Glaucoma drainage implants in Asian eyes

OBJECTIVE: Previous studies have suggested that there are racial differences in the outcome of conventional filtration surgery. This study aims to evaluate the outcome of glaucoma drainage implants in Asian eyes with complicated glaucoma and to determine whether there are racial differences in the results of such implant surgery compared to previous reports in non-Asian patients. DESIGN: The study design was a retrospective review of all patients with more than 6-months' follow-up after glaucoma implant surgery at the Singapore National Eye Centre between January 1993 and August 1996. PARTICIPANTS: A total of 83 Asian patients with uncontrolled complicated glaucoma participated. INTERVENTION: A total of 29 patients received Molteno implants and 54 received Baerveldt implants. MAIN OUTCOME MEASURES: The surgical outcome was assessed in terms of final intraocular pressure (IOP), visual acuity outcome, and incidence of complications. Success was defined as final IOP less than 22 mmHg with no medications and qualified success as an IOP less than 22 mmHg with medication. RESULTS: With mean follow-up of 13.41 months, success in IOP control was achieved in 73.5% of patients and qualified success in 12%. Visual acuity remained stable or improved in 85.5%. There were no patients who encountered intraoperative complications, and the incidence of serious postoperative complications was low. The most frequently observed short- and long-term postoperative complication was hyphema in 14 eyes (16.9%) and bullous keratopathy in 7 eyes (8.4%), respectively. CONCLUSIONS: Glaucoma drainage implants have good outcome and visual stabilization in Asian eyes with success rates for IOP control comparable to those reported in previous studies in non-Asian eyes.     

Extracapsular cataract extraction with posterior chamber lens implantation in primary angle-closure glaucoma

PURPOSE: To evaluate long-term intraocular pressure (IOP) control after extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (IOL) implantation in patients with primary angle-closure glaucoma. SETTING: Ophthalmology Department, Groote Schuur Hospital, Cape Town, South Africa. METHODS: This retrospective study comprised 17 patients (19 eyes) with primary angle-closure glaucoma who had ECCE and posterior chamber IOL implantation. Four presented initially with acute glaucoma, 5 with subacute angle-closure glaucoma, and 8 (10 eyes) with chronic angle-closure glaucoma. In all, less than half the circumference of the angle was permanently closed. The drainage angle was evaluated preoperatively and postoperatively to monitor changes in the amount of angle closure. Intraocular pressure was measured in the early and late postoperative periods. RESULTS: On the first postoperative day, mean IOP was 17.2 mm Hg, although 5 patients (26%) had an IOP rise above 21 mm Hg despite the use of perioperative topical pilocarpine gel. After a mean follow-up of 19 months, IOP remained below 22 mm Hg without medication in 13 eyes (68%) and with topical medication in 5 eyes (26%). Mean number of glaucoma medications was reduced from 1.5/eye preoperatively to 0.5/eye postoperatively. CONCLUSION: Cataract extraction with IOL implantation resulted in good long-term IOP control in patients with primary angle-closure glaucoma, suggesting that combined cataract and trabeculectomy surgery may not be necessary to achieve long-term IOP control in these patients.     

Intraocular pressure and visual field defects

During a five-year study period, therapeutic levels of intraocular pressure (IOP) and visual field defects were assessed in 108 patients with open-angle glaucoma. In a group of 53 glaucoma patients with non-progressive visual field changes (mean age 65.2 +/- 6.3 years), the IOP level was 15.8 +/- 2.6 mm Hg, whereas in a group of 58 patients with progressive visual field changes (mean age 68.7 +/- 8.3 years) the IOP level was 19.9 +/- 2.9 mm Hg. Study results suggested that preservation of the visual field in glaucoma patients requires therapeutic IOP levels of < 16 mm Hg.     

