Transscleral suture fixation of posterior chamber lenses combined with trabeculectomy.

OBJECTIVE: To evaluate the outcome of transscleral suture-fixated posterior chamber intraocular lens (PCIOL) implantation in glaucoma patients when combined with a trabeculectomy. DESIGN: A retrospective study of 56 consecutive glaucoma patients with a minimum follow-up of 6 months after transscleral suture-fixated PCIOL implantation combined with trabeculectomy. SETTING: Patients were drawn from the clinical glaucoma practice of the Kresge Eye Institute, Detroit, MICHIGAN: PATIENTS: Fifty-six eyes of 56 consecutive chronic glaucoma patients who had undergone transscleral suture-fixated PCIOL implantation in combination with a trabeculectomy were included in the analysis. RESULTS: The mean follow-up time was 38.5 +/- 19.1 months. Mean intraocular pressure (IOP) was significantly reduced, from 22.9 +/- 10.9 mmHg before surgery to 16.7 +/- 6.7 mmHg at the last follow-up visit (P = 0.0005), with the mean number of medications used also significantly decreased, from 2.3 +/- 0.9 to 1.9 +/- 0.9 (P = 0.0002). Postoperative IOP control to 21 mmHg or less was achieved or maintained in 84% of patients. Visual acuity improved or remained stable within two Snellen lines of the preoperative level in 39 eyes (70%) and within three Snellen lines in 45 eyes (80%) at the last follow-up visit. Overall, 46% to 68% of the patients had both stable visual acuity and satisfactory pressure control at the last postoperative visit, depending on criteria of varying stringency. However, 19 eyes (34%) required one or more additional surgical interventions for pressure control. Patients with anterior chamber intraocular lens (ACIOL) complications, diabetes mellitus, or a preoperative IOP level of more than 21 mmHg on maximum tolerated medications were especially prone to requiring additional surgical interventions. CONCLUSIONS: We conclude that transscleral suture-fixated PCIOL implantation can be combined successfully with a trabeculectomy and can be useful in glaucoma patients in need of both visual rehabilitation and IOP control. However, patients with ACIOL complications, diabetes, or preoperative IOP of more than 21 mmHg on maximum tolerated medications were prone to requiring additional surgical interventions.

Efficacy of apraclonidine 1% versus pilocarpine 4% for prophylaxis of intraocular pressure spike after argon laser trabeculoplasty.

OBJECTIVE: The authors compared the efficacy of apraclonidine 1% versus pilocarpine 4% prophylaxis of post-argon laser trabeculoplasty (ALT) intraocular pressure (IOP) spike. DESIGN: Prospective randomized clinical trial. PARTICIPANTS: Two hundred twenty-eight eyes of 228 patients with primary open-angle glaucoma undergoing ALT were studied. INTERVENTION: Patients were given 1 drop of either apraclonidine 1% (n = 114) or pilocarpine 4% (n = 114) 15 minutes before ALT. MAIN OUTCOME MEASURES: Peri-ALT IOPs and incidences of post-ALT IOP spikes at 5 minutes, 1 hour, and 24 hours were compared between the two groups. RESULTS: The two groups were similar in age, race, and medical dependency. Post-ALT mean IOPs at 5 minutes, 1 hour, and 24 hours were significantly lower than pre-ALT mean IOPs in both apraclonidine (P < 0.001) and pilocarpine (P < 0.001) groups. Incidences of IOP spikes greater than 1, 3, and 5 mmHg at 1 hour post-ALT were 21.1%, 14.9%, and 8.8% for the apraclonidine group and 12.3%, 5.3%, and 4.4% for the pilocarpine group (P = 0.076, 0.015, and 0.18 chi-square test). In the apraclonidine prophylaxis group, patients on long-term apraclonidine showed significantly higher incidence of post-ALT IOP spike than the patients without such long-term apraclonidine use (35.7%, 15 of 42 eyes, vs. 12.5%, 9 of 72 eyes; P = 0.003). In addition, peri-ALT pilocarpine prophylaxis tended to be less effective in patients undergoing long-term pilocarpine therapy but without statistical significance (17.4%, 8 of 46 eyes, vs. 9.4%, 6 of 64 eyes; P = 0.17). CONCLUSION: Peri-ALT pilocarpine 4% was at least as effective as, if not more effective than, apraclonidine 1% in post-ALT IOP spike prophylaxis. Peri-ALT apraclonidine prophylaxis was not effective in patients on long-term apraclonidine, and peri-ALT pilocarpine prophylaxis tended to be less effective in patients undergoing long-term pilocarpine therapy. Pilocarpine 4% can be considered as a first-choice drug for post-ALT IOP spike prophylaxis, especially in patients under treatment with apraclonidine.

Comparison between high-pass resolution perimetry and differential light sensitivity perimetry in patients with glaucoma.

