Angle Surgery Research Articles

Extended pharmacological miosis is superfluous after glaucoma angle surgery: A retrospective study

Background: Pilocarpine is commonly used after angle surgery for glaucoma despite a host of side effects and risks. We hypothesized that a pharmacological miosis during the first two months does not improve short- and long-term results of trabectome-mediated ab interno trabeculectomy. Methods: In this retrospective comparative 1-year case series, we compared 187 trabectome surgery eyes with (P+) or without (P-) 1% pilocarpine for two months. Primary outcome measures were the surgical success defined as intraocular pressure (IOP) ≤ 21 mmHg and decreased ≥ 20%, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, and IOP. Results: We categorized 86 (46%) eyes as P- and 101 (54%) eyes as P+. The mean age was 69.8±10.1 in P- and 70.5±9.4 in P+ (P=0.617) with equal gender distribution (P=0.38). The cumulative probability of qualified success at 12 months was 78.1% in the P- and 81% in the P+ (P=0.35). The IOP was decreased significantly from 20.2±6.8 mmHg at baseline to 15.0±4.8 mmHg at 12 months follow-up in P- (P=0.001) and 18.8±5.3 and 14.7±4.0, respectively (P=0.001). The medications decreased significantly from 1.4±1.2 in P- and 1.4±1.2 in P+ at baseline to 1.0±1.2 and 0.7±1.0, respectively (P=0.183). P- and P+ did not differ in IOP or medications (all P>0.05). In Multivariate Cox Regression models, the baseline IOP and central corneal thickness were associated with failure. Conclusions: Use of postoperative pilocarpine does not improve the efficacy of trabectome surgery.

Delayed facial nerve palsy after vestibular schwannoma surgery

Background: Facial nerve dysfunction may occur immediately after vestibular schwanoma surgery. Electromyographyc monitoring of motor cranial nerves during cerebellopontine angle surgery has become an essential tool. Although delayed onset of facial nerve dysfunction hours to months following vestibular schwanoma surgery are rare. Case description: We describe the case of a 70-years-old male who was admitted with a left side tinnitus and hearing loss of the last 3 years. Magnetic resonance imaging (MRI) T1-weighted demonstrated an isointensity lesion, 30mm in diameter, at the left cerebello-pontine angle with a small portion in the internal auditory canal. The patient was surgically treated by means of a standart suboccipital retrosigmoid approach. The facial nerve was monitored by continuously during surgery. Surgical removal was macroscopically complete. The facial nerve was well-preserved during surgery and showed at the end of the procedure normal electromyographic activity. The patient did well postoperatively and was discharged at the 4th postoperative day and facial function was normal (House-Brackmann grade I). On the 10th postoperative day he notices difficult closing his left eye that progressed to complete facial nerve palsy (House-Brackmann grade III). Steroid therapy was performed for five days associated with physical therapy. One month later his facial nerve function had completely recovered. After six months, the patient remains asymptomatic and neurologically intact. MRI obtained at the 16th postoperative day showed intense enhancement of the intracranial facial nerve segment and also demonstrated no residual tumor. Immunological study at the time of onset showed herpes simplex virus antibody titer normal as well as those for herpes zoster virus. Conclusions: Delayed facial nerve palsy remains an under reported and consequently not very known phenomenon in the neurosurgical practice and literature. Because of the 2009favorable rate of recovery, patients should be reassured in the interim and should not undergo any corrective surgical procedures to improve facial nerve function. Delayed facial nerve palsy is uncommon after vestibular schwannoma surgery. Excellent recovery of facial nerve function to the original postoperative status nearly always occurs in those circumstances.

Extended pharmacological miosis is superfluous after glaucoma angle surgery: A retrospective study.