Fundoplication and gastrostomy

BACKGROUND: There are conflicting reports on the value of cyclocryotherapy and it seems that the success rate is depending on glaucoma conditions, the period of follow-up and the technique. This retrospective study was carried out to assess the efficacy and complication rate of cyclocryosurgery for advanced glaucoma with and without neovascularization. PATIENTS AND METHODS: We induced 76 eyes of 75 patients with inadequately controlled glaucoma, which underwent cyclocryotherapy during the period of 1993 and 1996 (treatment time 60 seconds with -80 degrees C, 6-12 applications (mean 9.8 +/- 2.3), 180-360 degree (median 270 degree), diameter of the probe tip 2.5 mm, 1-2 mm distance from the limbus). Depending on the etiology we distinguished between neovascular (NVG) and non-neovascular glaucoma (nNVG). Pre- and postoperative data from all patients were studied retrospectively, for follow-up after 12-36 months patients were examined. RESULTS: Intraocular pressure (IOP) decreased in all patients from 44.7 +/- 12.6 mm Hg preoperatively to 15.6 +/- 6.5 mm Hg postoperatively after a follow-up of 12-36 months. In 88.2% IOP was lowered to < or = 25 mm Hg. NVG showed a mean IOP reduction from 49.1 +/- 12.5 mm Hg before cyclocryotherapy to 15.6 +/- 5.0 mm Hg at follow-up. In the nNVG group IOP was 40.5 +/- 11.3 mm Hg and 15.7 +/- 7.6 mm Hg after cyclocryotherapy. Pressure was controlled (< or = 25 mm Hg) for 83.8% of NVG and 92.3% of nNVG. A cyclocryotherapy-induced intense inflammation was seen more frequent in NVG (43.2%) than in nNVG (17.9%). 2 patients with NVG and 3 with nNVG developed phthisis postoperatively (total 6.7%). CONCLUSIONS: Cyclocryosurgery is an effective method to reduce IOP in advanced, refractory glaucoma, when other methods have failed. The risk/success rate seems to be acceptable.     

Topical plus subconjunctival anesthesia for phacotrabeculectomy: one year follow-up

PURPOSE: To evaluate the results of topical plus subconjunctival anesthesia for phacotrabeculectomy surgery and postoperative glaucoma control over 1 year. SETTING: Pacific Eye Center, Brisbane, Australia. METHODS: In this retrospective study of consecutive patients with glaucoma and cataract, topical plus subconjunctival anesthesia was used for combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy). Patients with proliferative diabetic retinopathy or neovascular glaucoma were excluded. RESULTS: Thirty-eight eyes had phacotrabeculectomy using topical plus subconjunctival anesthesia over 2 years. Patients reported no discomfort intraoperatively or postoperatively, and none required intravenous sedation. Eighty-one percent of patients achieved a best corrected visual acuity of 20/40 or better 6 months after surgery. Mean drop in intraocular pressure (IOP) was 5.91 mm Hg at 3 months and 5.86 mm Hg at 12 months, at which time IOP was controlled without additional medication in 72% of patients. There were no serious complications postoperatively. CONCLUSION: In this series, no patient reported intraoperative or postoperative discomfort and surgical results were excellent in terms of visual outcome and IOP control.     

Three-year prospective adherence to three breast cancer screening modalities

PURPOSES: To determine the long-term risk/benefit ratio of phacoemulsification and intraocular lens (IOL) implantation combined with trabeculotomy to manage eyes with pseudoexfoliation syndrome and co-existing cataract. SETTING: Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine; Kurihara Eye Clinic; Departments of Ophthalmology, Tenri Hospital, Kumamoto University, and Matsue Red Hospital; Nagata Eye Clinic, Japan. METHODS: This multicenter retrospective study comprised 49 eyes of 36 patients with pseudoexfoliation syndrome and co-existing cataract who had the combined procedure for uncontrolled intraocular pressure (IOP) (> 21 mm Hg) even on antiglaucoma medication. RESULTS: After a mean follow-up of 20.0 months +/- 13.2 (SD), IOP in all 49 eyes was well controlled (< or = 21 mm Hg). Mean IOP at the final examination was 14.6 +/- 2.6 mm Hg on a mean of 0.9 +/- 0.8 glaucoma medications. Complications included an IOP spike in 11 eyes and fibrin exudation in 1 eye. CONCLUSION: Phacoemulsification and IOL implantation combined with trabeculotomy was an effective treatment for patients with pseudoexfoliation syndrome and cataract.     