PURPOSE: High-pass resolution perimeters such as the Ophthimus (High Tech Vision, Malmö, Sweden) may provide an easier, faster assessment of the visual field than conventional perimeters such as the Humphrey (Humphrey Instruments Inc., San Leandro, CA, U.S.A.), which is based on differential light sensitivity. The Ophthimus provides global indices and statistical analyses conceptually similar to those produced by the Humphrey. In addition, the Ophthimus provides, as a unique parameter, the estimated neural capacity. PATIENTS AND METHODS: Twenty-one patients with chronic open-angle glaucoma and reliable fields on both Humphrey and Ophthimus testing were evaluated. The results from the two different techniques were compared. RESULTS: The estimated neural capacity was correlated to global deviation and mean deviation at a statistically significant level. There were also correlations between mean deviation and global deviation and between pattern standard deviation and local deviation, but not between retest standard deviation and short-term fluctuation. CONCLUSION: It is not clear at this point if the neural capacity of the Ophthimus provides any clinically useful information over and above global deviation. Mean test time was shorter with the Ophthimus system than the Humphrey. Performance on the reliability indices was better for the Ophthimus. The Ophthimus may prove useful in following patients with glaucoma.

The effect of adjunctive mitomycin C in Molteno implant surgery.

PURPOSE: The purpose of the study is to assess the effect of adjunctive intraoperative mitomycin C (MMC) in Molteno drainage device implantation for patients with recalcitrant glaucomas. METHOD: Forty-nine eyes of 49 patients who underwent one-stage, single-plate Molteno device implantation with adjunctive intraoperative MMC (0.5 mg/ml) for 3 to 5 minutes (MMC group) were compared to a historic control group of 51 eyes of 51 patients (control group) who received one-stage, single-plate Molteno device implantation without MMC. Success (survival) was defined as an intraocular pressure (IOP) between 6 and 21 mmHg, inclusive, with (qualified success) or without (complete success) glaucoma medications and with no additional glaucoma surgery, phthisis, implant removal, or loss of light perception. RESULTS: Preoperative conditions were similar between the two groups. There was no significant difference in surgical survival rate between the two groups (P = 0.13, log-rank test). There also were no significant differences in the postoperative IOP levels and numbers of antiglaucoma medications between the two groups at all times (P > 0.05). Visual acuity was improved or remained within one line of preoperative visual acuity in 76.1% of the MMC group and 78.7% of the control group at 1 year after surgery (P = 0.76, chi-square test). Complications and reoperation for complications were similar in both groups (P > 0.05, chi-square test) except for the incidence of early postoperative hypotony and the total number of eyes with complications not requiring reoperation, which were more common in the MMC group (P = 0.027, 0.005, respectively, chi-square test). The most common complications included hypotony with or without a flat anterior chamber or choroidal detachment, followed by hyphema and tube plugging. CONCLUSION: Molteno device implantation with adjunctive intraoperative MMC in patients with complicated glaucoma may not offer a better chance of surgical success compared with Molteno implantation without MMC.

Chronic use of apraclonidine decreases its moderation of post-laser intraocular pressure spikes.

OBJECTIVE: The purpose of the study is to investigate the efficacy of 1.0% apraclonidine in preventing intraocular pressure (IOP) spike after argon laser trabeculoplasty (ALT) in patients on chronic apraclonidine therapy compared with patients not on chronic apraclonidine use. DESIGN: The study design was a prospective study. PARTICIPANTS: This study consisted of 231 consecutive eyes of patients with primary open-angle glaucoma undergoing ALT: 70 eyes (30%) were started on a regimen including chronic apraclonidine 0.5% use (group A) and 161 eyes (70%) were started on a regimen without chronic apraclonidine 0.5% use (group B). INTERVENTION: Both groups received one drop of apraclonidine 1.0% 15 minutes before ALT to 180 degrees of previously untreated trabecular meshwork. Intraocular pressure was measured before the procedure and at 5 minutes, 1 hour, and 24 hours after the laser treatment. MAIN OUTCOME MEASURES: Incidences of an IOP spike and mean IOPs at 5 minutes, 1 hour, and 24 hours after the laser treatment were compared between the two groups. Multivariate logistic regression analysis also was carried out to identify the significant risk factors for post-ALT IOP spikes despite prophylactic apraclonidine 1.0% treatment. RESULTS: The incidences of IOP spikes greater than 0 mmHg, greater than 2 mmHg, and greater than 5 mmHg at 1 hour after ALT were 32.9%, 22.9%, and 12.9%, respectively, in group A versus 13.7%, 11%, and 3.1%, respectively, in group B (P = 0.0007, P = 0.009, and P = 0.004). Chronic apraclonidine 0.5% use was found to be the only significant risk factor for IOP spikes at 1 hour after ALT by multivariate logistic regression analysis. CONCLUSIONS: The incidences of IOP spikes in group A were significantly greater than in group B and approached the reported incidences of IOP spikes without perilaser apraclonidine prophylaxis. This indicates that peri-ALT apraclonidine is relatively ineffective in patients with chronic apraclonidine 0.5% use (group A) compared with patients without chronic apraclonidine use (group B), presumably because of saturation of the ocular alpha-2 receptors with apraclonidine in patients with chronic apraclonidine use. Therefore, in patients receiving chronic apraclonidine therapy, it is especially important to monitor their post-ALT IOPs and to be prepared to treat postlaser IOP spikes using agents other than apraclonidine.

