Background: African-derived populations are disproportionately affected by primary open-angle glaucoma (POAG) and face increased risks of surgical failure due to anatomical and genetic factors. This report identifies challenges in glaucoma care and strategies to optimize surgical outcomes in patients from African-derived backgrounds. Methods: Six UK-based consultant ophthalmic glaucoma surgeons with extensive experience in diverse patient populations convened to discuss challenges and key approaches for optimising glaucoma filtration surgery outcomes in African-derived populations. Their opinions were supplemented by published literature to propose tailored recommendations and address some of the known challenges in this important patient group. Results: Surgical treatment of glaucoma among African-derived populations includes challenges such as Tenon's thickness, variable wound healing, and an increased risk of scarring. Preoperatively, outcomes can be improved through patient education, counselling and ocular surface optimisation, including reduction of preservative exposure. Intraoperatively, surgeons may consider the use of general anaesthesia or conscious sedation in younger patients, higher or prolonged mitomycin C exposure tailored to individual risk, and separate closure of Tenon's capsule and conjunctiva to reduce bleb failure. Proactive postoperative care should include intensified steroid regimens and 5-fluorouracil use when indicated. Conclusion: These insights support the delivery of culturally informed, evidence-based glaucoma care tailored to patients from African-derived backgrounds. By adopting a personalised and proactive approach, healthcare professionals may achieve more consistent and favourable surgical outcomes in this high-risk group.

Purpose: To report efficacy and outcomes of Preserflo MicroShunt surgery in patients with uveitic glaucoma at a tertiary center. Design: Retrospective cohort study. Methods: Consecutive patients with uncontrolled uveitic glaucoma who underwent Preserflo MicroShunt surgery with a minimum of 2 years of follow-up. Baseline characteristics, pre-operative and post-operative intraocular pressure (IOP), number of glaucoma medications, visual acuity, and adverse events were recorded. Results: A total of 48 eyes with uveitic glaucoma underwent Preserflo MicroShunt with 0.4–0.5 mg/mL mitomycin C (MMC) were followed up at 2 years post-operation and 38 eyes at 3 years post-operation. The mean age was 51 ± 17 (21–84) years, and 27 (56.3%) were female. The mean baseline IOP of 29 ± 8 (range: 14–45) mmHg was reduced at each year post-operatively (P < 0.0001). The mean post-operative IOP at 1 year was 12.5 ± 5.0, at 2 years, it was 11.4 ± 4.8, and at 3 years, it was 13.6 ± 6.8 mmHg. The mean number of pre-operative glaucoma medications was 3.2 ± 1.3 (range: 0–5) compared with 0.4 at 1 year, 0.3 at 2 years, and 0.6 at 3 years (P < 0.0001). Adverse events included hypotony (two eyes), required revision of Preserflo MicroShunt (six eyes), and required further glaucoma surgery (six eyes). At the last follow-up visit, the overall success rate (IOP ≤ 21 mmHg and a 20% reduction ± medication) was 75%. Conclusion: Our study showed good IOP control with Preserflo MicroShunt surgery at 3 years for patients with uncontrolled uveitic glaucoma.

PurposeA pilot study to assess the safety and efficacy of a Primary Eyecare Glaucoma Service (PEGS), with low-risk glaucoma patients being reviewed within primary care optometry.Methods98 low-risk glaucoma patients were identified as suitable for monitoring in primary care and reviewed by accredited optometrists in community practice supported by a clinical management plan. Safety was assessed by reviewing concordance of management plans created by primary care optometrists and the secondary care team. Patients' and primary care optometrists' feedback were collated via surveys. Carbon emissions were calculated through comparison of patient travel to primary and secondary care.Results93.8% of patients reviewed by primary care met criteria for ongoing monitoring in primary care after initial review with 4.9% of patients being recalled to secondary care due to clinical instability. Safety and efficacy were demonstrated with agreement of management plans between primary and secondary care of 97.8%, kappa =0.88 (95% confidence intervals 0.60-1.00), with no patients being identified as false negatives where recall back to secondary care was required. Overall satisfaction with PEGS was 100% according to a patient survey. Respondents of the primary care optometry survey felt very or somewhat confident in delivering care, with comments suggesting they felt supported by secondary care. Carbon emissions are reduced by approximately two thirds when patients are seen in primary care versus attending the hospital.ConclusionPEGS is a safe and effective service, reducing the burden for secondary care, while carbon emissions are reduced due to shorter travelling distances, demonstrating environmental sustainability.