Superoxide as an intracellular radical sink

BACKGROUND: A major complication of unvalved drainage tube implants is hypotony. Occluding stents to internally block the tube, but which lie exposed in the inferior fornix, have been described. The authors report modifications of this technique. METHODS: A nonexposed 3-0 Supramid suture is used to internally block the tube, with the end placed subconjunctivally. Small venting slits are made in the extrascleral portion of the tube to provide early control of intraocular pressure. Molteno implants were placed in 32 eyes of 29 patients using these modifications. RESULTS: Mean preoperative intraocular pressure was 30.3 mmHg on an average of 2.6 medications. The stent was pulled without difficulty in the office treatment room a mean of 26 days postoperatively. Intraocular pressure from postoperative day 2 until the day of stent removal ranged from 2 to 26 mmHg, with 72% of eyes having intraocular pressure between 5 and 19 mmHg. There were 3 (9.4%) minor complications in the 32 eyes, with 1 case of early anterior chamber shallowing and 2 cases of moderate choroidal detachments, which settled spontaneously. With an average follow-up of 10.2 months, mean intraocular pressure at the final visit was 13.4 mmHg on an average of 1 medication. CONCLUSION: The "occluding stent" described here can be a helpful adjunct to unvalved drainage tube surgery in preventing early postoperative hypotony.     

Routine psychophysiological screening of 384 men with erectile dysfunction

BACKGROUND AND OBJECTIVE: To determine the efficacy of combined phacoemulsification--trabeculectomy in preventing early postoperative increases in intraocular pressure (IOP). PATIENTS AND METHODS: Eighty patients were enrolled in a prospective cohort study. Thirty-six patients with cataracts and uncontrolled glaucoma underwent combined phacoemulsification--trabeculectomy, and 44 patients with cataracts underwent phacoemulsification alone. The operations were performed in a standardized manner by one surgeon. IOP was measured at 4 hours, 1 day, and 7 days after surgery. The need for intervention (digital massage, medications) and the presence of complications were documented. RESULTS: Four hours after surgery, 5.5% of patients undergoing the combined procedure had IOPs greater than 30 mm Hg, compared with 22.7% of phacoemulsification patients (P < .05). No significant difference in IOP was found between the groups at postoperative day 1 or day 7. CONCLUSION: These results suggest that combined phacoemulsification-trabeculectomy protects against early postoperative elevations in IOP. This finding may influence the surgical management of cataracts in patients with poorly controlled glaucoma and significant compromise of visual field or optic nerve.     

Avoiding complicated shunt systems by open fenestration of symptomatic fourth ventricular cysts associated with hydrocephalus

BACKGROUND: The effect of thyroid orbitopathy on intraocular pressure (IOP) remains controversial. We carried out a study to determine the effect of orbital decompression surgery on the IOP in patients with advanced thyroid orbitopathy. METHODS: The records of 12 consecutive patients (22 eyes) who underwent decompression surgery for severe thyroid orbitopathy between 1985 and 1996 were reviewed. All patients were maintained on essentially the same medications before and after surgery. The IOP readings, obtained by means of applanation tonometry in primary gaze, from the pre- and postoperative visits were recorded, and the net change was calculated. RESULTS: The mean preoperative and postoperative IOP values were 19.8 mm Hg and 16.8 mm Hg respectively, a significant difference (p = 0.008). Seven of eight eyes with an IOP of 21 mm Hg or greater preoperatively had a postoperative IOP less than 21 mm Hg; these eyes showed a mean decrease in IOP of 5.6 mm Hg. The degree of preoperative IOP elevation was found to be a strong predictor of the amount of IOP lowering after surgery (p = 0.014). INTERPRETATION: Our results support the concept that orbital congestion associated with thyroid orbitopathy produces an increase in IOP by elevation of episcleral venous pressure (EVP) and that orbital decompression may reduce the IOP by decreasing EVP. Decompression surgery may obviate the need for more aggressive management of glaucoma in patients with severe thyroid orbitopathy.     

