy in Candida endophthalmitishas not been systematically studied but extrapolation frombacterial studies and anecdotal experiences suggested thatthe combination of vitrectomy and intravitreal ampho-tericin or fluconazole may be the most appropriatetherapy.5

This patient was treated with oral fluconazole andintravitreal amphotericin with no improvement in vision.Vitrectomy, however, cleared the media and restored thepatient’s vision.

In summary, panuveitis in patients with uncontrolleddiabetes mellitus should raise the suspicion of endogenousendophthalmitis with Candida being the most importantdifferential. Blood and vitreous cultures for fungi willincrease the microbiological yield. Prompt treatment withsuitable intravitreal and systemic antifungal agentstogether with vitrectomy may save the patient from adevastating visual outcome.

References

1. Allione A, Montanaro M, Marmont F, et al. Fungal endophthalmitis in acute leukaemia.

Br J Haematol 2004; 124: 257.

2. Flynn HW Jr, Scott IU, Bord RD, Han DP. Current management of endophthalmitis.

Contemporary Ophthalmol 2005; 4: 1-5.

3. Vazquez JA. Treatment of candidiasis in hospitalized patients. Curr Treat Options

Infect Dis 2003; 5: 495-506.

4. Binder MI, Chua J, Kaiser PK, et al. Endogenous endophthalmitis: an 18-year review

of culture-positive cases at a tertiary care center. Medicine 2003; 82: 97-105.

5. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin

Infect Dis 2004; 38: 161-189.


PASSAGE



LIBORIO L. MANGUBAT, MD1924 to 2006

The Philippine Journal ofOphthalmology pays tribute toone of the pioneers ofPhilippine ophthalmology,Dr. Leonardo L. Mangubat,who died on December 2,2006 at the age of 84. He leftbehind his wife, Trinidad;children Leonardo, Ma.Rosario, Liborio Jr.,Leopoldo, Lauro, and Luis;and their families.

Dr. Mangubat served as managing editor of the

Philippine Journal of Ophthalmology from 1969 to 1975,helping nurture the journal in its infancy.

He graduated from the University of the PhilippinesCollege of Medicine in 1948, completed his residency inophthalmology and otolaryngology at the UP–PhilippineGeneral Hospital (UP–PGH) in 1952 and his postgraduatestudies at the New York Polyclinic Medical School andHospital in 1955.

As a researcher and author, Dr. Mangubat published46 scientific papers in various journals and books andserved as editor of the Transactions of the First Congressof the Asia Pacific Academy of Ophthalmology in 1960 inManila.

In memory of the manBy Angeles M. de Leon, MD

Excerpts from the First Liborio L. Mangubat Memorial Lecturedelivered at the Annual Meeting of the Philippine Academy of Ophthalmology,

December 2007

WHEN I was asked to give the first Liborio L. MangubatMemorial Lecture at the annual meeting of the PhilippineAcademy of Ophthalmology in December 2007, I decidedto talk on the history of oculoplastic surgery in thePhilippines. It was befitting the memory of the man wholeft us a legacy in the field of oculoplasty. In 1999, whenoculoplasty was the topic of the postgraduate course atEast Avenue Medical Center, I invited him to be thekeynote speaker and introduced him as a reveredacademic, an ophthalmologist par excellance, a civicleader, and a gentleman.

As a revered academician, Dr. Mangubat spent 34 yearswith the Department of Ophthalmology, College ofMedicine, University of the Philippines Manila, initiallyas an instructor and rising to the rank of full professor.He served as department chairman for 8 years (1969 to1976) and introduced several innovations in teaching andlearning. He started (1961) and nurtured the oculoplastyservice at the Philippine General Hospital which heheaded for 28 years. Currently known as the Plastic andLacrimal Service, it is the oldest in the Philippines and

one of the best referral centers for eyelid disorders andmalposition, tumors, and lacrimal problems, servicingmany patients from all over the country. He publishedand presented almost a hundred scientific papers, andtrained oculoplastic specialists who are leaders in othereye centers.

As an ophthalmologist par excellance, Dr. Mangubatwas respected by the ophthalmology community. He wasa diplomate of both the American and the PhilippineBoard of Ophthalmology. As President of the PhilippineOphthalmological Society from 1967 to 1970, he wasinstrumental in the merger of the two eye societies(Philippine Ophthalmological Society and Ophthal-mological Society of the Philippines) existing at that timeto become the Philippine Society of Ophthalmology. Inrecognition of his contribution to Philippine ophthal-mology, he was chosen as the XI Jose P. Rizal MemorialLecturer during the 1975 Philippine Academy ofOphthalmology and Otolaryngology annual meeting.