Background: Pilocarpine is commonly used after angle surgery for glaucoma despite a host of side effects and risks. We hypothesized that a pharmacological miosis during the first two months does not improve short- and long-term results of trabectome-mediated ab interno trabeculectomy. Methods: In this retrospective comparative 1-year case series, we compared 187 trabectome surgery eyes with (P+) or without (P-) 1% pilocarpine for two months. Primary outcome measures were the surgical success defined as intraocular pressure (IOP) ≤ 21 mmHg and decreased ≥ 20%, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, and IOP. Results: We categorized 86 (46%) eyes as P- and 101 (54%) eyes as P+. The mean age was 69.8±10.1 in P- and 70.5±9.4 in P+ (P=0.617) with equal gender distribution (P=0.38). The cumulative probability of qualified success at 12 months was 78.1% in the P- and 81% in the P+ (P=0.35). The IOP was decreased significantly from 20.2±6.8 mmHg at baseline to 15.0±4.8 mmHg at 12 months follow-up in P- (P=0.001) and 18.8±5.3 and 14.7±4.0, respectively (P=0.001). The medications decreased significantly from 1.4±1.2 in P- and 1.4±1.2 in P+ at baseline to 1.0±1.2 and 0.7±1.0, respectively (P=0.183). P- and P+ did not differ in IOP or medications (all P>0.05). In Multivariate Cox Regression models, the baseline IOP and central corneal thickness were associated with failure. Conclusions: Use of postoperative pilocarpine does not improve the efficacy of trabectome surgery.

Update on Microinvasive Glaucoma Surgery.

Update on Microinvasive Glaucoma Surgery.

In vivo fluoroscopic kinematography of cranio-caudal stifle stability after tibial tuberosity advancement (TTA): a retrospective case series of 10 stifles.

It was the aim of the study to determine retrospectively cranio-caudal stifle instability following TTA (tibial tuberosity advancement) using fluoroscopic kinematography. Ten stifles (eight dogs, mean body weight 27.3 kg) with complete rupture of the cranial cruciate ligament and a mean follow-up of 12.8 weeks (5.4 - 28.4 weeks) after TTA underwent latero-lateral, uniplanar fluoroscopic kinematography while walking on a treadmill. Immediately before TTA, each stifle was explored arthroscopically and in the case of a longitudinal or bucket-handle tear of the caudal horn of the medial meniscus the unstable axial portion was resected. The high-speed fluoroscopic video sequences obtained were inspected visually for femoro-tibial translation (cranial drawer). The influence of postoperative patellar tendong angle (PTA), cage size and meniscal surgery on stifle stability was analyzed using logistic regression analysis. In three stifles, resection of unstable meniscal tissue was necessary. Fluoroscopically, nine out of ten stifles showed cranio-caudal instability. Three stifles were potentially overcorrected (post PTA < 90°), seven potentially undercorrected (post PTA > 90°). None of the three parameters analyzed had a significant influence on postoperative in vivo stability (p=0.0988). In conclusion, it appears that inadequate cranialization of the tibia tuberosity might be an expected result of the TTA procedure, as well as persistent cranio-caudal instability during walking. However, instability cannot solely be attributed to insufficient cranialization because three out of nine unstable stifles were sufficiently or even overcorrected (PTA ≤ 90°). Further in vivo studies are needed to resolve these conflicting findings.

Intraoperative Seizures Detected as Increased Bispectral Index Values during Posterior Fossa Surgeries

AbstractWe present a case series of four cerebellopontine angle surgeries with intraoperative detection seizure activity. The cases discussed follow the uniform anesthetic protocol of maintenance with infusion of propofol, fentanyl and dexmedetomidine excluding muscle relaxant, targeted to maintain bispectral index (BIS) in the range of 40 to 60. The cases experienced either of the two scenarios: (I) Unexplained increased or widely varying BIS values associated with increases in BIS electromyography (EMG) and motor manifestation of seizure activity in limbs. (2) Varying BIS values with EMG activation of facial nerve monitoring without motor manifestation in limbs. A common theme noticed in all these cases was the utilisation of tranexamic acid in cumulative doses of 25 to 30 mg/kg and amelioration of the seizure activity with a loading dose of phenytoin (15 mg/kg). A hypothesis is being presented linking intraoperative seizures with a combination of tranexamic acid utilisation.