Neurofibromatosis 2 in the pediatric age group

Cataract surgeons frequently face the challenge of treating an open-angle glaucoma patient presenting for cataract surgery and intraocular lens implantation. It seems logical to treat both problems during the same surgical procedure if it can be done without jeopardizing the results of either. We present a short historic overview of the trabeculotomy procedure in adults, together with our technique using the new Fukasaku modification of the instrumentation (probes and forceps) and report 50 consecutive cases with a 100% three-month follow-up. The mean preoperative intraocular pressure was 19.3 mm Hg (range 16.0 to 37.0 mm Hg); three months after surgery it was 14.2 mm Hg (range 6.0 to 24.0 mm Hg). The mean preoperative pressure-reducing medications were 2.3 drugs per patient, and the postoperative mean was 0.7. Except for three cases of small postoperative hyphemas, no other complications were encountered during the study.     

Epidemiology of prostate cancer in two European countries: Scotland and Norway

PURPOSE: The authors assess whether adjunctive mitomycin C improves Molteno tube shunt surgery in terms of intraocular pressure (IOP), visual acuity, and complication rates. PATIENTS AND METHODS: Twenty-five eyes of twenty-five consecutive patients undergoing double-plate Molteno implant surgery were randomized to receive either mitomycin C (MMC) 0.4 mg/mL for 2 minutes or a control balanced salt solution in a masked, prospective study. Intraocular pressure, visual acuity, and complications were recorded 1 week and 1, 3, 6, and 12 months after surgery. A repeated measures analysis of variance (ANOVA) model was used to test the overall effect of the drug on IOP and percent change from preoperative IOP. RESULTS: Thirteen eyes received balanced salt solution and 12 eyes received MMC. There was no difference between the groups with respect to age, preoperative IOP, log mean angle of resolution (LogMar) visual acuity, or number of preoperative medications. Except for week 1, there were no differences between the groups at any of the clinic visits with respect to IOP and percent change from baseline IOP. Analysis of the visual acuity (LogMar) showed reduction in vision for both groups. Complications were similar in each group, as were number of postoperative hypotensive agents required. CONCLUSIONS: Adjunct MMC does not demonstrate a significant difference in outcomes compared with placebo in pressure-ridged Molteno implant surgery. Results of this study are limited by a small number of patients in each group and a fixed dose of MMC.     

Trabeculectomy function after cataract extraction

OBJECTIVE: To examine the effect of cataract extraction (CE) after trabeculectomy on intraocular pressure (IOP) control. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: A total of 115 consecutive patients who underwent extracapsular CE (N = 58) or phacoemulsification (N = 57) with intraocular lens (IOL) placement after trabeculectomy were studied. INTERVENTION: Cataract extraction with IOL after trabeculectomy was performed. MAIN OUTCOME MEASURES: Preoperative, intraoperative, and postoperative factors were evaluated for association with loss of IOP control requiring additional medications, bleb needling, or further glaucoma surgery, using Kaplan-Meier survival analysis and Cox multivariate proportional hazards survival regression. RESULTS: After mean postoperative follow-up of 21.1 +/- 14.3 months, additional glaucoma medication or needling of the filtering bleb to maintain IOP control was required in 35 eyes (30.4%) and was significantly associated with intraoperative iris manipulation and early postoperative peak IOP greater than 25 mmHg. Additional glaucoma surgery was eventually required in 11 eyes (9.6%) and was significantly associated with age of 50 years or younger, preoperative IOP greater than 10 mmHg, and early postoperative peak IOP greater than 25 mmHg. The cumulative proportion of patients who did not require reoperation for glaucoma was 93% and 90% at 1 and 2 years, respectively. The mean IOP at last visit had increased 1.6 mmHg above the pre-CE level and did not vary significantly after the first postoperative month. The median interval from CE to the addition of glaucoma medication or bleb needling was 1.6 months (within 3 months in 20 of 33 eyes) and that from nonsurgical intervention to further glaucoma surgery was 3.6 months (before the 7th postoperative month in 6 of 11 eyes). Of 19 eyes with hypotony (IOP < or = 6 mmHg) before CE, 11 eyes remained hypotonous after CE despite an increase in the mean IOP from 4.6 to 7.5 mmHg. CONCLUSIONS: When CE is performed after trabeculectomy, age of 50 years or younger, preoperative IOP greater than 10 mmHg, intraoperative iris manipulation, and early postoperative IOP greater than 25 mmHg are associated with worsened postoperative IOP control. Most bleb failures occur soon after CE. Resolution of pre-existing hypotony after CE is unpredictable.     