Dr. Mangubat is a pillar of the Philippine Society ofCosmetic Surgery, having served as its President for 8 years


Doctor, father, husbandBy Leonardo R. Mangubat, MD

Past President (1999–2000), Philippine Society of Ophthalmic Plastic and Reconstructive Surgery

LIBORIO “Boying” Lacson Mangubat was born andraised in Dasmarinas, Cavite. He was the youngest childand only son of Leoncio and Catalina Mangubat. Beingdisciplinarians as they were, my grandparents instilled intotheir children the values of hard work and respect, whichour father, in turn, handed over to us.

When I was in the Ateneo High School, my father wouldoften ask me to accompany him during his outreachprograms in the provinces. He taught me how to assisthim in screening patients for eye problems. I would watchhim intently and with great curiosity as he treated hispatients. I watched in awe as his patients got better. Hetreated them to the best of his ability whether or not theyhad the capacity to pay. He earned the love and respectof his patients well. It was with his example that I decidedto embark on a medical career myself, wanting to be anophthalmologist as well.

Papa had an eye for beauty. He was an artist in his ownway. Long before the cosmetic industry became the trendthat it is today, my father blazed the trail by specializing incosmetic surgery. He liked “fixing” people’s faces, whetherit was that of a trauma patient seeking reconstruction or achinky-eyed person seeking a more western look. Whetherit was for function or aesthetics, Papa tried to make hispatients happier. And he was quite successful in makingmany people happy! Again, as witness to all these, Idecided that oculoplasty was also for me.

My father was a very dedicated ophthalmologist andprofessor. He loved to teach and headed the Departmentof Ophthalmology of the University of the Philippines–Philippine General Hospital for 8 years. He listened tohis students and taught them well. It was during hischairmanship that he began to allow residents-in-training

the freedom to operate on charity patients. He was alsothe one who started the department’s regular morningconferences on Tuesdays and Thursdays, as well as thebasic and clinical training courses for the residents. I wasextremely proud to be his son and his student, feelingmore so when I joined the ranks of the residents as well.He taught me my formative skills and ingrained upon methe discipline and integrity that came with being a goodphysician.

Papa was a good father and provider. Despite his hecticschedule, he always made time to listen to our concerns.Sundays were devoted to family time—Sunday massfollowed by trips to our grandparents’. That was, after hehad finished making his rounds!

Papa tried to give us everything that he could affordand yet never failed to make us deserve what we had. Weknew he could give us what we wanted, but we always hadto earn it first. He taught us the value of discipline andthe importance of cherishing what we had.

He was also a loving husband. He never missed out onspecial occasions. He loved to surprise Mama with giftsand flowers. Mama was an only child who was spoiled byher parents and Papa continued to spoil her as his wife.Together, they raised 5 sons and 1 daughter and I wasfortunate to be his eldest child and the heir to his legacy.

When he passed away last December 2, 2006, I felt agreat sense of loss and emptiness. I shall miss his presencein the clinic, at home, but most especially in my heart. Iam very glad that I chose to become an ophthalmologistand oculoplastic surgeon like Papa. I hope to pass on hislegacy as well to my patients and students. I am what I amtoday because of him, and for that, I will be forevergrateful.

(1987-1994). After his retirement from the University ofthe Philippines, he founded the Philippine Society ofOphthalmic Plastic and Reconstructive Surgery in 1992.Its main aims were to provide specialty updates and a venuefor exchange of ideas among its members and conductsymposiums and courses during the annual meeting ofthe Philippine Academy of Ophthalmology.

His civic concern was manifested by his involvement asan active member of the San Juan Lions’ Club,establishment of a charity eye clinic at the St. Martin dePores Charity Hospital, and serving as president and

chairman of the Dr. Jose P. Rizal Memorial Foundationwhich runs a 100-bed charity hospital in Cavite.

