Long-term surgical outcomes of patients with glaucoma secondary to the iridocorneal endothelial syndrome.

PURPOSE: To report the long-term outcomes of patients with iridocorneal endothelial (ICE) syndrome who required surgery for glaucoma. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-six patients with ICE syndrome who underwent surgery for glaucoma at one institution between January 1987 and January 2000. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), visual acuity, number of glaucoma medications, and further surgical interventions were measured. RESULTS: Five eyes had a trabeculectomy with an antifibrotic agent alone, seven eyes had a trabeculectomy with an antifibrotic agent and a subsequent glaucoma drainage implant (GDI), and 14 eyes had a GDI alone. In eyes that underwent a trabeculectomy with an antifibrotic agent, preoperative IOP was reduced from a mean of 38.8 +/- 10.5 mmHg on 2.3 +/- 0.8 glaucoma medications to a mean of 11.8 +/- 4.3 mmHg on 1.2 +/- 1.4 medications at last follow-up after surgery (83.8 +/- 40.3 months). In eyes that underwent GDI surgery, preoperative IOP was reduced from a mean of 35.2 +/- 13.0 mmHg on 2.0 +/- 1.3 glaucoma medications to a mean of 8.7 +/- 11.2 mmHg on 1.2 +/- 1.1 medications at last follow-up after surgery (50.5 +/- 40.7 months). Twenty-four eyes (92%) had an IOP less than 22 mmHg, and 22 eyes (85%) had visual acuity 20/400 or better at last follow-up (55.8 +/- 41.5 months). Mean number of glaucoma surgeries per patient over the follow-up period was 1.6 +/- 1.2. Trabeculectomy with antifibrotic agents had a survival of 73% at 1 year, 44% at 3 years, and 29% at 5 years. Glaucoma drainage implants had a survival of 71% at 1 year, 71% at 3 years, and 53% at 5 years. CONCLUSIONS: Glaucoma associated with ICE syndrome can be managed successfully surgically, although multiple procedures are often needed.

Surgical management of secondary glaucoma after pars plana vitrectomy and silicone oil injection for complex retinal detachment.

OBJECTIVE: To evaluate the outcomes of surgical intervention for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Forty-three eyes of 43 patients who underwent incisional surgery for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment over a 9-year period. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), intraoperative and postoperative complications, visual acuity, and the need for further surgical intervention for glaucoma. Success was defined as IOP < or =21 mmHg and > or =5 mmHg with or without medication but without surgical reoperation for glaucoma. RESULTS: Findings associated with elevated IOP included emulsified oil in the anterior chamber (n = 14), pupillary block from silicone oil (n = 13), open-angle glaucoma without silicone oil in the anterior chamber (n = 9), and angle-closure glaucoma without pupillary block (n = 7). The mean (+/- standard deviation) IOP was 41.4 +/- 15.1 mmHg before surgery for glaucoma and 17.2 +/- 10.2 mmHg after an average follow-up of 19.6 months (P < 0.001). Cumulative success was 69%, 60%, 56%, and 48% at 6, 12, 24, and 36-months respectively. In patients who underwent silicone oil removal alone for surgical management of glaucoma (n = 32), 11 of 12 IOP failures (92%) were due to uncontrolled IOP, whereas most IOP failures in the group who underwent silicone oil removal plus glaucoma surgery (n = 8) failed because of hypotony (3 of 4, 75%, P = 0.027). Of three patients who underwent glaucoma surgery alone to control IOP, one failed because of hypotony. There was no significant change in visual function at last follow-up (logarithm of the minimum angle of resolution [logMAR] 2.01) compared with preoperative visual function (logMAR 2.07, P = 0.74). CONCLUSION: Surgical management of secondary glaucoma after silicone oil injection for complex retinal detachment may achieve good IOP control and stabilization of visual function in most patients. Patients who undergo silicone oil removal alone to control IOP are more likely to have persistent elevation of IOP and possibly undergo reoperation for glaucoma, whereas patients who undergo concurrent silicone oil removal and glaucoma surgery are more likely to have hypotony.

Late endophthalmitis associated with glaucoma drainage implants.