Effect of adjunctive dexmedetomidine on anesthesia and analgesia requirement and recovery characteristics during Bispectral Index-guided anesthesia for cerebello-pontine angle surgeries: A randomized clinical trial.

Background and Aims:The study was conceived to elucidate the effects of dexmedetomidine as an anesthetic adjunct to propofol (total intravenous anesthesia) on anesthetic dose reduction and anesthesia recovery parameters in cerebello-pontine angle (CPA) surgeries.Material and Methods:This prospective randomized study was conducted on 49 patients (25 with dexmedetomidine, 24 without). After standardized anesthetic induction, anesthesia was maintained using propofol (via target controlled infusion, titrated to maintain BIS between 40 and 60), fentanyl (0.5 μg/kg/hour) and either dexmedetomidine (0.5 μg/kg/hour) or a sham infusion. Neuromuscular blocking agents were excluded to allow cranial nerve EMG monitoring. Adverse hemodynamic events, recovery parameters (time to opening eyes, obeying commands, and extubation) and postoperative sedation score, shivering score, nausea, and vomiting score were recorded.Results:Propofol and fentanyl utilization (as total dose, adjusted for duration of surgery and body weight, and number of extra boluses) was significantly lower in the dexmedetomidine group. There was no difference in any of the recovery parameters between the two groups. Incidence of bradycardia was significantly higher with dexmedetomidine, while no difference was found for hypotension, hypertension, and tachycardia.Conclusion:Dexmedetomidine–fentanyl–propofol anesthesia compares favorably with fentanyl–propofol anesthesia during CPA neurosurgical procedures with regard to anesthesia recovery times, but with lower intraoperative opioid and hypnotic utilization rates.

Level Specific CE-Chirp® BAEP's: A new faster technique in neuromonitoring cochlear nerve during cerebello-pontine angle tumor surgery

Abstract Background Level Specific (LS) CE-Chirp® Brainstem Auditory Evoked Potentials (BAEP's) are the most recent evolution of classical Click BAEP's, performed both in clinical studies and in intraoperative neuromonitoring (IONM) of acoustic pathways during several neurosurgical procedures. LS CE-Chirp® is a new group of acoustic stimuli, latter evolution of Broadband CE-Chirp®, designed by Claus Elberling to provide faster recording of larger amplitude BAEP's V waves in infants. While the original Broadband CE-Chirp® was conceived for optimal response amplitude of V wave at low and medium stimulation intensities, the LS CE-Chirp® provides clearer I–III–V waves at high intensities. Material and method We report a consecutive series of 31 cases in which the new LS CE-Chirp® BAEP's were performed during different skull base surgery procedures during the last 24 months: 25 vestibular schwannomas, 3 cerebello-pontine angle (CPA) meningiomas and 3 CPA epidermoid tumors. Results Using LS-CE-Chirp® BAEP's monitoring, neurosurgeon was alerted in 10–15 s about variation of conduction parameters of acoustic pathways. At the end of surgery, BAEP's were normal in 11 patients, showed deconstructed waves in 14, and elongated waves in 6. At a minimum clinical and BAEP's follow-up of 6 months, hearing function was preserved in 19 cases (61,3%). Conclusions We herein confirm that LS CE-Chirp® BAEP's provide a fast feedback to surgeons regarding acoustic pathways function, helping them during skull base tumor removal in the attempt to hearing preservation when it is socially useful in the preoperative evaluation.