Intraoperative mitomycin C in complicated glaucomas

Filtering surgery has been found to be less successful in certain types of glaucoma. These include young patients, those with pigmentary glaucoma, secondary glaucoma, angle recession glaucoma, aphakic or pseudophakic glaucoma, and patients requiring reoperation. This study describes the authors' attempt to evaluate the effectiveness of conventional trabeculectomy with intraoperative application of mitomycin C in such patients. Ten eyes of 8 patients were evaluated in this study. Of these cases 4 eyes (2 bilateral cases) were from the primary juvenile open angle group; 2 eyes each had pseudophakic glaucoma and previous anti-glaucoma surgery which had failed; one eye had aphakic glaucoma and the last suffered from angle recession glaucoma. The intraocular pressure was successfully controlled in all the ten eyes. The preoperative IOP ranged from 28 to 50 mm Hg and the postoperative IOP ranged from 7 to 16 mm Hg. The postoperative complications were minimal.     

Occlusive ligature and standardized fenestration of a Baerveldt tube with and without antimetabolites for early postoperative intraocular pressure control

OBJECTIVE: To determine the effectiveness of a surgical modification for a nonvalved aqueous tube shunt in controlling intraocular pressure (IOP) in the early postoperative period. The effect of antimetabolite use on IOP also was studied. DESIGN: A retrospective study of consecutive patients who underwent modified Baerveldt 350-mm2 implant with varied, nonrandomized, exposure to antimetabolites. PARTICIPANTS: Fifty-one eyes of 46 patients with uncontrolled glaucoma were examined. INTERVENTION: Identical surgical modification of a Baerveldt 350-mm2 tube was performed in all cases and consisted of placement of an occlusive 7-0 polyglactin suture just anterior to the plate followed by a through-and-through penetration of the tube just anterior to the occlusive ligature with a standardized 15 degrees blade. Seventeen eyes were not exposed to antimetabolite, while 2 groups of 17 eyes had 3 minutes' episcleral exposure to either 5-fluorouracil 50 mg/ml or mitomycin C 0.4 mg/ml at the location corresponding to the fenestration. The Tenon's layer and conjunctiva were not exposed because of concerns regarding conjunctival erosion over the device. MAIN OUTCOME MEASURE: Intraocular pressure and number of antiglaucoma medications required were analyzed. RESULTS: For the group, mean IOP before surgery and on postoperative days 1, 4, 10, 21, 42, 63, 84, and 112 was (in millimeters of mercury) 34.6, 20.1, 17.0, 17.2, 22.0, 17.3, 18.7, 17.4, and 15.6, respectively. There was an elevation of IOP at day 21 relative to fibrotic blockage of the fenestration before suture autolysis. This was temporized with antiglaucoma medication until suture autolysis occurred or treated with laser suture lysis (8 eyes). On day 1, hypotony occurred in 3 (6%) eyes whereas IOP greater than 30 mmHg was observed in 13 (26%) eyes. By day 10, the frequency had decreased to one (2.1 %) eye and three (6.4%) eyes, respectively. The use of antimetabolites did not result in lower IOP or less medication needed for any group at any interval (analysis of variance). CONCLUSION: This modification of a nonvalved glaucoma tube shunt device provides adequate IOP control in the early postoperative period with a low rate of hypotony and surgical complications. If elevation of IOP occurs before suture autolysis, it generally is well controlled by antiglaucoma medications or laser suture lysis. Antimetabolite exposure did not influence early postoperative IOP in this study.     