BACKGROUND/OBJECTIVES:Evaluate the mid-term outcomes of the PAUL Glaucoma Implant (PGI) in the management of uveitic glaucoma. SUBJECTS/METHODS:This was a single-centre, multi-surgeon, retrospective analysis of 50 consecutive cases of PGI for uveitic glaucoma performed between April 2019 and August 2021. Primary outcomes include: complete and qualified success (IOP ≥5 mmHg to ≤21 mmHg with ≥20% IOP reduction) or failure (IOP exceeding the success criteria, additional glaucoma procedures, no perception of light vision). Secondary outcomes included: visual acuity, IOP, medications, complications and intraluminal stent removal. RESULTS:We included 50 eyes of 41 patients. Mean age was 45.8 ± 19.8 years (range 6-81 years) in this heterogenous and complex cohort. Mean pre-op IOP was 30.6 ± 9.8 mmHg on 3.9 ± 0.9 medications. In total, 62% of patients were on acetazolamide, and 64% required systemic immunosuppression. At final follow-up (mean: 35.8 ± 9.8 months, range 5-58 months), IOP and medications were significantly reduced (12.2 ± 4.4 mmHg, requiring 1.1 ± 1.3 medications, p < 0.0001). Resulting in 48% complete and 92% qualified success rates. Failure occurred in 8% of cases, 6% due to hypertension but only one case of prolonged hypotony (2%). CONCLUSIONS:To date, this study represents the first publication looking specifically at the efficacy and safety of the PGI in the management of complex uveitic glaucoma. With an average follow-up of 3 years, it shows high levels of complete and qualified success with few complications.

Primary open angle glaucoma (POAG) is a chronic, adult-onset optic neuropathy associated with characteristic optic disc and/or visual field changes. With a view to identifying modifiable risk factors for this common neurodegenerative condition, we performed a ‘phenome-wide’ univariable Mendelian randomisation (MR) study that involved analysing the relationship between 9661 traits and POAG. Utilised analytical approaches included weighted mode based estimation, the weighted median method, the MR Egger method and the inverse variance weighted (IVW) approach. Eleven traits related to POAG risk were identified including: serum levels of the angiopoietin-1 receptor (OR [odds ratio] = 1.11, IVW p = 2.34E-06) and the cadherin 5 protein (OR = 1.06, IVW p = 1.31E-06); intraocular pressure (OR = 2.46–3.79, IVW p = 8.94E-44–3.00E-27); diabetes (OR = 5.17, beta = 1.64, IVW p = 9.68E-04); and waist circumference (OR = 0.79, IVW p = 1.66E-05). Future research focussing on the effects of adiposity, cadherin 5 and angiopoietin-1 receptor on POAG development and progression is expected to provide key insights that might inform the provision of lifestyle modification advice and/or the development of novel therapies.

OBJECTIVES:To describe a surgical technique and early post-operative outcomes for a novel glaucoma drainage device-the PAUL® glaucoma implant (PGI). METHODS:A consecutive cohort study of subjects who had PGI surgery between February 2019 and May 2020 with a minimum of 6-month follow-up. Primary outcome measures included failure (intraocular pressure (IOP) > 21 mmHg or a <20% reduction of IOP, removal of the implant, further glaucoma intervention or visual loss to no light perception). Secondary outcomes included mean IOP, mean number of medications, logMAR visual acuity (VA) and complications. RESULTS:Ninety-nine eyes of 97 patients had a preoperative IOP (mean ± standard deviation) of 28.1 ± 9.0 mmHg, falling to 18.2 ± 6.8 mmHg at 1 month, 17.9 ± 6.7 mmHg at 3 months and 13.6 ± 4.7 mmHg at 6 months. 52 patients had a 12-month mean IOP of 13.3 ± 4.4 mmHg. The mean change in number of medications was a reduction of 2.38 ± 1.48. A significant reduction in the number of medications and intraocular pressure was demonstrated after PGI (p < 0.0001). No significant change was demonstrated in VA (p = 0.1158). A total of nine cases were deemed failures (six had <20% IOP reduction from baseline and three had IOP >21 mmHg). Thirty-eight (38.4%) of eyes had complete success and achieved an unmedicated IOP <21 mmHg. Ninety (90.1%) of eyes were qualified successes (with or without topical medications). Seventy-four (74.7%) eyes have achieved an intraocular pressure of <15 mmHg. Two cases of hypotony were observed. CONCLUSION:This study presents a safe surgical technique, which significantly reduces IOP and number of medications with minimal complications.

