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This issue at a glance
This Issue At A Glance
Ophthalmology Volume 111, Number 4, April 2004
Mohs Micrographic Surgery Treatment of Choice for Periocular Basal Cell Carcinoma In a follow-up study looking at periocular basal cell carcinoma (BCC) outcome at 5 years, Malhotra et al (p. 631) confirmed that Mohs micrographic surgery (MMS) is the “treatment of choice” for this disease. The Australian MMS study is the largest prospective nationwide series of high-risk periocular BCC managed by MMS, a procedure that involves complete microscopic examination of all surgically removed tissues as well as detailed mapping techniques to aid in removing the roots and extensions of the skin cancer. The authors reported “strict 5-year recurrence rates,” meaning that only those cases with 5-year follow-up were included in the statistical review. Of the 819 patients with lower eyelid (54%), medial canthus (41%), and upper eyelid (5%) BCC, 347 individuals (42%) were available for follow-up at 5 years. There were no recurrences for primary BCC, and the 5-year recurrence rate for previously recurrent BCC was 7.8%. The authors conclude that this study confirms the effectiveness of MMS for periocular BCC.
Race Difference Seen in Glaucoma Treatment Response Findings from the Advanced Glaucoma Intervention Study (AGIS) (p. 651) indicate significant race–treatment interactions. Specifically, the AGIS Investigators found that in patients with medically uncontrolled glaucoma, visual function was better maintained through 10 years with initial argon laser trabeculoplasty (ALT) in eyes of black patients and with initial trabeculectomy in eyes of white patients. The study involved 332 black patients (451 eyes) and 249 white patients (325 eyes) randomized to 1 of 2 treatment sequences: ALT–trabeculectomy–trabeculectomy (ATT) or trabeculectomy–ALT–trabeculectomy (TAT). They were observed every 6 months from 8 years to 13 years. In both black and white patients, the average percentage of eyes with visual acuity loss was less in the ATT sequence than in the TAT sequence—a difference statistically significant for 10 years in black patients but only for the first year in white patients. In contrast, white patients experienced less visual field loss in the TAT sequence, a trend that continued to increase in years 8 to 10. The authors conclude that race differences and race–treatment interactions should be taken into consideration in any future glaucoma studies.
Needle Revision Technique Augmented with 5-FU Effective in Patients with Failed Trabeculectomy Blebs Broadway et al (p. 665) report an effective needle revision technique augmented with 5-fluorouracil (5-FU) for patients with failed trabeculectomy blebs. In the procedure, done at the slip lamp, a 29-gauge needle attached to an insulin syringe was passed into the subconjunc-
tival space. Using a sweeping motion, the cutting edges of the needle tip were then used to disrupt any episcleral fibrosis. Finally, a subconjunctival injection of 5-FU was given in the superior bulbar subconjunctival space above the bleb site. Of the 101 bleb needling procedures, 60 eyes had an intraocular pressure (IOP) of ⬍22 mmHg after a median number of 1 needling procedure at a minimum of 9 months’ follow-up. The authors found strong evidence that the immediate attainment of a low IOP (⬍11 mmHg) after surgery is a key factor for long-term efficacy. They conclude that bleb needling should be considered in the management of failed filtration blebs.
Two Cataract Surgery Techniques Demonstrate Similar Corneal Endothelial Cell Loss Bourne et al (p. 679) have demonstrated that there is no overall significant difference in corneal endothelial cell loss between extracapsular cataract extraction (ECCE) and modern phacoemulsification surgery techniques. However, they caution that an increased risk of severe cell loss with phacoemulsification does occur in a subgroup of patients with hard cataracts. The authors randomized 500 patients 40 years or older into an ECCE group and a phacoemulsification group. At 1 year postoperatively, there was no significant difference in overall percentage corneal endothelial cell loss (a 10% reduction in cell count was recorded) between the 2 groups. Although phacoemulsification carried a higher risk of severe loss in the 45 patients with hard cataracts relative to ECCE, both procedures achieved similar postoperative visual acuity outcomes in these patients. Vitreous loss or capsular rupture was also associated with excessive cell loss. They conclude that ECCE may be of benefit in patients with hard cataracts.
Uveitis Frequently First Indication of Undiagnosed HLA-B27–Associated Extraocular Disease In a study representing the largest report of patients with HLAB27–associated uveitis, Monnet et al (p. 802) systematically screened for associated extraocular manifestations. They observed spondyloarthropathies in approximately 78% of patients. Although most participants already had symptoms of extraocular disease, the condition usually went undiagnosed until the first attack of uveitis. In this observational case series of 175 consecutive patients with HLA-B27–associated uveitis, an associated extraocular disorder was seen in 136 cases. The onset of extraocular symptoms occurred at a younger age (mean, 26.4 years) than the first attack of uveitis (mean, 34.0 years), and the diagnosis of an extraocular disease was made only after the appearance of ophthalmic manifestations in 88 of 136 patients. In light of these data, the authors recommend routine rheumatologic evaluation for all patients with a first attack and recurrent HLA-B27–associated uveitis.