Circumferential Trabeculotomy Versus Conventional Angle Surgery: Comparing Long-term Surgical Success and Clinical Outcomes in Children With Primary Congenital Glaucoma

This study compares the long-term efficacy of circumferential trabeculotomy to that of conventional angle surgeries in primary congenital glaucoma (PCG), as judged by glaucoma and visual outcomes. Retrospective observational case series. Setting: Emory Eye Center, Atlanta, Georgia. This was a single-institution retrospective study involving children with PCG who underwent circumferential trabeculotomy, standard trabeculotomy, or goniotomy with ≥2-year follow-up. Postoperative success (intraocular pressure [IOP] < 22mm Hg ± glaucoma medications, without glaucoma progression/additional IOP-lowering surgery), Snellen-equivalent visual acuity (VA), and IOP at last follow-up. Kaplan-Meier method estimated the probability of glaucoma control vs time postoperatively, and values were compared between angle surgery cohorts using Wilcoxon signed rank tests, Mann-Whitney U tests, and Fisher exact tests. Included were 58 eyes (33 children) after circumferential trabeculotomy and 42 eyes (27 children) after standard trabeculotomy/goniotomy, with mean follow-up of 7.2 ± 4.0 and 8.2 ± 4.5 years, respectively. Postoperative success at last follow-up in the circumferential vs conventional cohorts was 81% (47 of 58 eyes) vs 31% (13 of 42 eyes) (P < .0001). At last follow-up, the circumferential cohort had better median VA than the conventional cohort (20/30 (interquartile range [IQR] 20/25 to 20/70) vs 20/70 (IQR 20/40 to 20/200), P= .009), required fewer glaucoma medications (0.55±1.2 vs 1.61 ± 1.51, P < .0001), had lower IOP in first operated eye (15.2 ± 3.6 vs 18.2 ± 7.0, P= .048), and had comparable incidence of devastating complications (P= .065). In this retrospective study, circumferential trabeculotomy afforded better long-term success and visual outcomes than conventional angle surgery for children with PCG.

Gender and response to initial angle surgery differ for CYP1B1-related primary congenital glaucoma

Primary congenital glaucoma (PCG) is considered to be more common in boys and to respond well to initial angle surgery (goniotomy or trabeculotomy). However, these characteristics are based on studies done in regions where bi-allelic mutations in CYP1B1 are uncommon. We report our observations regarding a cohort of PCG with confirmed bi-allelic mutations in the gene.

Effects of pre-surgical administration of prostaglandin analogs on the outcome of trabeculectomy.

For primary open angle glaucoma (POAG), laser treatment or surgery is used when the target intraocular pressure (IOP) cannot be achieved by pharmacological agents, such as prostaglandin (PG) analogs; these drugs also have varied effects. We retrospectively reviewed the medical records of 74 POAG patients (74 eyes) whose IOP was inadequately controlled by PG analogs (bimatoprost [13 eyes], latanoprost [34 eyes], tafluprost [11 eyes], and travoprost [16 eyes]) and underwent primary trabeculectomy. The proportion of patients with no recurrent IOP elevation within 24 months post-trabeculectomy was significantly (P < 0.001) lower in the bimatoprost group (31.3%) than in the latanoprost (83.2%), tafluprost (45.5%), or travoprost groups (65.6%). Deepening of the upper eyelid sulcus (DUES) was observed before trabeculectomy in 18 of 74 eyes (24.3%) treated with bimatoprost (9 eyes; 50.0%), latanoprost (3 eyes; 16.7%), tafluprost (1 eye; 5.5%) and travoprost (5 eyes; 27.8%). The proportion of patients with no recurrent IOP elevation up to 24 months post-trabeculectomy was significantly (P < 0.0001) lower in the DUES(+) group (34.7%) than in the DUES(-) group (74.3%). Multivariate stepwise logistic regression analysis, with no recurrent IOP elevation used as dependent variable, and bimatoprost, latanoprost, travoprost, tafluprost, β-blocker, carbonic anhydrase inhibitor, brimonidine, gender, age, preoperative IOP, mean deviation, duration of PG analog use before surgery, and the number of ophthalmic solutions used as independent variables, identified only bimatoprost as a significant independent factor (P = 0.0368). Thus, the outcome of trabeculectomy varied depending on the PG analog used preoperatively, and bimatoprost use was associated with a high risk of recurrent IOP elevation up to 2 years post-trabeculectomy. This may indicate that the incidence of DUES differed with the PG analog used. Patients with glaucoma who are treated with bimatoprost should be monitored for DUES, and when these patients undergo trabeculectomy, the postoperative course of IOP should be followed carefully.