Trabeculectomy with adjunctive mitomycin C in pediatric glaucoma

PURPOSE: To determine the safety and efficacy of trabeculectomy with adjunctive mitomycin C in patients 17 years of age or younger, and to identify risk factors for failure of this surgical technique. METHODS: Retrospective review of consecutive cases of pediatric glaucoma that underwent mitomycin C augmented trabeculectomy between January 1991 and December 1995. Forty-nine patients (60 eyes) with a mean age of 7.6 years (range, 6 weeks to 17.6 years) were identified and followed up until repeat glaucoma surgery, or after a minimum of 6 months. Success was defined as intraocular pressure control of 22 mm Hg or less with or without topical glaucoma control medication, no evidence of glaucoma progression, no further glaucoma surgery necessary, and no visually devastating complication. RESULTS: Cumulative probabilities of success +/- SD for 49 eyes (one eye per patient) were 67% +/- 13% at 12 months and 59% +/- 15% at 24 months. Multivariate regression analysis yielded the following characteristics as significantly increased risk for failure: age of less than 1 year at time of surgery (risk ratio, 5.6; confidence interval, 2.1 to 14.7; P = .0005), and aphakia (risk ratio, 2.7; confidence interval, 1.1 to 6.9; P = .0364). Shallow anterior chamber (17 [28%] of 60 eyes) and serous choroidal detachment (13 [22%] of 60 eyes) were the most common complications. Four (11%) of 38 eyes with obtainable Snellen acuity were noted to have a decrease in best-corrected visual acuity of more than 2 Snellen lines or loss of light perception. In 5 (8%) of 60 eyes bleb-related endophthalmitis was noted. CONCLUSIONS: Trabeculectomy with adjunctive mitomycin C is generally effective for the treatment of pediatric glaucoma, especially in phakic children over 1 year of age. However, late-onset bleb-related endophthalmitis is a substantial risk in this patient population.     

Rapid verification of the identity of questionable specimens using immunohistochemistry with monoclonal antibodies directed against HLA-class I antigens

PURPOSE: To evaluate the effect of substituting topical cyclosporin A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma. METHODS: Topical cyclosporin A 0.5% was prospectively substituted for topical corticosteroids to treat 25 patients with postkeratoplasty glaucoma. RESULTS: Twenty-one (84%) of 25 patients showed a reduction in intraocular pressure (IOP) (range, 1-22 mm Hg; mean, 8.7 mm Hg). Follow-up ranged from 3 to 12 months (mean, 5.8). Graft clarity was maintained in all patients, with one allograft rejection episode. Thirteen patients were able to discontinue one or more glaucoma medication(s). CONCLUSION: Topical cyclosporin A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty patients with glaucoma. However, the resultant decrease in IOP may be associated with an increased risk for immune rejections.     

Short-and long-term effect of clear corneal incisions on intraocular pressure

PURPOSE: To evaluate short- and long-term intraocular pressure (IOP) after cataract surgery using clear corneal incision to assess whether there is a statistically significant postoperative IOP decrease. SETTING: Advanced Vision Care, West Hills, California. METHODS: We retrospectively 135 eyes of 89 randomly selected patients who had scleral tunnel or clear corneal cataract surgery with a follow-up of at least 6 months. Patients with pre-existing glaucoma were excluded. RESULTS: In the clear corneal group (n = 84), mean IOP was statistically significantly lower (P = .019) 12 months after surgery than preoperatively (13.65 versus 15.57 mm Hg). Although there was a trend toward decreased IOP in the scleral tunnel incision group (n = 51), the difference was not statistically significant (P = .178). CONCLUSION: We found a trend toward lower IOP that, if permanent, raises serious implications about the necessity of combined procedures in patients with both glaucoma and cataract.     