Analysis of reliability indices from Humphrey visual field tests in an urban glaucoma population.

PURPOSE: Visual field assessment is extremely important in glaucoma management, but interpretation is affected by the quality of the patient's performance. The authors have investigated the reliability of visual field performance by a randomly selected sample of the chronic glaucoma population at an urban tertiary care practice. METHODS: Patient reliability in Humphrey automated visual field testing was studied in 106 randomly selected chronic open-angle glaucoma patient charts, which provided 768 tests (mean, 7.2 +/- 4.8 fields; range, 2-18 fields). Reliability criteria were established as less than 20% fixation losses, less than 33% false-negative error, and less than 33% false-positive error, as recommended by Humphrey Instruments, Inc (San Leandro, CA). RESULTS: Patients performed reliably in 61% of right eye fields, 58% of left eye fields, and 59.5% overall. Of the 106 patients, only 35 (33%) were always reliable in both eyes, whereas 8 (7.5%) were always unreliable in both eyes. The most common cause of unreliability was fixation loss (39%), whereas false-positive error (5%) and false-negative error (9%) were less frequent. A more severely depressed mean deviation correlated significantly with poorer performance on the three reliability indices, with false-negative error having the greatest correlation, followed by fixation loss and false-positive error. Corrected pattern standard deviation correlated closely only with false-negative error. Prolonged test time also correlated with all three reliability indices. Age was a significant factor for fixation loss but not for false-negative or false-positive error. CONCLUSIONS: The authors conclude that fewer than two thirds of the Humphrey visual fields were reliable with the authors' urban tertiary care population of patients with glaucoma. Relaxing the fixation loss criterion to less than 33% improved the rate of reliability to approximately 75%. The severity of glaucomatous visual field defects, test time, and age were identified as factors influencing the reliability of the Humphrey visual fields.

Anterior chamber maintenance during drainage of a suprachoroidal hemorrhage in two phakic eyes.

BACKGROUND AND OBJECTIVES: The authors describe a technique for hemorrhage drainage following glaucoma surgery that uses an anterior chamber maintainer to minimize risk to the anterior lens capsule. PATIENTS AND METHODS: Two patients had suprachoroidal hemorrhages following filtration surgery. Because their eyes were phakic, an anterior chamber maintainer, as opposed to a 23-gauge butterfly needle, was used for aqueous replacement during hemorrhage drainage. RESULTS: The maintainer provided a stable anterior chamber environment during both drainage procedures. No damage to anterior chamber structures occurred, and the postoperative course was unremarkable in both patients. CONCLUSIONS: The use of a sharp-tipped infusion cannula may be contraindicated for the phakic patient who has a suprachoroidal hemorrhage. The anterior chamber maintainer is a useful alternative instrument in such cases.

Use of fascia lata in revision of filtration surgery.

PURPOSE: To report on a successful use of fascia lata patch graft in revision of trabeculectomy for management of severe chronic discomfort associated with an exuberant conjunctival filtering bleb over a very nasal filtering site. METHODS: After dissecting a conjunctival flap over the area of the trabeculectomy at the nasal quadrant, fascia lata patch graft was sutured in place over the filtering site when primary suture closure was found ineffective. A new trabeculectomy was performed temporal and superior to the old site, and the conjunctival wound closed watertight. RESULTS: The fascia lata patch graft was effective in closing the filtration over the old trabeculectomy site at the nasal quadrant, and a new filtering bleb developed superiorly over the new trabeculectomy site, resulting in sustained IOP control. CONCLUSION: Fascia lata patch graft was effective in revision of trabeculectomy.

Cellulose sponge punch for controlled mitomycin application.

We describe a new punch for cellulose sponges that helps to standardize the application of mitomycin during glaucoma filtration surgery. The punch was used to create 40 cellulose application disks. The height, diameter, and weight were measured in both wet and dry states. The disk dimensions and weights were reproducible, with a coefficient of variation less than 5 for all categories. The punch has been very useful in our clinical practice and research.

Herpes simplex keratitis following argon laser trabeculoplasty.

Many complications have been reported with argon laser trabeculoplasty (ALT). In the following article, we report the first case of Herpes simplex keratitis recurrence being triggered after ALT.

Relative deprivation theory and responses to discrimination in a gay male and lesbian sample.

Relative deprivation (RD) theory states that the perception of the relative positions of one's group and an out-group in terms of status and privilege is psychologically important. RD theory predictions for members of oppressed groups include increased endorsement of militant acts, decreased feelings of control and life-satisfaction as a function of perceived relative deprivation and perceived discrimination. In the present study, these predictions were tested with 74 members of Toronto's gay male and lesbian community. RD measures encompassed the cognitive-affective (i.e. concerned with knowledge vs. feelings about the deprivation) and egoistical-fraternal (i.e. concerned with the status of the individual vs. the in-group) dimensions, with a measure of concrete fraternal discrimination (CFD) also included for comparison. The results indicated that CFD was the best predictor of increased militancy, decreased control and decreased satisfaction. Implications for RD theory are discussed.