Regular Versus Releasable Sutures in Surgery for Primary Congenital Glaucoma.

To compare releasable and regular sutures in combined angle and filtering surgery for primary congenital glaucoma. A prospective study was conducted on 39 eyes (26 right eyes) of 39 children (20 boys; 19 girls) who had primary congenital glaucoma treated with combined trabeculotomy-trabeculectomy with mitomycin C and scleral flap closure with regular or releasable sutures. Follow-up was 24 months. Success rates (defined as an intraocular pressure [IOP] < 16 mm Hg without hypotony-related complications and/or lack of IOP-related progression of the disease) were studied and complications were noted. The mean age of the study participants was 6.7 ± 5.8 months (range: 1 to 24 months; median: 5 months) in the regular suture group (20 eyes) and 5.3 ± 2.8 months (range: 1 to 13 months; median: 5 months) in the releasable suture group (19 eyes). The initial glaucoma surgery was successful in 13 (65%) and 13 (68.4%) eyes in the regular suture and releasable suture groups, respectively. The mean IOP was 17.4 ± 7.3 and 16.0 ± 5.4 mm Hg (P = .84) preoperatively and 8.0 ± 9.7 and 5.8 ± 3.6 mm Hg (P = .40) at the end of follow-up in the regular suture and releasable suture groups, respectively. There was no statistically significant difference in the clinical parameters between the two groups. Complications included rhegmatogenous retinal detachment, cataract, and superior lens subluxation, with each complication developing in one eye. Releasable sutures were not more advantageous than regular sutures in combined trabeculotomy-trabeculectomy with mitomycin C surgery for primary congenital glaucoma. [J Pediatr Ophthalmol Strabismus. 2017;54(5):295-301.].

Long-Term Visual Outcomes in Children with Primary Congenital Glaucoma.

To determine the long-term visual outcomes and risk factors for visual loss in children with primary congenital glaucoma (PCG) who underwent angle surgery over a 21-year period. This was a retrospective study of patients who underwent trabeculotomy, trabeculectomy, or combined trabeculotomy-trabeculectomy for PCG. Visual acuity (VA), surgeries, and underlying cause of visual impairment were recorded and compared. Main outcome measures were final best-corrected good VA (20/20 to 20/50), moderate VA (<20/50 to 20/200), or poor VA (<20/200); age at surgery, sex, laterality, type of initial glaucoma surgery, and number of surgeries were recorded. Fifty-three eyes were eligible to be included in the study. The mean logMAR VA was 0.61 ± 0.57. A good VA was attained in 51%, moderate VA in 30%, and poor VA in 19%. The main cause of visual impairment with VA <20/50 was deprivation amblyopia (64%). There was no association between VA level and status of success (controlled with or without medications) (p = 0.202). The mean spherical equivalent of refraction was -4.47 ± 5.66; myopia was the predominant refractive error (74%) and astigmatism >2 D (40%). A statistically significant high myopic shift was more frequent in the visually impaired group. None of the studied factors was statistically associated with moderate to poor visual outcome (all p>0.05). A favorable VA outcome was achieved. Topical antiglaucoma medication has an adjuvant role in maintaining the success rate of surgery without risking the visual outcome. Corneal opacification and anisometropia were the cause of amblyopia.

Pediatric glaucoma: review of recent literature.