OBJECTIVE: To report the clinical course of a series of patients who had late endophthalmitis develop after glaucoma drainage implant (GDI) surgery. DESIGN: Noncomparative, interventional, consecutive case series. PARTICIPANTS: Four patients were identified with late endophthalmitis associated with Baerveldt glaucoma implants. METHODS: The medical records of all patients with endophthalmitis associated with a GDI treated at the Bascom Palmer Eye Institute or University of Florida between January 1, 1987 and December 31, 1999 were retrospectively reviewed. Patients with culture-positive endophthalmitis diagnosed more than 1 month after GDI surgery were included in this series. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure (IOP). RESULTS: Late endophthalmitis associated with Baerveldt glaucoma implants developed 7 weeks to 2 years postoperatively. Exposure of the GDI tube was present in all cases. The implant was removed in three of four patients. Visual acuity worsened from preinfection level in two of four cases. IOP was controlled at last follow-up in all patients, although replacement of the explanted GDI was required in one patient. CONCLUSIONS: Late endophthalmitis may occur after GDI surgery. Exposure of the GDI tube seems to represent a major risk factor for these infections. To prevent this potentially devastating complication, we recommend prophylactic surgical revision with a patch graft in all cases in which there is an exposed GDI tube.

Glaucoma filtration surgery using amniotic membrane transplantation.

PURPOSE: To investigate the potential use of amniotic membrane transplantation (AMT) in the construction of glaucoma filtering blebs. METHODS: Twenty-four albino rabbits underwent glaucoma filtration surgery in one eye. In alternate cases, the conjunctival flap was replaced with AMT. Postoperative examination data were grouped into three time points. Six animals with AMT and six filtration surgery-controls were euthanatized at each of two postoperative time points, and tissue was obtained for histologic examination. Conjunctival biopsies were explanted for estimation of fibroblast outgrowth. RESULTS: Bleb formation was observed in all eyes, and amniotic membranes were epithelialized after 11.2 +/- 2.48 (mean +/- SD) days. Throughout the study IOPs were significantly lower in operated than unoperated fellow eyes. Between postoperative days 11 and 16 (the middle time point), the percentage IOP reduction in AMT eyes was significantly greater than in filtration surgery controls (P = 0.014), though not at other time points. Filtration surgery survival was significantly longer in the AMT group (22.3 +/- 3.8 days; mean +/- SE) than in "No AMT" controls (14.0 +/- 1.6 days; P = 0.035). In tissue culture, significantly less fibroblast outgrowth occurred from AMT explants when compared with unoperated conjunctiva (P = 0.01) between postoperative days 3 and 9 (the early time point). Amniotic membrane transplants were intact on histologic examination after 14 days but were associated with considerable granulomatous inflammation. After 36 days, the ocular surfaces remained clinically intact, but lysis of AMT was noted histologically. CONCLUSIONS: AMT exhibits potential as an alternative tissue to conjunctiva in the construction of glaucoma filtration blebs. The healing response as demonstrated by fibroblast outgrowth is retarded when compared with conventional conjunctival closure. The improvement in bleb survival must be weighed against the potential for complications related to delayed healing. In rabbits, human amniotic membrane elicited a late xenograft reaction, leading to granulomatous inflammation and dissolution of the membrane.

Glaucoma filtering bleb dysesthesia.

PURPOSE: To determine the prevalence and risk factors for glaucoma filtering bleb dysesthesia (discomfort). METHODS: A prospective cross-sectional observational study of consecutive patients with unilateral glaucoma filtering blebs from trabeculectomy was conducted. A self-report questionnaire was administered, which asked about the frequency and severity of the following symptoms: ocular pain, discomfort, burning, foreign body sensation, and tearing. The following variables were recorded by the investigators: age, race, sex, type and date of glaucoma surgery, antifibrotic agent used, intraocular pressure, location, thickness, and size of bleb, percent coverage of the bleb by the eyelid, angle that the bleb made to the cornea, and the presence of epithelial defects or dellen. Dysesthesia scores between the affected eye and control eye were compared using the paired Student t test. Risk factors for dysesthesia were evaluated using analysis of variance or Pearson correlation coefficient. RESULTS: A total of 97 patients were enrolled in the study. The mean total dysesthesia score (+/-SD, range) in the affected eye was 11.1 (+/-9.4, 0 to 42) and in the unaffected eye 3.4 (+/-4.9, 0 to 25, P =.001). Factors that predisposed to dysesthesia included younger age (P =.005), superonasal location of bleb (P =.036), presence of bubbles (P =.028), and poor lid coverage (P =.013). The steeper the angle of the bleb to the cornea, which was an indirect measure of the height of the bleb, the more likely a patient was to have bubbles (P =.001). CONCLUSION: Eyes with glaucoma filtering blebs experience more dysesthesia than eyes without filtering blebs. Young age, superonasal bleb location, poor lid coverage, and bubble formation are all associated with glaucoma filtering bleb dysesthesia.