For all his achievements, Dr. Mangubat had time forhis wife and 6 children, who are all successful in theirchosen careers, one of whom also became a successfulophthalmologist and a leading oculoplastic specialist. Hehad time for his colleagues, especially those in the samefield such as myself who had known him since my residencydays. As my mentor, he had traveled with me to participatein international conferences where he had exhibitedhimself time and again to be a true gentleman.

ii PHILIPP J OPHTHALMOL VOL 33 NO. 1 JANUARY - JUNE 2008 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

INSTRUCTIONS TO AUTHORS

SUBMISSION

The PHILIPPINE JOURNAL OF OPHTHALMOLOGY adheres tothe policies set forth in the “Uniform Requirements forManuscripts Submitted to Biomedical Journals” writtenby the International Committee of Medical Journal Editors(N Engl J Med 1997; 336:309-314).

The journal publishes articles in the followingcategories:

• Original Articles, including clinical or laboratoryinvestigations, clinical epidemiology, and evaluation ofdiagnostic and surgical techniques

• Evidence-Based Medicine (EBM), includingsystematic review and metaanalysis

• Lectures and Symposiums• Case Reports and Case Series• Brief Reports• Special Matters Letters, correspondence, and guest editorials may also

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Editor in ChiefPhilippine Journal of OphthalmologyUnit 815 Medical Plaza MakatiAmorsolo Street, corner Dela Rosa Street1229 Makati City, Metro ManilaPhilippines

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7. Appropriate footnotes.8. Five keywords.

ABSTRACTProvide a structured abstract of 300 words or less with

the following four headings:

Objective: State the purpose or objective of the study.

Methods: The following must be included:• Study Design: Identify the study design using a

phrase such as randomized or nonrandomized clinicaltrial, case-control study, cross-sectional study, cohortstudy, case series, case report, systematic review, meta-analysis, review, experimental study, or historicalmanuscript. Additional modifiers can be included(consecutive, retrospective, prospective, observational,interventional, nonconsecutive, etc).

• Setting: Such as multicenter, institutional, clinicalpractice, etc.

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Ophthalmology

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PHILIPP J OPHTHALMOL VOL 33 NO. 1 JANUARY - JUNE 2008 iiiPHILIPPINE ACADEMY OF OPHTHALMOLOGY

clusion criteria, randomization procedure, and mask-ing.

• Intervention or Observation Procedure(s)• Main Outcome Measure(s)• Data and Statistical Analyses

Results: Briefly summarize the principal outcome mea-surements/data obtained. Results should be accompaniedby data with confidence intervals and the exact level ofstatistical significance.

Conclusions: Provide brief and concise conclusion(s)directly supported by the data.

TEXTNumber the pages of the manuscript consecutively,

beginning with the title page as page one. The text should,in general, not exceed 18 double-spaced typewritten pages.

Organize and prepare the manuscript to include thefollowing sections:

Introduction: The Introduction, without a heading,should refer only to the most pertinent past publicationsand should not be an extensive review of the literature.Include a brief background, the research question and/or rationale, objectives/purposes of the study, and majorhypothesis to be tested, if any.

Methods: Methods should be written with sufficientdetail to permit others to duplicate the work. Thefollowing should be included:

• Study Design: Identifies the study design using aphrase such as randomized or nonrandomized clinicaltrial, case-control study, cross-sectional study, cohortstudy, case series, case report, systematic review,metaanalysis, review, experimental study, or historicalmanuscript. Additional modifiers may be included (e.g.consecutive, nonconsecutive, retrospective, prospect-ive, observational, interventional).

• Setting: (e.g. multicenter, institutional, clinicalpractice)

• Participants, Patients, or Study Population: Numberof patients/eyes, selection procedures, inclusion/exclu-sion criteria, randomization procedure, and masking.

• Intervention or observation procedure(s)• Main and secondary outcome measure(s)• Data and statistical analyses.

For clinical studies, statements regarding adherence tothe Declaration of Helsinki, approval by InstitutionalReview Board (IRB)/Ethics Committee, and descriptionof the informed consent process should be included. For

animal research, the Association for Research in Visionand Ophthalmology (ARVO) guidelines for animalresearch should be followed and adherence to the saidguidelines should be stated. Previously publishedprocedures should be identified by reference only.

Results: Results must be concise. Provide demographicdata of the study population. Describe outcomes andmeasurements in an objective sequence with minimumdiscussion. Data should be accompanied by confidenceintervals (usually at the 95% interval) and exact p valuesor other indications of statistical significance.