Lori Baker Schena and John Kerrison, MD
Ophthalmology Volume 111, Number 4, April 2004
Mohs Micrographic Surgery Treatment of Choice for Periocular Basal Cell Carcinoma In a follow-up study looking at periocular basal cell carcinoma (BCC) outcome at 5 years, Malhotra et al (p. 631) confirmed that Mohs micrographic surgery (MMS) is the “treatment of choice” for this disease. The Australian MMS study is the largest prospective nationwide series of high-risk periocular BCC managed by MMS, a procedure that involves complete microscopic examination of all surgically removed tissues as well as detailed mapping techniques to aid in removing the roots and extensions of the skin cancer. The authors reported “strict 5-year recurrence rates,” meaning that only those cases with 5-year follow-up were included in the statistical review. Of the 819 patients with lower eyelid (54%), medial canthus (41%), and upper eyelid (5%) BCC, 347 individuals (42%) were available for follow-up at 5 years. There were no recurrences for primary BCC, and the 5-year recurrence rate for previously recurrent BCC was 7.8%. The authors conclude that this study confirms the effectiveness of MMS for periocular BCC.
Race Difference Seen in Glaucoma Treatment Response Findings from the Advanced Glaucoma Intervention Study (AGIS) (p. 651) indicate significant race–treatment interactions. Specifically, the AGIS Investigators found that in patients with medically uncontrolled glaucoma, visual function was better maintained through 10 years with initial argon laser trabeculoplasty (ALT) in eyes of black patients and with initial trabeculectomy in eyes of white patients. The study involved 332 black patients (451 eyes) and 249 white patients (325 eyes) randomized to 1 of 2 treatment sequences: ALT–trabeculectomy–trabeculectomy (ATT) or trabeculectomy–ALT–trabeculectomy (TAT). They were observed every 6 months from 8 years to 13 years. In both black and white patients, the average percentage of eyes with visual acuity loss was less in the ATT sequence than in the TAT sequence—a difference statistically significant for 10 years in black patients but only for the first year in white patients. In contrast, white patients experienced less visual field loss in the TAT sequence, a trend that continued to increase in years 8 to 10. The authors conclude that race differences and race–treatment interactions should be taken into consideration in any future glaucoma studies.
Needle Revision Technique Augmented with 5-FU Effective in Patients with Failed Trabeculectomy Blebs Broadway et al (p. 665) report an effective needle revision technique augmented with 5-fluorouracil (5-FU) for patients with failed trabeculectomy blebs. In the procedure, done at the slip lamp, a 29-gauge needle attached to an insulin syringe was passed into the subconjunc-
tival space. Using a sweeping motion, the cutting edges of the needle tip were then used to disrupt any episcleral fibrosis. Finally, a subconjunctival injection of 5-FU was given in the superior bulbar subconjunctival space above the bleb site. Of the 101 bleb needling procedures, 60 eyes had an intraocular pressure (IOP) of ⬍22 mmHg after a median number of 1 needling procedure at a minimum of 9 months’ follow-up. The authors found strong evidence that the immediate attainment of a low IOP (⬍11 mmHg) after surgery is a key factor for long-term efficacy. They conclude that bleb needling should be considered in the management of failed filtration blebs.
Two Cataract Surgery Techniques Demonstrate Similar Corneal Endothelial Cell Loss Bourne et al (p. 679) have demonstrated that there is no overall significant difference in corneal endothelial cell loss between extracapsular cataract extraction (ECCE) and modern phacoemulsification surgery techniques. However, they caution that an increased risk of severe cell loss with phacoemulsification does occur in a subgroup of patients with hard cataracts. The authors randomized 500 patients 40 years or older into an ECCE group and a phacoemulsification group. At 1 year postoperatively, there was no significant difference in overall percentage corneal endothelial cell loss (a 10% reduction in cell count was recorded) between the 2 groups. Although phacoemulsification carried a higher risk of severe loss in the 45 patients with hard cataracts relative to ECCE, both procedures achieved similar postoperative visual acuity outcomes in these patients. Vitreous loss or capsular rupture was also associated with excessive cell loss. They conclude that ECCE may be of benefit in patients with hard cataracts.
Uveitis Frequently First Indication of Undiagnosed HLA-B27–Associated Extraocular Disease In a study representing the largest report of patients with HLAB27–associated uveitis, Monnet et al (p. 802) systematically screened for associated extraocular manifestations. They observed spondyloarthropathies in approximately 78% of patients. Although most participants already had symptoms of extraocular disease, the condition usually went undiagnosed until the first attack of uveitis. In this observational case series of 175 consecutive patients with HLA-B27–associated uveitis, an associated extraocular disorder was seen in 136 cases. The onset of extraocular symptoms occurred at a younger age (mean, 26.4 years) than the first attack of uveitis (mean, 34.0 years), and the diagnosis of an extraocular disease was made only after the appearance of ophthalmic manifestations in 88 of 136 patients. In light of these data, the authors recommend routine rheumatologic evaluation for all patients with a first attack and recurrent HLA-B27–associated uveitis.
Lori Baker Schena and John Kerrison, MD