Diode laser transscleral cyclophotocoagulation as a primary surgical treatment for primary open-angle glaucoma.

OBJECTIVES: To evaluate the feasibility of diode laser transscleral cyclophotocoagulation (TSCPC) as a primary surgical treatment for primary open-angle glaucoma and to compare 2 laser energy settings used for treatment. METHODS: In a prospective clinical trial in Cape Coast and Accra, Ghana, 1 eye of each of 92 patients with primary open-angle glaucoma was treated by diode laser TSCPC as a primary surgical treatment. Eyes were randomly assigned to receive treatment by 20 applications of either 1.5 W applied for 1.5 seconds or 1.25 W applied for 2.5 seconds. RESULTS: Seventy-nine (86%) of 92 patients completed 3 months of follow-up; follow-up was 13.2 +/- 6.0 months (mean +/- SD). Intraocular pressure decreased in 53 (67%) of the 79 eyes. The drop in intraocular pressure was 20% or more in 37 eyes (47%) and final intraocular pressure was 22 mm Hg or less in 38 eyes (48%). An atonic pupil was a previously unreported complication that arose in 27 (28%) of 92 eyes. There were no serious complications of hypotony, phthisis bulbi, or sympathetic ophthalmia. Visual acuity decreased in 18 (23%) of 79 eyes treated by TSCPC and in 10 (23%) of 47 fellow eyes treated only with glaucoma medications. There was no difference in outcomes between the 2 laser energy settings. CONCLUSIONS: Diode laser TSCPC is a practical, rapid, well-tolerated procedure that may provide a modest and variable lowering of intraocular pressure. The treatment, used with conservative energy levels applied to the eye, seems to have few serious complications, although a previously unrecognized complication of atonic pupil needs further evaluation. A moderate variation in laser energy settings does not influence the results of treatment.

Motility disturbance due to true Tenon cyst in a child with a Baerveldt glaucoma drainage implant.

Epithelial ingrowth of the bleb cavity, a true Tenon cyst, is a rare complication of a glaucoma drainage implant. Previous cases have been associated with persistent bleb leak, and most have occurred in eyes with prior extraocular surgery. We describe a case of a true Tenon cyst causing strabismus and an elevated intraocular pressure that was successfully treated by surgical revision.

Retrograde infusion of fluorescein to confirm location and patency of a glaucoma drainage device.

BACKGROUND: During surgical revision of a glaucoma drainage device, the status of the implant tube can be in question. We report two cases in which retrograde infusion of fluorescein-stained balanced salt solution was used to confirm the patency and location of the tube. METHODS: Fluorescein-stained balanced salt solution was made by dipping a sterile fluorescein strip into a 3-mL syringe of balanced salt solution until the fluid was visibly yellow. A 30-gauge canula was inserted into the tube at the reservoir end, and fluorescein-stained balanced salt solution was infused into the eye. RESULTS: Retrograde infusion of fluorescein-stained balanced salt solution confirmed the location and patency of the glaucoma drainage device implant tube, obviating the need for more extensive surgical intervention in these two cases. Neither patient experienced an adverse event. CONCLUSION: Retrograde infusion of fluorescein-stained balanced salt solution is a useful adjunctive technique for surgical revision of glaucoma drainage devices.

Amniotic membrane transplantation for repair of leaking glaucoma filtering blebs.