Discussion: The Discussion should be restricted to thesignificant findings presented. Avoid excessive generali-zation and undue speculation. Digressions and theorizingare not appropriate. Elucidate on (but do not reiterate)the results, provide responses to other and contradictoryliterature, identify limitations or qualifications of the study,and state the conclusions that are directly supported bythe data. Give equal emphasis to positive and negativefindings, whether and what additional study is required,and conclude with the clinical applications or implicationssupported by the study. The conclusion(s) is (are) incor-porated into the end of the discussion and should be directlysupported by the results. Authors should avoid makingstatements on economic benefits and costs unless theirmanuscript includes economic data and analyses. Avoidclaiming priority of the content unless you provide theliterature search protocol used.

BRIEF REPORTSA brief report is an original contribution (generally an

interesting case, a case series, surgical technique, orexperimental study) with a concise message. Manuscriptmust adhere to the PJO format guidelines, except that theabstract should contain no more tha 150 words and thebody no more than 1,000 words. References should belimited to 5.

ACKNOWLEDGMENTSAcknowledge statistical consultation and assistance

(when provided by someone other than an author) in anacknowledgment at the end of the article, before thereferences. Include the name, degree, and affiliation of theindividual. Consultants (other than statistical consultants),editorial assistants, photographers, artists, laboratory asso-ciates, and others who assist in preparation of a manuscriptare not to be acknowledged, however valuable their service.

Because readers may infer their endorsement of thedata and conclusions, all persons acknowledged must havegiven permission to be acknowledged and this must beconfirmed in the cover letter.

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APPENDIXAn appendix should be used very sparingly. However,

it is appropriate to provide survey forms, to list the mem-bers of a study group, or explain complex formulas orinformation.

In studies involving a study group, the writing groupauthors should be listed along with the group name (e.g.Smith TT, Jones JJ on behalf of the Pediatric AmblyopiaStudy Group) on the title page. Other group membersshould be listed in an appendix. When the study groupname alone is listed on the title page, the Copyright Trans-fer Agreement requires only the original signature of theCorresponding Author. When a series of authors is listedon the title page in conjunction with the study groupname, the Copyright Transfer Agreement must includethe original signatures of these authors.

REFERENCESList only references that are pertinent to the manu-

script. Cite only published studies as references. Cite/Quote from the entire study, not the abstract. You mayacknowledge “unpublished data” or submitted articleswithin parentheses in the text. Reference to a “personalcommunication” within parentheses in the text must beaccompanied by a signed permission letter from the indi-vidual being cited.

References should be numbered consecutively in thetext and in the reference list. In the text, referencenumbers are entered as superscripts. The referencesmust be verified by the author(s) against the originaldocuments. PubMed (http://www.ncbi.nlm.nih.gov)offers a useful reference checker. References to journalarticles should include: the author or authors (for morethan four authors, list only the first three followed by“et al.”), title, journal name (as abbreviated in IndexMedicus), year, volume number, and inclusive pagenumbers.

References to books should include: the author orauthors, chapter title (if any), editor or editors (if any),book title, edition (other than the first), city of publication,publisher, copyright year, and inclusive pages of thechapter or section cited.

Web site references must include author (or web siteowner), title of article, date article was posted, publication(if applicable), complete web site address, and dateaccessed.

ExamplesJournal Article (If four or fewer authors, list all)Fishman GA, Alexander KR, Milam AH, Derlacki DJ.

Acquired unilateral night blindness associated with anegative electroretinogram waveform. Ophthalmology 1996;103: 96-104.

Journal Article (If five or more authors, list only the firstthree and add et al.)

Vail A, Gore SM, Bradley BA, et al. Clinical and surgicalfactors influencing corneal graft survival, visual acuity, andastigmatism. Br J Ophthalmol 1996; 103: 41-49.

Chapter in a BookParks MM, Mitchell PR. Cranial nerve palsies. In: Tasman

W, Jaeger EA, eds. Duane’s Clinical Ophthalmology, revised ed.Philadelphia: JB Lippincott, 1993; v. 1, chap. 19: 550-551.

BookMiller NR. Walsh and Hoyt’s Clinical Neuro-Ophthalmology,

4th ed. Vol. 4. Baltimore: Williams & Wilkins, 1991; 2102-2114

Web siteWorld Health Organization. Hospital infection control

guidelines for severe acute respiratory syndrome. April16, 2003: http://www.who.int/csr/sars/infectioncontrol/en (accessed April 24, 2003).