The purpose of this review is to update the clinician on the recent work in the field of pediatric glaucoma. Using the iCare tonometer to measure intraocular pressure (IOP) in children is highly successful. New data from the Infant Aphakia Treatment Study show that after 5 years of follow-up the risk of developing glaucoma is similar between patients that receive initial intraocular lens implantation and those who are left aphakic. New data show effective lowering of IOP using either approach to trabeculotomy: treating the angle partially with trabeculotomes or circumferentially with a suture or iTrack microcatheter. Recent data on an updated approach to trabeculectomy in children show success in lowering IOP with few complications; however, visual outcomes continue to be suboptimal. A separate study shows that the addition of tenonectomy may not increase surgical success, but may increase survival time and reduce bleb encapsulation. Glaucoma drainage devices in general, and the Ahmed implant in particular, continue to be found to be moderately successful to control IOP, and are therefore employed, especially after initial angle surgery has failed. Continued work to evaluate the techniques used in the clinical and surgical management of pediatric glaucoma patients supports that both newer and older approaches remain standard of care.

Effect of granulocyte colony-stimulating factor on the cochlear nuclei after creation of a partial nerve lesion: an experimental study in rats.

OBJECTIVE The risk of injury of the cochlear nerve during angle (CPA) surgery is high. Granulocyte colony-stimulating factor (G-CSF) has been found in various experimental models of peripheral and CNS injury to have a neuroprotective effect by inhibiting apoptosis and inflammation. However, to the authors' knowledge, the influence of G-CSF on cochlear nerve regeneration has not been reported. This study investigated the neuroprotective effect of G-CSF after a partial cochlear nerve lesion in rats. METHODS A lesion of the right cochlear nerve in adult male Sprague-Dawley rats was created using a water-jet dissector with a pressure of 8 bar. In the first group (G-CSF-post), G-CSF was administrated on Days 1, 3, and 5 after the surgery. The second group (G-CSF-pre/post) was treated with G-CSF 1 day before and 1, 3, and 5 days after applying the nerve injury. The control group received sodium chloride after nerve injury at the various time points. Brainstem auditory evoked potentials (BAEPs) were measured directly before and after nerve injury and on Days 1 and 7 to evaluate the acoustic function of the cochlear nerve. The animals were sacrificed 1 week after the operation, and their brains were fixed in formalin. Nissl staining of the cochlear nuclei was performed, and histological sections were analyzed with a light microscope and an image-processing program. The numbers of neurons in the cochlear nuclei were assessed. RESULTS The values for Waves 2 and 4 of the BAEPs decreased abruptly in all 3 groups in the direct postoperative measurement. Although the amplitude in the control group did not recover, it increased in both treatment groups. According to 2-way ANOVA, groups treated with G-CSF had a significant increase in BAEP Wave II amplitudes on the right side (p = 0.0401) after the applied cochlear nerve injury. With respect to Wave IV, a trend toward better recovery in the G-CSF groups was found, but this difference did not reach statistical significance. In the histological analysis, higher numbers of neurons were found in the G-CSF groups. In the statistical analysis, the difference in the numbers of neurons between the control and G-CSF-post groups reached significance (p = 0.0086). The difference in the numbers of neurons between the control and G-CSF-pre/post groups and between the G-CSF-post and G-CSF-pre/post groups did not reach statistical significance. CONCLUSIONS The use of G-CSF improved the function of the eighth cranial nerve and protected cochlear nucleus cells from destruction after a controlled partial injury of the nerve. These findings might be relevant for surgery that involves CPA tumors. The use of G-CSF in patients with a lesion in the CPA might improve postoperative outcomes.