PURPOSE: To compare the safety and efficacy of human preserved amniotic membrane transplant with conjunctival advancement for repair of late-onset glaucoma filtering bleb leaks. METHOD: A prospective, randomized clinical trial compared amniotic membrane transplant with conjunctival advancement in patients with leaking glaucoma filtering blebs. Intraocular pressure, number of glaucoma medications, and reoperation for glaucoma or persistent or recurrent bleb-leak were compared in the two groups. Patients were followed for a minimum of 1 year. RESULTS: Mean intraocular pressure was the same at 6 (amniotic membrane transplant, 15.4 +/- 4.4, conjunctival advancement 14.1 +/- 6.4, P = 0.6), 12 (amniotic membrane transplant, 15.0 +/- 6.3, conjunctival advancement, 13.2 +/- 6.6, P = 0.5), and 24 (amniotic membrane transplant, 17.2 +/- 7.1, conjunctival advancement, 15.0 +/- 6.3, P = 0.6) months. The mean number of glaucoma medications in use was the same in the two groups at all time intervals. After an average follow-up of 19 months, there were seven failures in the amniotic membrane transplant group (two with persistent leaks that were unresponsive to further suturing, two with late-onset leaks, and three who required repeat glaucoma surgery) and none in the conjunctival advancement group. The cumulative survival rate for amniotic membrane transplant was 81% at 6 months, 74% at 1 year, and 46% at 2 years. The cumulative survival rate was 100% for conjunctival advancement throughout follow-up. CONCLUSIONS: Amniotic membrane transplantation does not offer an effective alternative to conjunctival advancement for repair of leaking glaucoma filtering blebs.

Trabeculectomy with intraoperative mitomycin C versus 5-fluorouracil. Prospective randomized clinical trial.

OBJECTIVE: To evaluate the relative efficacy and safety of 5-fluorouracil (5-FU) and mitomycin C (MMC) when used as adjuncts with primary trabeculectomy in eyes not at high risk for failure. DESIGN: Prospective multicenter, randomized clinical trial. PARTICIPANTS: One hundred thirteen patients with primary open-angle, pseudoexfoliative, pigmentary, or angle-closure glaucoma undergoing primary trabeculectomy were recruited. METHODS: One eye of each patient was randomized to receive either 5-FU (50 mg/ml for 5 minutes) or MMC (0.4 mg/ml for 2 minutes). MAIN OUTCOME MEASURES: Intraocular pressure (IOP), visual acuity, complications, and interventions were documented at fixed intervals after surgery. The study also examined progression of visual field loss, long-term complications, and bleb appearance 3 years after surgery. RESULTS: Of the 108 patients with complete perioperative information, 54 eyes received 5-FU and 54 received MMC. The proportion of patients reaching different predefined target IOPs after surgery was slightly higher in the MMC group than in the 5-FU group. This difference was less than 25%, which would have been necessary to achieve statistical significance with a power of 0.8 and the sample size used. Likewise, there was no statistically significant difference between the groups with regard to mean preoperative IOP, complications, or interventions. Mean postoperative follow-up was 309 and 330 days in the 5-FU and MMC groups, respectively (P = 0.593). CONCLUSIONS: 5-Fluorouracil and MMC were found to be equally safe and effective adjuncts to primary trabeculectomy in the short- and medium-term postoperative periods.

Baerveldt drainage implants in eyes with a preexisting scleral buckle.

OBJECTIVE: To describe the surgical insertion of a Baerveldt drainage implant and postoperative visual acuity and intraocular pressure (IOP) outcomes in patients with a preexisting scleral buckle. METHODS: Medical records of all patients with a preexisting scleral buckle who underwent insertion of a Baerveldt drainage implant at Bascom Palmer Eye Institute, Miami, Fla, from January 1, 1994, through December 31, 1998, were reviewed. Outcome measures included visual acuity and IOP at 1 year. RESULTS: At 1 year postoperatively, 14 (88%) of 16 patients had stable or improved visual acuity. Preoperatively, mean IOP was 30.9 mm Hg and the mean number of antiglaucoma medications was 3.4; at 1 year postoperatively, mean IOP was 12.0 mm Hg and the mean number of antiglaucoma medications was 0.8 (P<.001). Nine patients (56%) achieved an IOP of greater than 5 and no greater than 21 mm Hg without medication, and an additional 7 (44%) achieved this level of IOP control with medication. No patient required further surgery for uncontrolled IOP during the follow-up interval, which ranged from 19. 1 to 45.5 months. CONCLUSION: Baerveldt drainage device insertion behind or over a preexisting encircling band is often successful in managing refractory glaucoma in patients who have undergone previous scleral buckling procedures. Arch Ophthalmol. 2000;118:1509-1513

Two-staged Baerveldt glaucoma implant for childhood glaucoma associated with Sturge-Weber syndrome.