TABLESTables should follow references. Each table must be

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Submit three (3) identical complete sets of prints anda digital copy if available. Each print must be separatelylabeled with the author’s name, figure number and anindication (arrow) as to orientation (up). Put allinformation on a separate label on the back of theillustration to avoid writing on or damage to the prints.

Prints of figures (clinical photographs, fluoresceinangiograms, CT, MRI, X-ray, photomicrographs, TEM,SEM, graphs, etc.) must be large enough to be easily read,preferably 4 x 6 inches. The digital copy of eachphotograph or illustration should be saved in individualfiles in either TIF or JPEG format with a resolution of atleast 300 dpi. Photographs and illustrations saved in“Power point” or “Word” format are not acceptable.Graphs may be submitted in “Power Point” or “Excel”format. Text in figures must not be smaller than 10 pointswhen finally reproduced in the Journal.

Each figure must be numbered consecutively in Arabicnumerals by order of citation in the text. Each should

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have a brief explanatory legend. Legends must identifyall symbols or letters that appear on the prints. Histologicfigures, stains, and magnifications should be noted in thelegend. Graphs that indicate the mean should include thestandard deviation. Any figure that has been publishedelsewhere should have an acknowledgment to the origi-nal source. A copy of the release to publish the figuresigned by the copyright holder must also be submitted.

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Color reproduction of figures will be published at theauthor’s expense based on prevailing rates. Check with thePAO office for exact cost. If a manuscript has been reviewedand accepted with color photos, it must be published withcolor photos. The author may opt to have them printed inblack and white at no expense.

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understood. Avoid abbreviations that have meaning onlyin the context of your specific manuscript. If an abbrevia-tion is to be used, it should appear in parentheses imme-diately after the term or phrase to which it refers when itis stated for the first time in the text.

INSTRUMENTS, DRUGS, AND MANUFACTURERNAMES

Use generic names only in the text body. State the tradename of a particular drug cited in parentheses including

manufacturer’s name, city, state and/or country when firstmentioned in the text. With regard to instruments uti-lized in the study, enclose in parentheses the specificmodel, manufacturer’s name, city, state and/or country.

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COPYRIGHTConsideration of manuscripts for publication in the

PHILIPPINE JOURNAL OF OPHTHALMOLOGY is dependent onthe assurance that the material (in whole or part) is notunder consideration by another journal, is not in press inany other format, and has not been previously published.Each author must sign a statement transferring copyrightownership to the Philippine Academy of Ophthalmology.Manuscripts which have been accepted for publicationmay be published in another journal after securing awritten consent from the editor in chief of the PHILIPPINE

JOURNAL OF OPHTHALMOLOGY.

These instructions may be downloaded from the PJO web site at www.pao.org.ph

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vi PHILIPP J OPHTHALMOL VOL 33 NO. 1 JANUARY - JUNE 2008 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

COPYRIGHT TRANSFER

Title of Article________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Authors1. ________________________________2. ________________________________3. ________________________________4. ________________________________5. ________________________________

In submitting the above-titled article, I/we hereby transfer, assign, or otherwise convey all copyright ownershipto the Philippine Academy of Ophthalmology in the event that such work is published in the PHILIPPINE JOURNAL

OF OPHTHALMOLOGY (PJO). Such conveyance covers any product, whether print or electronic, that may derive fromthe published journal. I/We affirm that this article has not been previously published in or submitted for pub-lication to another journal, except under circumstances communicated to PJO in writing at the time the articlewas first submitted.

Each author must sign a Copyright Release form. The signatures need not appear on the same page. All manuscripts submittedbecome the property of the journal.

Name (print) Proprietary Signature Dateor Financial Interest(Yes/No*)

1. _____________________________ _____________ _____________________________ ________________2. _____________________________ _____________ _____________________________ ________________3. _____________________________ _____________ _____________________________ ________________4. _____________________________ _____________ _____________________________ ________________5. _____________________________ _____________ _____________________________ ________________*If yes, please explain on the title sheet. See instructions to authors for details.

Submit this signed transfer with your manuscript to:

The Editor in ChiefPhilippine Journal of OphthalmologyUnit 815 Medical Plaza MakatiAmorsolo Street, corner Dela Rosa Street1229 Makati City, Metro ManilaPhilippines

Other Contact DetailsPhone: +63-2-8135324Fax: +63-2-8135331E-mail: [email protected]

This form may be downloaded from the PJO web site at www.pao.org.ph


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