The auxiliary effect of suramin application in acute angle closure glaucoma surgery patients

Objective To investigate the effects of suramin application in acute angle closure glaucoma surgery patients. Methods A prospective study method was used. From February 2012 to January 2016, 178 acute angle closure glaucoma surgeries in our hospital for treatment were selected, and were equally divided into observation and control groups (89 cases in each group) according to the order of admission, and two groups were given filtration surgery. The observation group was treated with suramin adjuvant therapy after surgery. The duration were 1~14 d after operation. The prognosis of two groups was observed. Results All patients were successfully completed surgery. The intraoperative and postoperative complications were no seriously occurred; the postoperative intraocular pressure in the observation group and the control group were (11.52±3.24) mmHg and (16.98±5.33) mmHg that compared preoperative [(31.98±5.22) mmHg, (31.87±5.11) mmHg] with significantly different (P<0.05), while the observation group was significantly lower than that of the control group (P<0.05). The postoperative peak systolic velocity (PSV) and end diastolic velocity (EDV) values of the central retinal artery of the observation group and the control group were significantly higher than that of preoperation (P<0.05), and the postoperative PSV and EDV values of the central retinal artery of the observation group were significantly higher than that in the control group (P<0.05). The postoperative ratios of functional filtering bleb in the observation group and control group were 80.9% and 60.7%, respectively. The observation group was significantly higher than that of the control group (P<0.05). Conclusions The application of suramin in acute close angle glaucoma filtration surgery can promote the function of filtering bleb and intraocular pressure reduction, and improve the ocular blood flow speed that has good application effects. Key words: Suramin/TU; Glaucoma, angle-closure/TH; Filtering surgery

New method for an evaluation of the esthetical improvements resulting from a mandibular angle reduction.

ObjectivesThis paper proposes Han's ratio as an objective and quantitative comparative result obtained from pre and postoperative data in patients with a mandibular angle reduction.Materials and MethodsThirty patients, 12 men and 18 women, who visited the Department of Oral and Maxillofacial Surgery with the chief complaints of skeletal mandibular prognathism and prominent mandibular angle were selected. The subjects were classified into 3 groups according to the types of surgical procedures involved. Group A consisted of patients who underwent mandibular angle resection and mandibular setback. Group B was comprised of patients with mandibular angle resection, mandibular setback and genioplasty. Group C consisted of patients with mandibular angle resection, mandibular setback, Le Fort I osteotomy, and genioplasty. The landmarks placed in pre and postoperative frontal photographs were used to obtain the Han's ratio in each group. The Han's ratios were compared pre- and postoperation and according to the surgical techniques applied.ResultsOf the 3 groups who had undergone a mandibular angle resection, all showed a statistically significant increase in Han's ratio. On the other hand, there was no statistically significant difference based on the surgical techniques used.ConclusionThe ratio of the lateral lower face proposed in this study is a potential indicator of postoperative esthetic enhancement in mandibular angle reduction surgery.

360-Degree Trabeculotomy for Medically Refractory Glaucoma Following Cataract Surgery and Juvenile Open-Angle Glaucoma

Although angle surgeries show good success in primary congenital glaucoma, reported success in glaucoma following cataract surgery (GFCS) and juvenile open-angle glaucoma (JOAG) is variable and with relatively short follow-up. We evaluated longer-term outcomes of 360-degree trabeculotomy for medically refractory GFCS and JOAG. Retrospective case series. First operated eyes of consecutive patients with medically refractory GFCS and JOAG in a single-surgeon pediatric glaucoma practice who underwent illuminated microcatheter-assisted 360-degree trabeculotomy from February 2008 to June 2015 were reviewed. Baseline characteristics, time to failure or last visit, surgical details, final intraocular pressure (IOP), and complications were recorded. Success required IOP ≤22mm Hg and 20% reduction without additional glaucoma surgery or devastating complication. Thirty-five eyes (35 patients) were included: 25 GFCS and 10 JOAG (mean age at surgery 5.6 vs 16.7 years, respectively, P < .001). Success for GFCS and JOAG was 18 of 25 (72%) vs 6 of 10 (60%) eyes at mean follow-up of 31.9 ± 26.1 vs 24.5 ± 19.7months, respectively. IOP was significantly reduced from baseline for both GFCS and JOAG (31.5 ± 7.5mm Hg vs 19.2 ±7.7mm Hg, P < .001; and 29.5 ± 10.3mm Hg vs 15.8 ± 6.6mm Hg, P < .001, respectively). Fewer glaucoma medications were needed after surgery (P= .01) for GFCS but not JOAG. Complications (all but 2 spontaneously resolving) included choroidal effusion (1), vitreous hemorrhage (3), Descemet detachment (1), and persistent hyphema (2). Three-year Kaplan-Meier success for GFCS vs JOAG was 75.3% vs 53.3%, respectively. Illuminated microcatheter-assisted 360-degree trabeculotomy is a useful, low-risk, modestly successful initial surgical treatment for both medically refractory GFCS and JOAG.