PURPOSE: To report the outcome and complications of 10 eyes of 9 children with Sturge-Weber syndrome (SWS) who underwent two-stage insertion of a Baerveldt glaucoma implant (BGI) for glaucoma. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: The authors reviewed the medical records of children under the age of 14 years with SWS who underwent two-stage BGI for glaucoma at two tertiary care referral centers. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, intraocular pressure (IOP), number of glaucoma medications, visual acuity, and further surgical intervention. RESULTS: Ten eyes of nine patients were included in the study. Ages of the nine patients at time of first stage BGI ranged between 6 weeks and 13 years. With average follow-up of 35 months (range, 10-50), all eyes had adequate IOP control (< or = 21 mmHg) without the need for additional glaucoma surgery. Intraocular pressure was reduced from a mean (+/- standard deviation) of 24.8 +/- 6.2 mmHg preoperatively to 16.9 +/- 2.3 mmHg at last follow-up visit (P = 0.001). The number of medications used for control of glaucoma was reduced from a mean (+/- standard deviation) of 1.8 +/- 1.0 preoperatively to 1.1 +/- 1.4 at last follow-up visit (P = 0.2). One eye had serous choroidal effusions with overlying serous retinal detachment that resolved spontaneously after 7 days with no permanent visual loss, and one eye had low choroidal effusion that lasted 4 days. There were no intraoperative or postoperative suprachoroidal hemorrhages. At last follow-up, visual acuity had improved by one or more lines in all patients in whom vision was measurable. CONCLUSIONS: Two-stage BGI surgery appears to be a safe and effective treatment for refractory glaucoma in children with SWS.

Combined pars plana vitrectomy and glaucoma drainage implant placement for refractory glaucoma.

PURPOSE: To report visual acuity and intraocular pressure outcomes among patients who have undergone combined pars plana vitrectomy and placement of a glaucoma drainage implant. METHODS: The medical records of all patients who underwent combined pars plana vitrectomy and placement of a glaucoma drainage implant at the Bascom Palmer Eye Institute by one of the authors between January 1, 1990, and February 28, 1998, were reviewed. Forty patients (40 eyes) were identified, including 14 patients with neovascular glaucoma secondary to proliferative diabetic retinopathy or central retinal vein occlusion, 15 patients with other posterior segment disease, seven patients with secondary angle-closure glaucoma, and four patients with aphakia with ruptured anterior hyaloid face. Main outcome measures included visual acuity and intraocular pressure at 1 year postoperatively. RESULTS: At 1 year postoperatively, 31 (77.5%) of 40 patients had stable or improved visual acuity; three eyes (7. 5%) had a final visual acuity of no light perception and three additional eyes (7.5%) were enucleated (because of chronic pain in two eyes and endophthalmitis in one eye). Mean preoperative intraocular pressure was 34 mm Hg and the median number of preoperative antiglaucoma medications was two. At 1 year postoperatively, mean intraocular pressure was 13 mm Hg and the median number of antiglaucoma medications was zero. Twenty-two patients (55.0%) achieved an intraocular pressure greater than 5 mm Hg and less than or equal to 21 mm Hg without antiglaucoma medication, and an additional seven patients (17.5%) achieved this level of intraocular pressure control with medication. Only one patient (2.5%) underwent further glaucoma surgery for uncontrolled intraocular pressure. CONCLUSIONS: Although combined pars plana vitrectomy and placement of a glaucoma drainage implant is often a successful management option in selected patients with refractory glaucoma, visual outcome may be poor because of severe underlying ocular disease and postoperative complications.

Risk factors for glaucoma filtering bleb infections.