Purpose: Over-filtration and subsequent hypotony are recognised complications of penetrating glaucoma procedures, especially when augmented with antimetabolites. Patients with uveitis are especially at risk of hypotony and this can reduce the final acuity achieved, compromise surgical outcomes and adversely affect the inflammatory status. The incidence of hypotony following XEN45 implant insertion is higher for uveitic patients and we present a method of surgically addressing this hypotony with transconjunctival compression sutures that are placed over the overdraining XEN45 implant. Methods: We present a retrospective case series of consecutive uveitic glaucoma patients who had conjunctival compression sutures between 2015 and 2018 following XEN45 insertion, at the Manchester Royal Eye Hospital, UK. Two 9/0 nylon sutures were placed in a horizontal figure-of-eight conformation transconjunctivally across the overdraining bleb: one directly over the XEN45 implant and one at the posterior limit of the implant in order to restrict flow. Results: Three patients underwent conjunctival compression sutures following XEN45 implant-related hypotony and all three had successful resolution of their hypotony and visual symptoms. No patients required long-term topical agents to control their intraocular pressure. Conclusion: Conjunctival compression sutures are an effective option for addressing persistent hypotony following XEN45 implant insertion in patients with uveitic glaucoma.

A 4-year-old girl presented with acute left visual loss 4 weeks after uneventful chickenpox. She was found to have left necrotising retinitis and profound retinal vasculitis and vitritis. Aqueous humour was PCR positive for varicella-zoster virus. Combined intravenous and intravitreal antiviral treatment led to rapid improvement with settled retinitis, no vascular occlusion and good recovery of vision. Her recent coinfection with Epstein-Barr virus may have acted to provoke the retinitis.

Purpose: Over-filtration is a well-known complication of trabeculectomy and related procedures, especially with adjunctive antimetabolites. Secondary hypotony can result in reduced visual acuity and compromise long-term surgical success. Persistent hypotony requires intervention and we describe an effective adaptation of placing conjunctival compression sutures directly over the scleral flap. Methods: A retrospective consecutive case series of all patients who underwent conjunctival compression suturing from 2012 to 2014 at Manchester Royal Eye Hospital, UK. Under sub-tenon’s anaesthesia, two 9/0 nylon figure-of-eight transconjunctival sutures were placed horizontally across the bleb: the first over the anterior flap/ostium and the second over the posterior flap edge to reduce flow through the trabeculectomy flap. Results: A total of 10 patients underwent conjunctival compression suturing, and all patients had successful reversal of hypotony and symptom resolution within 1 week with corresponding clinical improvement. Intraocular pressure control was maintained without topical pressure-lowering agents in seven patients (median = 10 mmHg, range = 7–12 mmHg) with a median follow-up of 35.9 months (range = 11–61 months). Two patients required topical therapy to maintain intraocular pressure ≤ 14 mmHg and one patient’s hypotony returned after 10 months but remained untreated due to pre-existing poor vision. No patients required a return to theatre. Conclusion: This series demonstrates that conjunctival compression sutures can successfully provide long-term control of trabeculectomy-bleb-related hypotony. This technique offers an effective alternative for glaucoma surgeons in addressing post-trabeculectomy hypotony.

A 54-year-old woman received multiple injections of hyaluronic acid filler to the brow region to address volume loss over a 21-month period. She then developed significant pitting edema of both upper eyelids, which persisted for 6 years. Hyaluronidase (Hyalase) was injected into the subcutaneous brows and resulted in complete resolution of the edema within 2 days. This confirms that the hyaluronic acid injected into the brows was responsible for this patient's chronic eyelid edema. This case illustrates an unusual long-term complication of periocular hyaluronic acid filler.