Endoscopic approach-routes in the posterior fossa cisterns through the retrosigmoid keyhole craniotomy: an anatomical study.

Endoscopy in cerebellopontine angle surgery is an increasingly used technique. Despite of its advantages, the shortcomings arising from the complex anatomy of the posterior fossa are still preventing its widespread use. To overcome these drawbacks, the goal of this study was to define the anatomy of different endoscopic approaches through the retrosigmoid craniotomy and their limitations by surgical windows. Anatomical dissections were performed on 25 fresh human cadavers to describe the main approach-routes. Surgical windows are spaces surrounded by neurovascular structures acting as a natural frame and providing access to deeper structures. The approach-routes are trajectories starting at the craniotomy and pointing to the lesion, passing through certain windows. Twelve different windows could be identified along four endoscopic approach-routes. The superior route provides access to the structures of the upper pons, lower mesencephalon, and the upper neurovascular complex through the suprameatal, superior cerebellar, and infratrigeminal windows. The supratentorial route leads to the basilar tip and some of the suprasellar structures via the ipsi- and contralateral oculomotor and dorsum sellae windows. The central endoscopic route provides access to the middle pons and the middle neurovascular complex through the inframeatal, AICA, and basilar windows. The inferior endoscopic route is the pathway to the medulla oblongata and the lower neurovascular complex through the accessory, hypoglossal, and foramen magnum windows. The anatomy and limitations of each surgical windows were described in detail. These informations are essential for safe application of endoscopy in posterior fossa surgery through the retrosigmoid approach.

Differential Canalograms Detect Outflow Changes from Trabecular Micro-Bypass Stents and Ab Interno Trabeculectomy.

Recently introduced microincisional glaucoma surgeries that enhance conventional outflow offer a favorable risk profile over traditional surgeries, but can be unpredictable. Two paramount challenges are the lack of an adequate training model for angle surgeries and the absence of an intraoperative quantification of surgical success. To address both, we developed an ex vivo training system and a differential, quantitative canalography method that uses slope-adjusted fluorescence intensities of two different chromophores to avoid quenching. We assessed outflow enhancement by trabecular micro-bypass (TMB) implantation or by ab interno trabeculectomy (AIT). In this porcine model, TMB resulted in an insignificant (p > 0.05) outflow increase of 13 ± 5%, 14 ± 8%, 9 ± 3%, and 24 ± 9% in the inferonasal, superonasal, superotemporal, and inferotemporal quadrant, respectively. AIT caused a 100 ± 50% (p = 0.002), 75 ± 28% (p = 0.002), 19 ± 8%, and 40 ± 21% increase in those quadrants. The direct gonioscopy and tactile feedback provided a surgical experience that was very similar to that in human patients. Despite the more narrow and discontinuous circumferential drainage elements in the pig with potential for underperformance or partial stent obstruction, unequivocal patterns of focal outflow enhancement by TMB were seen in this training model. AIT achieved extensive access to outflow pathways beyond the surgical site itself.