OBJECTIVE: To determine risk factors for bleb-related ocular infection after glaucoma filtering surgery. METHODS: A case-control study comparing all consecutive cases of glaucoma filtering bleb-related infections (55 eyes of 55 patients) with matched control eyes between January 1, 1990, and June 30, 1998, was performed. Bleb-related infection was classified as blebitis when a mucopurulent infiltrate was identified within the bleb and associated with mild to moderate anterior segment inflammation. Eyes with endophthalmitis had hypopyon, cells in the anterior vitreous cavity, or a positive vitreous biopsy sampling result. A control was selected for each case based on matching of the surgeon, date and type of glaucoma surgery, and type of antifibrotic agent used. Multivariate, matched, case-control logistic regression analysis was performed using age, race, sex, diagnosis, number of previous incisional operations, filtering bleb location, and presence of bleb leak to determine which variables were associated with bleb-related infection. RESULTS: The odds of an eye with a bleb-related infection being seen with a concomitant late-onset bleb leak are 25.8 times the odds of a noninfected eye having a late-onset bleb leak at any time in the postoperative period (P<.001; 95% confidence interval, 2.3-294.1). Other risk factors for bleb-related infection included younger age (P = .05), black race (P = .03), diagnosis of primary open-angle glaucoma (P = .03), and inferior location of the filtering bleb (P = .04). CONCLUSIONS: Late-onset bleb leakage is a significant risk factor for bleb-related infection. The risk of infection may warrant closure of late-onset bleb leaks in selected eyes.

Conjunctival advancement for late-onset filtering bleb leaks: indications and outcomes.

OBJECTIVE: To determine the indications and outcome of conjunctival advancement surgery for late-onset filtering bleb leaks. PATIENTS AND METHODS: Retrospective medical record review of a consecutive case series of all patients who underwent conjunctival advancement surgery for persistent late-onset glaucoma filtering bleb leaks at a tertiary referral center between December 1, 1985, and April 30, 1997. MAIN OUTCOME MEASURES: Indications for surgery, preoperative and postoperative intraocular pressure (IOP), visual acuity, status of bleb leak, and need for reinstitution of medical therapy or reoperation for glaucoma. RESULTS: Twenty-six eyes of 26 patients were analyzed. Complications from bleb leaks that necessitated surgical intervention included chronic ocular hypotony (n = 21), decreased visual acuity (n = 9), bleb-related infection (n = 11), hypotony maculopathy (n = 4), corneal edema with folds (n = 7), choroidal effusion (n = 3), and persistent shallow anterior chamber (n = 3). The mean +/- SD preoperative IOP was 5.7 +/- 4.9 mm Hg (range, 0-16 mm Hg). After a follow-up of 19.6 +/- 22.6 months, the IOP was 14.2 +/- 4.1 mm Hg for patients taking 1.1 +/- 1.3 glaucoma medications (all data given as mean +/- SD). Twelve patients (46%) had early-onset bleb leaks after revision, of which 7 (27%) closed spontaneously and 5 (19%) required resuturing. Two patients (8%) had a persistent bleb leak throughout the follow-up period. Thirteen patients (50%) required reinstitution of medical therapy during the follow-up period, and 2 (8%) required a reoperation for glaucoma for uncontrolled IOP. CONCLUSIONS: Conjunctival advancement is a successful procedure for closing late-onset filtering bleb leaks. Some patients require suturing in the early postoperative period, but most patients eventually obtain permanent closure of the leak. Patients should be counseled of the possibility of requiring medical or surgical intervention for IOP control after revision.

Aqueous misdirection after glaucoma drainage device implantation.

OBJECTIVE: To describe the clinical presentation, outcome, and possible underlying mechanism of aqueous misdirection after glaucoma drainage device implantation. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Ten eyes (five primary open-angle glaucoma, four chronic angle-closure glaucoma, one nanophthalmos) of nine patients with a mean age of 68.5+/-12.0 years (range, 43-83 years). INTERVENTION: The authors reviewed the medical records of all patients with a clinical diagnosis of aqueous misdirection after Baerveldt glaucoma drainage device implantation at two tertiary care referral centers from October 1992 to October 1997. Surgery was performed in a standardized fashion; all drainage tubes were inserted in the anterior chamber and occluded with an external 7-0 polyglactin ligature. All eyes were treated with topical corticosteroids, cycloplegia, and aqueous suppressants. Eyes with persistent aqueous misdirection received neodymium:YAG (Nd:YAG) hyaloidotomy or pars plana vitrectomy. MAIN OUTCOME MEASURES: Visual acuity, intraocular pressure, biomicroscopic anterior chamber depth, and antiglaucomatous medication. RESULTS: All eyes had axial shallowing of the anterior chamber, one or more patent iridotomies, and no ophthalmoscopic or B-scan ultrasonographic evidence of serous or hemorrhagic ciliochoroidal detachment. Median time to the development of angle-closure glaucoma was 33.5 days (range, 1-343 days) and mean intraocular pressure at diagnosis was 27.7+/-18.7 mm Hg (range, 10-62 mm Hg). Normalization of anterior segment anatomy was achieved with aqueous suppression and cycloplegia (one eye); Nd:YAG capsulotomy (four eyes); pars plana vitrectomy alone (two eyes) or with lensectomy (one eye), and pars plana vitrectomy with intraocular lens explanation (two eyes). Mean final intraocular pressure was 14.1+/-6.0 mmHg at a mean follow-up of 9.1+/-7.8 months after the development of aqueous misdirection (range, 1-23 months). CONCLUSIONS: Aqueous misdirection may develop days to months after glaucoma drainage device implantation. In this series, there was a poor response to medical therapy, and normalization in anterior chamber depth required aggressive laser and surgical therapy.