British Journal of Hospital MedicineVol. 74, No. 8 Case ReportIgG4 disease: a revised diagnosis of sarcoidosis after 36 years of treatmentJonathan Yu, Tim Hall, Salvita Kale, Aled Phillips, Simon MadgeJonathan YuSearch for more papers by this author, Tim HallSearch for more papers by this author, Salvita KaleSearch for more papers by this author, Aled PhillipsSearch for more papers by this author, Simon MadgeSearch for more papers by this authorJonathan Yu; Tim Hall; Salvita Kale; Aled Phillips; Simon MadgePublished Online:18 Nov 2013https://doi.org/10.12968/hmed.2013.74.8.470AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Kamisawa T Funata N Hayashi Y et al. (2003) A new clinicopathological entity of IgG4-related autoimmune disease. J Gastroenterol 38(10): 982–4 Crossref, Medline, Google ScholarKamisawa T Nakajima H Egawa N Funata N Tsuruta K Okamoto A (2006) IgG4-related sclerosing disease incorporating sclerosing pancreatitis, cholangitis, sialadenitis and retroperitoneal fibrosis with lymphadenopathy. Pancreatology 6(1-2): 132–7 Crossref, Medline, Google ScholarKhosroshahi A Stone JH (2011) Treatment approaches to IgG4-related systemic disease. Curr Opin Rheumatol 23(1): 67–71 Crossref, Medline, Google ScholarStrehl JD Hartmann A Agaimy A (2011) Numerous IgG4-positive plasma cells are ubiquitous in diverse localised non-specific chronic inflammatory conditions and need to be distinguished from IgG4-related systemic disorders. J Clin Pathol 64(3): 237–43 Crossref, Medline, Google ScholarZen Y Nakanuma Y (2010) IgG4-related disease: a cross-sectional study of 114 cases. Am J Surg Pathol 34(12): 1812–19 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetailsCited BySarcoidosis: muchas caras, una enfermedad. Revisión narrativa de la literatura2 July 2019 | Iatreia, Vol. 32, No. 3 1 August 2013Volume 74Issue 8ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 18 November 2013 Published in print 1 August 2013 Information© MA Healthcare LimitedPDF download

INTRODUCTION:Necrotising fasciitis (NF) is a rare, severe, rapidly progressing and life-threatening synergistic infection primarily affecting the superficial fascia. A novel method of definitive and aesthetic reconstruction of NF thigh defects by using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap without recourse to temporising skin grafts is presented.PRESENTATION OF CASE:A 30-year-old parous woman presented in extremis with fulminant NF of her left anteromedial thigh. Following emergency radical debridement and intensive care stabilisation she was reconstructed 48h later in a single stage with a pedicled TRAM flap islanded on the ipsilateral deep inferior epigastric vessels. There was excellent contour restoration of her thigh and coverage of the exposed femoral vessels.DISCUSSION:Pedicled flaps based on the rectus abdominis muscle provide a large, readily available reconstructive option for correction of substantial regional defects as herein illustrated. They are robust when based on dominant inferior vascular pedicle with a long reach and wide arc of rotation when designed transversely (as a TRAM flap).CONCLUSION:This case also illustrates that definitive flap reconstruction of NF can be successfully undertaken in the emergent setting, thereby negating the need for large areas of skin grafting which can lead to contractures with consequent functional impairment and suboptimal aesthetic results.

Introduction: Seroma following breast cancer surgery causes significant morbidity. Although quilting reduces seroma formation, it is often perceived as time consuming, producing a relatively small reduction in seroma rates. We report on the impact of quilting on seroma rates in our unit.

Topical vasodilators are widely used in reconstructive microsurgery in order to ameliorate intraoperative vascular spasm (vasospasm) and facilitate microvascular anastomoses. There is, however, a paucity of literature to support or discredit this practice. A survey of current practice in UK Plastic Surgery Departments was therefore undertaken.

Summary Background: The significance of internal mammary lymph nodes (IMLNs) encoun-tered during dissection of internal mammary vessels (IMVs) for microvascular free flap breastreconstruction (FFBR) remains uncertain. We report our experience with the opportunisticharvest of IMLNs during FFBR. Therapeutic implications and patient outcomes are explored.Methods: All IMV anastomoses for delayed (DBR) or immediate breast reconstruction (IBR),between 1997 and 2009 were recorded. Opportunistic IMLN harvests were identified andpatient characteristics and outcomes recorded from review of case records.Results: Of the 293 FFBRs, 43 patients had 46 IMLNs harvested during 20 immediate and 26 de-layed FFBRs. Six patients had positive nodes (4 IBR and 2 DBR), and were offered post operativechemotherapy. Four received radiotherapy to the internal mammary chain. Three of the fourIMLNþve IBR patients have died of metastatic disease at 23, 33 and 55 months after recon-struction. The two IMLNþve DBR patients were alive at 4 and 20 months.Discussion and Conclusion: Although routine biopsy of IMLNs for staging in breast cancer is not