Long-term results of noncontact transscleral neodymium:YAG cyclophotocoagulation

PURPOSE: To determine the long-term efficacy of noncontact transscleral neodymium:YAG (Nd: YAG) cyclophotocoagulation. METHODS: A retrospective analysis was made of 167 patients (173 eyes) with intractable glaucoma treated with noncontact Nd:YAG cyclophotocoagulation between December 1987 and November 1993, reviewing the treatment parameters, complications, and pre- and posttreatment intraocular pressure (IOP). The IOP was compared using a Student's t test, and the results were subjected to a Kaplan-Meier life-table analysis. Success was defined as an IOP of 22 mmHg or lower in the absence of phthisis and without having undergone any additional surgical procedures. RESULTS: Mean follow-up was 30.5 +/- 22.8 months. Mean preoperative IOP was 40.0 +/- 12.9 mmHg. Mean postoperative IOP was 19.8 +/- 11.4 mmHg (P < 0.05). The mean number of treatment sessions was 1.8 +/- 1.3 (range, 1-8) with 95 eyes (55%) having only one treatment. Kaplan-Meier survival analysis showed a probability of continued success at 3 years of approximately 73% and at 5 years of 45%. Complications included loss of two or more lines of Snellen visual acuity or one or more categories in the low-vision range (40%), phthisis (6.9%), epithelial defects (1.9%), and hyphema (0.6%). CONCLUSION: This study suggests that Nd:YAG transscleral cyclophotocoagulation provides a useful long-term reduction of IOP in eyes with advanced or complicated glaucoma, but there is a significant risk of visual loss associated with the procedure.     

Mitomycin-C in congenital glaucoma

BACKGROUND AND OBJECTIVE: To evaluate the adjunctive use of mitomycin-C (MMC) during trabeculotomy and trabeculectomy for eyes with high-risk congenital glaucoma. PATIENTS AND METHODS: A prospective, randomized, double-blind study was performed to compare the effect of a single, 4-minute intraoperative exposure to 0.2 mg/ml (group 1) or 0.4 mg/ml (group 2) of MMC on trabeculotomy with trabeculectomy in 16 high-risk cases (30 eyes) of congenital glaucoma. RESULTS: The preoperative and final postoperative intraocular pressures (IOPs) of the two groups did not differ significantly. At the final follow-up, IOP control (< 21 mm Hg) without medications was achieved in 60% of the eyes in group 1 and in 86.67% of the eyes in group 2 (P = 21). With medication, IOP control was achieved in 86.7% of the eyes of each group. In both groups, the rate of surgical failure was 13.3%. Avascular, thin, sharply demarcated blebs were noted in 33.3% of the eyes from group 1 and in 66.67% of those from group 2 (P = .14). Intraoperative and postoperative hyphema and postoperative hypotony were the complications encountered in both groups, whereas serous choroidal detachment and wound leakage were seen only in group 2. CONCLUSIONS: Intraoperative MMC applied at a concentration of 0.2 mg/ml controlled postoperative IOP as effectively as a 0.4-mg/ml concentration in high-risk cases of congenital glaucoma, but with a lower incidence of complications and thin-walled blebs.     

Fornix-based trabeculectomy with mitomycin-C

BACKGROUND AND OBJECTIVE: Mitomycin-C (MMC) has been shown to improve the surgical success of trabeculectomy; however, the advantages of MMC have been evaluated almost entirely as an adjunct to limbal-based trabeculectomy. This study evaluated the efficacy and safety of fornix-based trabeculectomy with MMC for glaucomatous patients. PATIENTS AND METHODS: Between January 1993 and April 1995, 71 patients underwent fornix-based trabeculectomy with topical application of 0.4 mg/ml of MMC for 3 minutes. The conjunctiva-Tenon's capsule flap was spread over the limbus and sutured in order to create a visible crease with a water-tight closure. The mean follow-up time was 14.5 months. RESULTS: The mean intraocular pressure (IOP) before surgery was 32.4 +/- 9.7 mm Hg. The average postoperative IOP was 14.04 +/- 9.57 mm Hg. An IOP of 20 mm Hg or less was observed in 57 eyes (80%). Postoperatively, 37 eyes (52%) required no additional medical therapy. One month after surgery, only 2 patients had wound leakage with hypotony and choroidal detachment. Two eyes (3%) had suprachoroidal hemorrhage with loss of vision. A conjunctival "buttonhole" occurred in 2 eyes (3%), but only 1 persisted more than a month. CONCLUSIONS: Fornix-based trabeculectomy using intraoperative application of 0.4 mg/ml of MMC for 3 minutes was found to be as safe and effective as limbal-based trabeculectomy with MMC.