Comparison of phacotrabeculectomy with 5-fluorouracil, mitomycin-C, and without antifibrotic agents.

BACKGROUND AND OBJECTIVE: To evaluate the potential benefits, complications, and prognostic risk factors for failure of phacotrabeculectomy performed with or without 5-fluorouracil (5-FU) and mitomycin-C (MMC). PATIENTS AND METHODS: Retrospective chart review of 78 patients who underwent phacotrabeculectomy during a 2-year period. Patients were divided into 3 groups, those who received 5-FU (N = 28). MMC (N = 29), or no antifibrotic agent (N = 21). RESULTS: All 3 groups had statistically significant lower intraocular pressures (IOP) on fewer antiglaucomatous medications at 6-month, 12-month, and last follow-up compared to preoperative levels (P < .05). Intraocular pressures were lower in the group that received MMC compared to the 5-FU group, but not in the group that did not receive antimetabolites, at all time intervals measured (P < .05). Black race was a strong predictor of failure of trabeculectomy (P = 009). No differences in final visual acuity or complications were found between groups. CONCLUSIONS: Phacotrabeculectomy is effective regardless of antimetabolite use. Race is a strong predictor of failure.

Elevated intraocular pressure and hypotony following silicone oil retinal tamponade for complex retinal detachment: incidence and risk factors.

OBJECTIVE: To evaluate the incidence of and risk factors for persistently elevated intraocular pressure (IOP) and hypotony in patients who have undergone pars plana vitrectomy with silicone oil injection for the management of complex retinal detachment. SUBJECTS AND METHODS: The medical records of 532 patients who underwent silicone oil injection for the management of complex retinal detachments between January 1, 1991, and December 31, 1996, at the Bascom Palmer Eye Institute, Miami, Fla, were reviewed. Elevated IOP was defined as elevated IOP requiring an operation at any time postoperatively or a persistently elevated IOP of greater than 25 mm Hg at or after the 6-month visit. Hypotony was defined as a persistent IOP of 5 mm Hg or less at or after the 6-month visit. Patients with transient perioperative IOP fluctuations were not counted. RESULTS: Survival analysis for patients without cytomegalovirus retinitis (n = 383) revealed that 12.9% had an elevated IOP and 14.1% had hypotony by 6 months, 21% had an elevated IOP and 20.3% had hypotony by 1 year, and 29.5% had an elevated IOP and 27.3% had hypotony by 2 years. Among patients with cytomegalovirus retinitis (n = 149), none had a persistently elevated IOP, 10% had hypotony by 6 months, and 5.9% had persistently elevated IOP and 10% developed chronic hypotony by 1 year. A history of glaucoma before silicone oil retinal tamponade (P = .03), diabetes mellitus (P = .02), and a high IOP on the first postoperative day (P = .006) were risk factors for elevated postoperative IOP in patients without cytomegalovirus retinitis. Risk factors for postoperative hypotony in patients without cytomegalovirus retinitis included preoperative hypotony (P<.001) and aphakia (P = .03). CONCLUSIONS: An elevated or low IOP often develops postoperatively in patients without cytomegalovirus retinitis who undergo silicone oil injection for the management of complex retinal detachment. Risk factors for an elevated postoperative IOP include a history of glaucoma, diabetes mellitus, and a high IOP on the first postoperative day. Risk factors for hypotony include preoperative hypotony and aphakia.

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.